Health insurance experts - help

[episodic]

I know that I can call tomorrow - but my wife and I are trying to figure something out.

If your insurance pays 80% and then it has a provision that reads: maximum yearly out of pocket is 2000$ - then does that mean the following:

You have a 40,000 dollar hospital bill:
So 20 percent is 8000 dollars.

You pay 2000 out of pocket. Then the other 6000 is covered?

Anyone can clear this up for me?

 

[GT1999]

It depends on the plan, percentages for different types of procedures (eg, X-Ray/CT/MRI may be covered at 90% or similar) and if there's a deductible, but generally speaking for group coverage that is correct.

 

[lykaon78]

Unless you have a quirky plan then I would assume your maximum would be $2000.

 

[yuchai]

Yes. The annual out of pocket maximum is your maximum obligation for the plan year.

Essentially the plan will pay the other $38,000. All other expenses you incur for the rest of the year will be covered at 100% as well. (assuming a calendar year plan year)

 

[Zee]

You pay 2000 out of pocket. and 8000 on top. No?

 

[spidey07]

out of pocket maximum means just that - your maximum out of pocket.

Sounds like you're looking at a standard 80/20 plan like it used to be. And if your max is 2K you'd be a fool not to take it.

GET IT. DO IT.

-edit-
And read the fine print on what contributes to your out of pocket contributions.

 

[Turin39789]

Maximum out of pocket includes your deductible + coinsurance. It does not include copays. So your $2000 MaxOOP - $500 ded = $1500 coins to reach your max.

BUT!

There is a different MAX OOP for In-network and Out of network, any out of network OOP should apply to your in network max oop. But basically if you stick to in network providers, the most you will have to pay will be $2k, not including copays or drugs(depending on your specific insurance)