> For plans purchased through employers the sky is the limit
Almost everyone with insurance has a maximum out of pocket limit now. It's possible to have a grandfathered employer health plan, but they'd have to have been running it since 2010 without substantial changes since then, including in benefits or cost increases. There are very few employer health insurance plans that would have met that criteria, and even fewer who tried to.
They also have to directly inform you that you're on a grandfathered plan, so it should not be a mystery to those who somehow are.
> Almost everyone with insurance has a maximum out of pocket limit now.
"maximum out of pocket" does not mean what any normal person would interpret it to mean. More than one year I have had to pay way more than the "maximum out of pocket".
The insurance company gets to decide unilaterally how much of what you pay out of pocket is credited toward their tally of what you supposedly paid out of pocket. In several years I've paid a lot more out of pocket than what the insurance statement credits me for having paid.
Why? Can you give me an example here, particularly as it relates to a medically necessary surgery or procedure? Or does it come down to difference in interpretation of what is medically necessary?
I don't have a specific example handy, it's been a few years.
How it works is that blue shield (with employers I've typically always had blue shield in California) sends a statement saying your doctor visit cost $XXXX, blue shield will pay $YYY and this will credit $ZZZ towards your annual out of pocket total.
But $XXXX - $YYY > $ZZZ, so what I actually had to pay to the doctor was more than blue shield credits me for having paid. So at the end of the year what I've actually had to pay has been well above the so-called "out of pocket maximum".
It doesn't happen most years (to me), but has happened on multiple years.
Based on the providers contract with Blue Shield, you should not be liable for anything beyond what they consider to be your out of pocket cost. If they requested more, you could have just refused to pay it, and get your insurance involved if they pushed back.
Labs that don't have a clear medical justification are probably easy to end up paying for out of pocket without getting the amount counted against the out of pocket insurance limit.
Would expect that to be clearly delineated on the bills though.
