Most insurances have a yearly out-of-pocket maximum. That means in any given year, the maximum you will pay for all covered medical costs is a number ranging from $500 to $15,000 (for high deductible plans). Look in your benefits document for your number. There are some special cases:
- First, your insurance company has to approve the treatment. Some procedures such as MRIs and PET scans require pre-approval. They may deny the procedure if their doctors do not think you need it. If you get denied and lose a subsequent appeal, you still have the option of paying for the procedure yourself.
- Second is the case of balance billing or out-of-network providers and facilities. Be sure to use a doctor and hospital network that is in-network to reduce your chance of being balance billed.
- Out-of-pocket maximums may not apply for types of services not originally covered by insurance, such as: investigational drugs and procedures, and certain drugs used off-label, meaning for problems the drug was not originally intended to treat. Other items not covered by health insurance include clinical trial drugs, family planning, and weight management.
The out-of-pocket maximum protects you, in that you will never have to pay more than your out-of-pocket maximum, regardless of what the provider and hospital bills (given the exceptions above).
Medicare is the only insurance that does not have an out-of-pocket maximum. That is very dangerous for elderly patients who have cancer or other high-cost procedures. It is recommended to buy a Medigap policy, or a Medicare Advantage plan that does have an out-of-pocket maximum.
