So I saw the question you recently answered about what counts towards a deductible. You didn’t talk about what counts towards out-of-pocket costs. Does every penny I spend on healthcare count towards my out-of-pocket costs limit?
No, not every penny you spend on healthcare will count towards your annual maximum out-of-pocket costs.
Like you, health insurers want to limit their annual costs towards your healthcare. To do this they may not count certain costs towards your annual out-of-pocket maximum. Monthly premiums never count towards your maximum so don’t factor these into any calculations of your annual out-of-pocket cost maximum. Copayments, coinsurance, and deductible payment traditionally counted towards out of pocket costs but not anymore.
To save money and share more of the cost burden with patients, insurers may not count certain costs, like copayments, towards your out-of-pocket limit. For example, you can reach your annual out-of-pocket maximum through deductible and coinsurance payments but still have to make copayments for services and medication if copayments do not count towards your annual out-of-pocket maximum.
For people with bleeding disorders, be sure to watch out for insurers who separate out-of-pocket costs for medication from all other out-of-pocket costs. You might reach your annual out-of-pocket maximum for medication but will still have to cover your agreed-upon portion of non-drug costs until that maximum also is met.
To protect yourself and your budget, read your policy carefully and ask your insurer questions about what counts towards your maximum out-of-pocket costs.
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.