HTSMC: Know Your OOP

This is one in a series of tips/ideas to how to stay in the middle-class (or HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

Don’t be a fool…

know Your OOP.

It Means “Out of Pocket Maximum

And it’s the most you can spend

on healthcare each year.

What’s the Max, you ask?

Depends on your plan

$1,500, $3,000, you gotta

read your Benefits booklet!

Etch That Amount

In Your Brain…Now

The Insurers Don’t Help

It’s Up To You

To Keep Track.

So my advice is:

Don’t pay more thant you should,

Know your OOP!!!

Okay, my poetry/rap SUCKS! I just thought it would be helpful to break up the information into little chunks. Not many people know about this rule but I cannot stress enough how important it is to understand this term and take full advantage of it.

The dictionary definition of Out-of-Pocket maximum is: The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits. – From

The first step is to read your benefits booklet.  In addition to knowing your out-of-pocket maximum per year, you need to know what is included or excluded.  For example, with my HMO, prescriptions do NOT count toward this out-of-pocket maximum.

The second step is to keep track of your family and individual spending.  However even if you’re great about tracking these expenses, your amount still may not match up with the insurance company since they don’t count it until after the bill is processed, which can take weeks or months. To add to the frustration about this process, it can take a long time for your doctor or hospital to bill the insurance company.

Let’s say your out-of-pocket maximum is $1,500 per calendar year.  You’ve spent $1,000 in qualifying expenses when you’re hit with a large hospital bill. This bill is $800, which will make you go over the OOP amount.  When you get the bill, however, the insurer hasn’t processed that bill yet.  That means you have to pay the bill and then figure how to get reimbursed.

Last year, I was successful in proving that my family met the out-of-pocket maximum.  I tried tracking our medical spending in Excel but my totals never quite matched the insurance company records. Not a big surprise. Lucikly, I discover a better option.  Most insurance companies have a Claims section on their website.  This should show you all claims for everyone in your plan.  In my case, it was easy to find a list of claims and filter out those that were “pending” or “denied”. Then I export the “processed claims” data into an excel spreadsheet and went through it line-by-line to make sure that these counted toward the OOP maximum.  Then I used this information to back up my email to the insurance company.

Even though I used the company’s own documentation, their customer service representative wrote in an email that their records did not match mine.  I wasn’t going to give up.  I continued monitoring the paper trail (or online trail) of claims information and planned to contact them again.  However, before I had a chance to re-submit, I received a letter from the insurance company stating that my family had met the out-of-pocket maximum effective [date, year].  It is very important to note that the insurance company states it is the client’s responsibility to contact them when they meet their out-of-pocket maximum.  I can only assume that my email was forwarded to another person who authorized the payment.

With this letter in hand at every medical appointment, we were no longer responsible for co-pays that year. Your medical provider can also call the insurance company to verify this information but it’s easier to just show the letter.

By knowing my out-of-pocket maximum, I was able to save hundreds that year.  If you had good or bad experiences with proving you met your OOP, please share in the comments.

Final tips: Be very persistent. Do as much as you can IN WRITING. Make copies.  


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