As we are coming up to the open enrollment period for the various health insurance options, Prof. Bill Zame of Economics sent me an email with a cautionary note readers may want to consider. (Edited excerpt):
When insurance plans use the
term "out of pocket maximums," they do not mean what an ordinary lay
person would mean by the term. As used by the insurance industry and
the [open enrollment] plans, only healthcare
expenses that are "ordinary and necessary" (by [industry] standards) are
included toward "out of pocket maximums" and only charges that are
deemed to be in the range normally charged for services are
included toward "out of pocket maximums." If one had a treatment
that the insurance company/plan deemed "experimental," it would likely
not be covered directly and the costs incurred would not be
counted toward "out of pocket maximums." If one chose a
surgeon/hospital not in a participating provider group, the plan would
pay only a fraction ([perhaps] 40% or 50%) of what a participating provider would
charge and count only the remainder of what a participating provider
would charge toward "out of pocket maximums." This is, of course, not a
small matter; uncovered charges for treatments
deemed "experimental" or for service charges higher than those a
participating provider could charge [could be large. For example,] CT scans, MRI's, and
hospitalization charges could easily run to hundreds of thousands of
dollars.
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Open enrollment runs Oct. 28 - Nov. 26. There is a link at UC benefits concerning the various plan changes and options at http://atyourservice.ucop.edu/oe/index.html.
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