Do in-network costs count towards out of network OOP maximum?

[holl]

E.g. let's say my PPO plan has a 5,000 in network OOP max and 8,000 out of network OOP. max

The following out of pocket coinsurance costs occurs in this order

1. 4,000 spent in network
2. 4,000 spent out of network
3. 4,000 spent out of network

Is the out of network OOP max hit after #2 or #3?

I realized today I have no reason to believe this, but I always assumed the "out of network OOP max" implied (in or out of network), which would mean #2.

Semi related question in the same example , is it possible for you to hit your out of network OOP maximum without hitting your in network OOP? E.g. after #3 it would appear you are in an odd situation where you are better off avoiding in network doctors.

 

[ngocvncom]

@holl It depends on your particular plan. It's not uncommon for in-net claims to accumulate towards both in and out of net OOP max. But it's definitely not always that way, they can be completely separate.

 

[tikhonofsc]

@holl Nobody can answer this for you. It entirely depends on how the employer/insurance company set it up. There's 3 possible setups:

• INN applies to both INN and OON (in-network applies to OON)
• OON applies to both OON and INN (out of network applies to INN)
• INN and OON cross apply (both in-network and out of network fully cross apply)

In-network applying to OON is the rarest. No employer/insurance company wants to incent people to be able to use OON care

OON applying to INN used to be more common before ACA, since employers wanted any unavoidable OON emergency care to help people with their INN amounts

Full cross application is the least common, from what I've seen

 

[resjudicata]

@holl It may depend on the company, but I do know that BCBS does include in network payments toward OON maxes as well as INN max. However, OON max does not count toward INN max.

 

[tikhonofsc]

@resjudicata This is an INSANE generalization, I wouldn't rely on it.

Is this just coming from your experience with one employer's plan?

 

[jay2242]

@holl Most likely no. I have never had this apply to my insurance.

 

[mountaintrip98]

@holl We can't answer that question because we don't know your plan design. None of the self-insured plans my company offers do, but some large self-insured plans do. Or have it cross-apply in both directions.