Obamacare Out of Pocket Limit

The new and improved health insurance plans promised to make “medical bankruptcy” essentially a thing of the past. Your Obamacare out of pocket limit was supposed to protect consumers from large medical bills.  obamacare out of pocket limit

Only the plans as conceived by Congress only addressed routine, low dollar claims such as preventive care. In doing so you are left exposed to uncovered, unpaid medical bills significantly higher than with current plan designs.

About that Obamacare out of pocket limit . . .

“This will reduce bankruptcies, but it won’t eliminate them. Until we know what the plans look like and how people are slotting themselves, we won’t know what the impact on bankruptcy will be. We know there will be some decrease but we don’t how much.”

MedPage Today

But the new plan designs were supposed to alleviate that issue.

For Americans not covered by Medicare or Medicaid, they will have two options: grandfathered and exchange health plans.

And what about the third option?

Non-exchange plans . . .

For exchange-sold plans, the maximum annual out-of-pocket cost is $6,350 per individual and $12,700 per family but those caps may reflect only part of the ACA story.

Note the distinction.

Exchange. Sold. Plans.

if the insurer uses a 3rd party prescription drug vendor such as Express Scripts to manage prescription drugs, the beneficiary may face two separate out of pocket expenses, one for medical costs and the other for prescription drugs.

Under such a scenario, after an individual or family pays their premiums and deductibles, they still could be left with a bill of $13,000 or $25,400, respectively.

Or even more.

Copay plans do NOT have an out of pocket maximum for prescription drugs. Drug copay’s do not count toward your major medical deductible nor out of pocket limits.

And these estimates only include in network claims. Out of network claims have separate deductibles, separate copay’s, and separate out of pocket maximums.

There is one other distinction to consider in reviewing Obamacare out of pocket maximums.

Your out of pocket limit only includes covered expenses.

If your prescription drug is not on the formulary, it is not covered, and not subject to copay’s or factored into your Obamacare out of pocket maximum.