Dear Addy: Out-Of-Pocket Maximums

Dear Addy_outofpocketmax

Dear Addy:
I see that my out-of-pocket maximums have gone up this year to $6,600 for an individual and $13,200 for my family. How am I supposed to afford this? With one severe bleed, between hospital stay, medication, and follow-up visits, we could reach this limit within a single month.
Sonya, Hemophilia A patient & Hemo Mom
Dear Sonya,
This is a question many people are asking, especially those with chronic diseases. Before the Patient Protection and Affordable Care Act (ACA) set annual limits on out-of-pocket expenses for health care there were no set limits. So you could say we are all better off now by having the limits we have. The thinking behind limiting out-of-pocket costs is that individual and families could budget for potentially incurring the full limit over the course of a year. Unfortunately, there is the potential for someone with a bleeding disorder to incur the full out-of-pocket limit in one month.
So what to do? Planning is critical. Review your health insurance policy carefully at each open enrollment period. You may find it better to pay a higher monthly premium to spread costs out over the year than to have a hefty deductible and have the deductible cost come due all at once, for example. See my posts on open enrollment and premiums vs. deductibles for more information.
Otherwise, if you are facing this hurdle, there are many programs that are willing to assist with payments. Check out HFA’s list of Patient Assistance Programs. We update this page every month, so be sure to check back often.
Also, in some states advocates are pushing bills in state legislatures that require insurance companies to spread out-of-pocket costs within the annual limits out over the course of the year. While monthly costs may still be high for many, the total sum will not be due immediately. Many states are also pursuing legislation that caps co-pays in various ways. Check with our advocacy team to see if advocates in your state are promoting such bills.

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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.