Most people focus on the Deductible of any insurance plan as the most important determinant of quality. The Deductible, however, is NOT the most important feature of a health plan. That honor would go to the plan element called Out-of-Pocket Maximum (or “OOP Max”). Under the ACA the OOP Max is the grand total of all Deductibles, Coinsurance Amounts, and Copays for all covered benefits.
For In-Network (“In-Net”) claims, the OOP Max is the ultimate protector of the subscriber. If the Subscriber has an In-Network Bill of $1,000,000 and a OOP Max of $2500, then they will only be responsible for the $2500 OOP Max. Prior to ACA, it was common to have In-Net OOP Max of $2500/$5,000 (Single/Family). Post-ACA, In-Net OOP Max have increased, and are commonly in the $6000/$12,000 Range.
As compared to In-Net claims, a subscriber’s Out-of-Network (“Out-Net”) responsibility is always higher than In-Net. Pre-ACA, plan summaries generally set Out-Net OOP Max’s at two times the In-Net Amount. Pre-ACA, OOP Max amounts were frequently in the $5,000/$10,000 range. The max amount that a carrier or network will pay for an Out-Net claim is generally 100% (or alternative percentage) of the Usual Customary and Reasonable (UCR) amount for any given service. The subscriber is protected by their Out-Net OOP Max for claims that are at or below the UCR amount.
However, since there is no contract between a carrier and an Out-Net provider, there is always the potential for the Out-Net provider to balance bill the subscriber above and beyond the UCR amount. That means the liability for the subscriber is not limited for Out-Net claims.
Post-ACA, Out-Net OOP Max claims have been de-linked from the previous 2x In-Net OOP Max that has been traditional Pre-ACA. One prominent carrier in Ohio carries an Out-Net OOP Max for Single at $100,000 and $200,000 for Family, and another prominent carrier describes their OOP Max as Unlimited.
Here are a few examples of actual insurance offerings in Ohio, with very high Out-Net OOP Max.
|Carrier Plan||Deductible (S/F)||In-Net OOP Max||Out-Net OOP Max|
|MMO Bronze||$5,000/$10,000||$6,600/$13,200||$100,000 / $200,000|
Using the same example above, if a $1,000,000 claim is incurred through an Out-Net provider, many such plans would require the subscriber to pay 40% of the UCR amount up to the OOP Max. With these three plan designs above, the subscriber would be liable for $18,000 of the Anthem plan, $100,000 of the MMO Plan, and an UNLIMITED amount of the Aetna plan. In addition, the subscriber would be liable for any balance billing Out-Net amounts.
So what can the consumer do about this? First, the consumer must educate themselves on the coverage types and conditions that they are considering through their employer, or as an individual. It is always best to know the panel network status of your doctors and hospitals prior to electing a policy.
Second, it is more important than ever to stay In-Net. Going Out-Net is something to be avoided if at all possible. However, if you absolutely need to see an Out-Net provider, it is very important to proactively discuss the cost of treatment with the provider, prior to receiving the service. Failure to do so could lead to major financial liability in the long run.