Explain it like I’m five-OOP MAX/deductibles

[tom_the_doubter]

Someone explain this to me like I’m five because I’m not understanding.

For context:
-Insurance is UMR
-My plan year runs from July 1-June 30
-OOP Max for family is 6,000 and deductible is 1450 for Tier 3 benefits - 65/35. Had to go w/Tier 3 because we moved in the middle of my pregnancy and I refused to switch doctors. I received prior authorization, though.

I had my daughter in Oct 2022. After it was all said and done I owed 5,498 to the hospital, then I received another bill related to her birth for $566.

In early June of 2023 she has to have a surgery. Most of it was covered but I received a bill for 1,261 and another for 84 and some change. It was in network so Tier 1 benefits.

So my question, didn’t I meet my OOP max with my daughter’s birth? Why am I having to pay anything for the surgery? Maybe I’m just confused someone please help!

 

[ttebayo]

@tom_the_doubter You should ask your insurance

And look at the EOB documents

 

[samuelc]

@ttebayo This is key. It doesn't matter what "bills" you get from the hospital. You have to log into your insurance portal, find those claims, and download the PDF of the EOB (explanation of benefits) for each one. That is a statement from your insurance that tells you exactly how much they allowed after discount, how much they paid, how much you owe, and how much was applied to deductible.

 

[curtisptrsn]

@ttebayo Your EOBs might also explictly tell you how much of your deductibles and OOP maxes you've used so far, which would be good information to have in deciphering this situation.

 

[greatbuss]

@tom_the_doubter I had a plan once where my plan year ran from July 1-June 30th, but my deductible/OOP still ran from Jan 1-Dec 31st. Super annoying and confused everyone. I changed plans on July 1st and my ded increased from 2000 to 3000. I had already met 1500, so I just had to meet an additional 1500 between July-December. So maybe it’s something like that?

 

[tigggertat]

@tom_the_doubter So, is that $1450 YOUR deductible or YOUR FAMILY deductible. If the former, you may want to reach out to your health insurer for some clarity, but I suspect that it’s a $1450 individual deductible and a separate family deductible .

So, for YOU, you should have had no more OOP costs. You met your individual deductible AND your out of pocket maximum. However, your family deductible likely hasn’t been met which means that your daughter would also have to meet her $1450 deductible as well.

 

[deanerenata32]

@tom_the_doubter Your daughter is a separate person from you when it comes to insurance; so you will each have your own deductibles and OOP’s.

Family deductibles and family OOPs are usually set at 2x-2.5x an individual rate….one single person can never exceed their own deductible and OOP, but in a family of 3 or 4, only 2 people have to do the real “work” for the rest of the family to benefit.

My guess is part of the bills you paid for the birth went to your daughter’s deductible. The surgery satisfied the rest of her deductible, but she has not met her own individual OOP yet.

 

[jander8629]

@tom_the_doubter Did you apply for hospital charity care? That would help with the June 2023 surgery. You MAY be able to get them to consider the delivery with good cause, like having a kid imo might apply.

 

[mooneyto]

@tom_the_doubter My tier one and tier two deductibles are wildly different. I have $500 for tier 1, and $1500 for the tier 2.

 

[curtisptrsn]

@tom_the_doubter It's possible that Tier 3 costs don't count toward the Tier 1 OOP Max. So even though you satisfied the Tier 3 OOP Max and wouldn't pay anymore for Tier 3, you were still allowed to pay for Tier 1 services. This seems counterintuitive... but I think it's possible

 

[sheisme55t]

@tom_the_doubter Simply put, your deductible and oops max renew when your benefits renew. This is not a one time thing, its a yearly renewal. So if your benefit year is July 1 to June 30, every July 1 it resets to 0. If you have benefit limits, like 10 chiropractic adjustments per year, they would also reset. Some plans have a 4th quarter deductible carry over. Where whatever applied to the deductible in Q4 of your benefit year can be carried to the next year. But this might not apply to you.