I just got my daughter’s January EOB, and I realized that my family is now responsible for up to $14,300 in out-of-pocket (OOP) expenses. Why did this amount go up $600, even though we kept our same insurance? And how can I afford this?!? HELP!
Anxious about OOPs
High OOP maximums are a concern for many in the bleeding disorders community. To save money, most insurance plans require patients to shoulder some of the costs of their care via copayments, coinsurance, and/or deductibles. While the Affordable Care Act (ACA) limited allowable OOP charges, the law’s limits go up each year. So even if you don’t change insurance plans, your costs can increase. For 2017, OOP costs can be as high as $7,150 for an individual and $14,300 for a family.
The ACA’s OOP maximum, actually, was intended to protect patients (before passage of the ACA there was no limit on the OOP expenses that insurance plans could charge). An additional safeguard: as of 2016, no individual can be required to pay more than the self-only OOP maximum, even if they are in a family plan. So once your daughter reaches her individual OOP limit for the year, no more OOP charges will apply to her (covered, in-network) care even if your family does not reach the $14,300 family maximum.
So what can you do about these (still high) OOP requirements? If you are insured by an ACA/Exchange insurance plan, check to see if you are entitled to cost-sharing reductions. Depending on your income level and your insurance plan, you may qualify for subsidies that lower your OOP costs over the policy period.
Also (regardless of whether you have an Exchange plan or employer-sponsored insurance), there are many Patient Assistance Programs that can help with OOP payments. HFA updates this list every month, so be sure to check back often.
Finally, some states have passed or are pursuing laws that (a) cap monthly co-pays for specialty tier drugs, or (b) require insurance companies to spread OOP payments out over the course of the year, rather than collecting them all at once. Check with HFA’s advocacy team or view our Legislative Action Center to see if your state has passed or is considering such legislation.
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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.
 The thinking was that individuals and families would be able to budget for OOP costs over the course of a year. Unfortunately, a person with a bleeding disorder can easily incur OOP charges up to the full maximum in the first month of the year.