Effective 1/1/2014, Obamacare mandates that all copays accumulate toward Out Of Pocket Maximums (OOP Max). Prior to Obamacare, anything that was deemed to be a copay, items such as office visits, emergency room visits, and prescription drug benefits, would not accumulate toward OOP Max. If you have a $20.00 office visit, $250 Emergency room Copay, or a $35.00 copay for a formulary drug, those costs would be charged to the subscriber the first time, as well as every other time during the plan year.
A copay is a per incident fee, which has never accumulated toward deductibles or OOP Maxs.
Out of Pocket Maximum (OOP MAX) has traditionally been the total of all deductibles, and coinsurance amounts.
Now, under Obamacare, it is mandated that these copays accumulate toward OOP Max. In theory, the consumer wins since he will reach his maximums more quickly, then after that ALL CHARGES, including Copays are paid at 100%.
HOWEVER, insurance companies are not in the business to lose money. Many have performed the calculations and determined that including the Copays in the OOP Max will cost them from $800 to $1500 per year, per subscriber.
As a result, they are increasing the OOP Max amounts on all plans that renew after 1/1/14 between $1000 and $1500. As an example: One plan that I recently reviewed had an OOP Max of $2250 and that amount has been increased to $3250. Another plan went from $4000 OOP Max to $5500.
Once again, if you like your plan…….too bad, its going to be changed.
ADDED: It is important to note that once you meet your OOP Max, the plan pays 100% of all claims. As such, you as a patient have no incentive to purchase and use healthcare in the most cost effective way. To you it is FREE for the rest of the year. As such, this mandate also is counter-productive in the effort to control or reduce healthcare costs.