Check out this example that was provided to us:
| Example is for one individual only. | |
| Current Non-Network Plan | |
| Non-Network doctor charges | $40,000 |
| Insurance pays 70% | $28,000 |
| Balance Due | $12,000 |
| Employee responsible for 30% up to $4,000 maximum out-of-pocket amount | $4,000 |
| Insurance now pays additional balance at 100% due to out-of-pocket maximum | $8,000 |
| Total Insurance Pays | $36,000 |
| Total Employee Pays | $4,000 |
| ___________________________________________________________ | |
| New Non-Network Plan Effective September 1, 2009 | |
| Non-Network doctor charges | $40,000 |
| Adjusted amount that insurance will accept (In-Network ACR Amount) | $30,000 |
| Insurance pays 70% of In-Network ACR amount | $21,000 |
| Balance of ACR Amount Due | $9,000 |
| Employee responsible for 30% of ACR amount up to $4,000 maximum out-of-pocket amount | $4,000 |
| Insurance now pays additional balance of ACR at 100% due to out-of-pocket maximum | $5,000 |
| Plus employee is responsible for total amount over ACR ($40,000 - $30,000) | $10,000 |
| Total Insurance Pays | $26,000 |
| Total Employee Pays (Amount over ACR Plus Out-Of-Pocket) | $14,000 |
So in this scenario presented above - under the current plan, on a $40k bill we would have to pay $4,000 (which would be out out-of-pocket maximum). This is what we had been planning for ever since we found out about the baby's medical condition and the surgeries she will need.
But under the new plan effective 9-1-09 for that same $40k bill we would have to pay $14,000. However, keep in mind that $10k of that does not apply to anything and if she was to have another $40k bill (which is VERY likely if she has another surgery) we would then need to pay ANOTHER $10k and this could go on as many times as billed for that calendar year. Then come January 1, 2010 it would all start up again and if she had another expensive "issue" it would be ANOTHER $14k because we would need to pay that $4,000 out of pocket maximum again.
I have to tell you that the term "Out-Of-Pocket Maximum" seems so stupid now considering IT IS NOT THE MAXIMUM we would pay - it is only the beginning of what we will be expected to pay. I'm sorry, I just think this is complete bullshit and the more I write the more pissed off I get. I think it is horrible that hard working families can be put in a situation like this when we have done nothing wrong. We seriously live such a modest life in an effort to have me stay home and be the primary care giver to our children - we don't have cable, get the newspaper, we RARELY ever go out to eat, we don't buy unnecessary things - we have tried to do it right so that we can provide for our children now and in the future and then something like this happens. No one plans to have an ill child and I think it is seriously unfair that this situation is going to so drastically change our financial future and the even shittier thing is there is really nothing we can do.
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