Yes, Kim, the plans my husband has been offered are BCBS/Anthem. If we wanted to keep our current policy with BCBS, we'd have that $22.5K out of pocket max.

Thanks, Stellatum, for again pointing out that cap. It's hard to remain reasonable sometimes when we are so worried about our futures, and those of our children.

Copied and pasted from Healthcare.gov

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan

Please note the line that reads: Some health insurance or plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.

Sounds to me that the 40% co-insurance on a bronze plan may NOT be part of the cap on "out of pocket" expenses. Maybe it is---- maybe it is NOT ???

I would want confirmation that I would NEVER be paying out of MY pocket more than $6350 per year (plus my premium amounts) before I would sign up for such an ambiguous statement.

Other terminology to be wary of includes "allowed amount". Example: Your doc charges $125, your plan pays 100% of the "allowed amount" of $75. You are left to pay the $50 and it may not go toward your "out of pocket" expenses?

The post is correct. My current physicians don't have to accept medicare. My first neuro, would not see me without cash up front. The surgery was cash too. I could not get health insurance due to pre-existing conditions. ginnie

Hi Ginnie,

Which post? I have posted so much on this tread, I am not sure which one you are referring to. I am so sorry that you were not covered.

I am freaking out about all this health care confusion and wondering how my care will be impacted as time goes on. I have a GREAT policy which has skyrocketed in price but I DO have coverage. I just don't know if the shoe will drop and I may soon find myself hunting for coverage like many others and if I can afford it. In two years I will be eligible for Medicare but until then I may wind up in the water with no paddle. Even Medicare coverage may leave me in the cold. I am very upset.

Maybe I should just pocket (save) what I pay in premiums and use that to pay CASH for all my medical care. Guess that won't work either.

I may have gotten confused once again. Comment was made about doctors not having to accept medicare and or medicaid. It is very true. These Government programs donot pay very much to the docs, certainly not what their charges are. My one doctor told me he feels he must, for ethical reasons of his own. the need is great,. I so hope the new program works out and that no one will fall through the cracks like I did,not being covered at all. The pre existing medical issues dumped me out of any insurance. If the new program works, people will not have to lose all they had as I did. I am blessed to have ssdi now, but during the wait time,....well you get the picture. So many are worried and need the care right now, not four years from now. I got gang green in my gallbladder, I waited too long to get checked out because of no insurance. It could have cost my life. That is what me being stupid did, out of fear of the cost. Same with the spinal fusions, waited too long, and they wiped me out financially. I hope no one has to go through something like that ever again. We do need this program. Let's all pray they get their act together, so suffering will be a thing of the past. Ginnie

Ginnie, so sorry that happened to you. Glad you have something now but it scares me that even your Medicare coverage may not fill your needs.

Hopeless;
Prior to being on Medicare, I was covered by two different providers over a 40 year period. Both providers had provisions that they would only pay reasonable and customary charges. That meant that any provider would agree to accept that amount or refuse service if they charged more. "Or I could pay the difference."
I was never asked to pay the difference.

When I received my explanation of benefits it would state, Amount charged, 125,
amount paid by my insurance, $75, amount due, $0.

I hope, for everybody having to go through this frightening experience "allowed amount" means reasonable and customary charges and will be treated the same.

scrubbs

Hi Scrubbs,

I hope you are correct that things will remain the same. Things have changed drastically since I worked in the health insurance industry several decades ago. Under many plans, especially HMO's, PPO's, POS, etc. there are negotiated fees and providers accept the negotiated fee. U and C of long ago did not work the same way as negotiated fees of today.

When it comes to insurance industry terminology, one needs to be VERY careful to know how it is defined and exactly what it means.

Last week I received something in the mail from an insurance company with a minor change in terminology, just ONE word changed and it made a HUGE difference in the amount I would be responsible to pay out of my pocket. It was very sutle and could have easily been overlooked.

I just want people to be aware that things are not always as they appear. Even when we "think" we understand what is meant, the insurer may have a very different meaning than what meets the eye. I just want people to be careful. KNOW what you are getting and what all the terminology means before diving in.

You made a very good point but my past experience makes me wary of not knowing EXACTLY what the terminology means and how it is defined by the insurer. Different insurers may also use the same terminology but have differing definitions for the same term.

Hi Scrubbs,

It has been several decades since I worked in the health insurance industry and much has changed.

Do any insurance companies offer any coverage without a "network" being a part of it?

The reason patients are not charged the "difference" between the amount charged and the amount allowed is due to a contractual obligation made between the provider and the insurance company. This is the reason there is a difference in coverage benefits from IN network and OUT of network. Providers OUT of network are usually NOT contractually obligated to accept the "allowed" amount as payment in full. In many of these cases, the patient may be held responsible for the difference or even the entire amount charged.

I am curious to know if anyone writes policies that have NO network restrictions. Has that gone the way of the dinosaur? Like I said, I have been out of the industry for several decades and only know what my personal situation and choices have been. I am in a POS plan which has a network. Do any policies still exist where you can see ANY doctor anywhere and be covered by your insurance without varying benefits?

Hopeless;

The last 15 years prior Medicare I was member of a large group that negotiated independently what reasonable and customary charges would be. Before that, for 25 years, I was with a small group that only negotiated the cost per participant only. That was with Blue Cross - Blue Shied and it was a plan that anybody could purchase but their premium would probably be more per person than our groups negotiated premium per person.

So much confusion right now it must be mind boggling for those of you who are going through this right now. The purpose of the ACA is to promote competition and hopefully force reasonable charges on insurance companies. It's starting out so bad it's no wonder your so worried and I sure hope the website will start working and everyone will eventually benefit.

scrubbs