Question about Health Insurance Out of Pocket Maximum?
We have a health insurance plan (Aetna) with in-network and out-of-network benefits. My husband had some medical expenses at an out of network facility (Mayo Clinic). Our OON Out of pocket maximum is supposed to be 00 annually, with 50% coinsurance. However, Mayo keeps sending us statements showing we owe them around K after insurance!!!! In the mean time, we have been making payments towards that amount. I keep going back and forth between Aetna and Mayo and each one blames the other for the overage, yet neither will make a correction. It seems we are getting caught in the middle. Am I misunderstanding how out of pocket maximums work or are they both jerking me around?
Tagged with: Aetna • coinsurance • health insurance • health insurance plan • insurance • mayo clinic • mean time • medical expenses • oon • pocket maximums
Filed under: Medical Health Insurance Plans
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You can easily check your minimal health care rates in internet, for example here – healthquotes.awardspace.info
There could be a few different reasons.
We can probably rule out a lifetime cap. From your description, I assume these expenses happened recently and lasted only for a short time. If this is a chronic condition that has run up the bills for some time, that could be what’s happening.
The other common trigger for overage is out of network, but it sounds like you have a cap for that as well.
So the most likely candidate is fees and services that weren’t covered. Some tips on figuring this out come from the insurance rep at a large hospital. It will take some time, and as you have discovered isn’t easy. Be sure to be polite. These are people who don’t have any power over your situation, and being polite to them will help them go the extra mile.
Try the hospital billing department again. Instead of finding out where the overage is, try to find out who handled your account and have them review what they reported to your insurance company. Then, with your insurance company, call them and ask them what you or the hospital can do to make certain charges covered by your plan. You’ll need to be very patient, but ask for clarification whenever there is something you don’t understand. They are not paid to help you find out how to get money from them, however they are legally bound to answer the proper questions. You’ll just have to keep poking and prodding to get to what you need to ask.
If all else fails, check with the hospital billing department and see if you qualify for financial assistance.
If out of plan expenses are partially to blame, and you still have more doctor visits coming up, you can also set up your insurance to be in-plan benefits with authorization for better coverage. You’ll need to check with the doctor you have any appointments with and make sure they know that they need to authorize for in-plan benefits. If they are good and on top of it, they’ll already know. And you’ll want to double check and confirm that the insurance company has made the change. This can help you better benefits covered by your plan.