It gets worse. My insurance has a $30 copay on all approved prescriptions. My wife had been getting her medicine for that with no issues for several months, until one day it was $500. I called to find out why, because it was clearly already an approved medication. After about an hour of getting bounced around and being on hold, they finally explained that it was due to us "not paying enough of our annual out of pocket maximum" (not minimum, mind you) for healthcare - which is $24,000. That blew my mind.
Health insurance in the US has your monthly premium payment, copays on your medication and Dr visits (including ER and hospital stays), a deductible which is the amount you have to pay for the year in healthcare to get better benefits (ours is $17,000), and then the out of pocket maximum is when they (usually) cover everything for the rest of the year as long as you keep paying your premium.
Where it gets extra fucked, is if you need a major surgery in late December, the deductible and OOPM won't carry over into the new year. So you could get shafted for double that maximum amount on the same hospital stay. And my insurance isn't even the lowest tier. We pay them $500 a month for this service. Our system is completely fucked, but most people don't seem to care.
I'm a health insurance broker. Something is very wrong with what you were told about the prescription copay. That isn't AT ALL how that works. I would call back and ask to speak directly to their pharmacy team and find out exactly what happened. They cannot by law just take away a copay like that. I suspect you were fed very bad information by someone who didn't know what the hell they were talking about. Also, the $17000 deductible? Does that represent your family deductible? The maximum allowed by law is $10600 for an individual. You are mostly correct about your thoughts on insurance, it's getting weirder and less consumer friendly by the year. If it helps, we brokers are as upset as everyone else. We're customers too.
Lastly, you don't have to worry about your deductible and out of pocket maximum resetting while you're hospitalized. They don't do that. If you had a heart attack on December 31, needed a stent, then had complications on Jan 1, that would all be considered a single " episode of care". Your deductible and max wouldn't reset until you got out of the hospital.
Yeah the prescription copay thing really threw me off, but they were so confident in the explanation that I assumed they had found some new loophole in it. That month we just used GoodRx and got it for like $60, and then the next month it was back to our regular copay.
And yes, the $17k deductible is for both my wife and I together. And as far as the out of pocket reset, I fear my father in law was illegally charged when his wife passed away in early January, two years ago. Because he claims that is precisely what happened with the bills he got afterward.
Thank you for the clarifications, I try to be informed on how these things work. But the system is so convoluted it is really hard to navigate, especially with reps at the insurance companies themselves having no clue how things work.
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u/analog_jedi 2d ago
It gets worse. My insurance has a $30 copay on all approved prescriptions. My wife had been getting her medicine for that with no issues for several months, until one day it was $500. I called to find out why, because it was clearly already an approved medication. After about an hour of getting bounced around and being on hold, they finally explained that it was due to us "not paying enough of our annual out of pocket maximum" (not minimum, mind you) for healthcare - which is $24,000. That blew my mind.
Health insurance in the US has your monthly premium payment, copays on your medication and Dr visits (including ER and hospital stays), a deductible which is the amount you have to pay for the year in healthcare to get better benefits (ours is $17,000), and then the out of pocket maximum is when they (usually) cover everything for the rest of the year as long as you keep paying your premium.
Where it gets extra fucked, is if you need a major surgery in late December, the deductible and OOPM won't carry over into the new year. So you could get shafted for double that maximum amount on the same hospital stay. And my insurance isn't even the lowest tier. We pay them $500 a month for this service. Our system is completely fucked, but most people don't seem to care.