Out-of-Pocket Maximum Explained

Medical bills can be a huge source of stress. They can seem like they are never ending, but there is actually a limit on how much you can spend on out-of-pocket healthcare costs. The out-of-pocket maximum, which is the annual limit that you are required to pay for covered health services, is your financial saving grace. Each health insurance plan has different out-of-pocket maximums. Understanding yours will help you get a better handle on how much you will be paying out-of-pocket with your policy. 

What Is an Out-of-Pocket Maximum?caucasian mans hand pointing at the end of a br that says maximum

An out-of-pocket maximum is the amount that you will have to pay for covered health services. Once you reach that amount, your insurance will pay for all covered services. All copayments, deductibles, and coinsurance count towards your out-of-pocket maximum. However, your  monthly premium payments do not go towards your out-of-pocket maximum. 

How It Works

If you need a medical procedure, generally you and your  insurance company will each pay a portion of the cost. You will pay enough to meet your annual deductible, and your insurance company will pay for the rest of the procedure, unless you have to pay coinsurance as part of your policy. If your plan does require you to pay coinsurance then you will also have to pay 20% (usually) of the cost of the procedure, even after meeting your deductible.

After you have met your deductible, you will continue to pay copays and coinsurance until you meet your out-of-pocket maximum. After you meet your maximum, insurance will then pay 100% of any medical costs. You will not have to pay for copays or coinsurance after meeting your maximum. 

calculator on paper with a pen sitting on top of it in the paper.
After you have met your deductible, you will continue to pay copays and coinsurance until you meet your out-of-pocket maximum.

Here’s an example to illustrate how out-of-pocket maximums work. Let’s say Mary has a health insurance plan with a $2,000 deductible, a 20% coinsurance requirement for all care after meeting the deductible, and a $5,000 out-of-pocket maximum. She has to have surgery and the total hospital bill is $20,000. The costs will break down like this:

  • Mary will pay her $2,000 deductible, leaving $18,000 of the bill. 
  • Her coinsurance requirement is 20% of the $18,000, which is $5400. But because Mary’s plan has an out-of-pocket maximum, she and her insurance company will end up each paying part of this cost.
  • Mary has already paid $2,000 to meet her deductible, and her out-of-pocket maximum is $5,000 so instead of owing $5,400 in coinsurance payments, she only owes $3,000 ($2,000 deductible + $3,000 coinsurance = $5,000 maximum out-of-pocket payment). 
  • Her insurance company will now cover the remaining $13,000 of the cost of the procedure.

Do All Plans Have a Maximum?

All plans that meet ACA standards have out-of-pocket maximums. For 2020, that number is $8,2000 for individuals and $16,400 for families. Some plans may have a lower maximum, but none will be higher than those amounts. Plans with higher monthly premiums generally have lower out-of-pocket maximums, while plans with  lower monthly premium plans, like  catastrophic or high-deductible health plans, have higher out-of-pocket maximums. 

In order to find the right plan for your needs and budget, you have to take into account everything that it has to offer, including things like out-of-pocket maximums. Doing all the research alone is time-consuming and can cause confusion and missed opportunities. EZ will make the process quick and painless; we’ll explain everything clearly, give you real-world examples of how the plan would work for you, compare quotes, and calculate costs for you. We will set you up with one agent that will help you find the right plan for your medical and financial needs. To start saving, enter your zip code in the bar above, or to speak to one of our licensed agents, call 888-350-1890.

Qualify For A Special Enrollment Period? Find Out What Documents You Need

The Affordable Care Act (ACA) changed a lot of things about the way healthcare works in the U.S. One of the changes it made was to create an open enrollment period for everyone shopping for a health insurance policy on the Marketplace. In most cases, you can only enroll in a health insurance plan, or change your plan, during this period, which runs from November 1 to December 15. If you miss open enrollment, then you cannot enroll in a plan, unless you have what is known as a qualifying life event. Experiencing one of these life events opens up a Special Enrollment Period (SEP) for you, meaning that you will be able to sign up for a new plan. Different types of qualifying life events require you to produce different documentation proving your eligibility for a SEP.

Qualifying Life Events

illustration of people moving with a truck and boxes and people carrying boxes.
One of the qualifying life events is moving to another county or state.

A Special Enrollment Period is only available to those who have a qualifying life event, including:

  • Change in residence (moving to different zip code or county)
  • Change in household size (having a baby or adopting a child, getting married, or getting divorced.)
  • Loss of health insurance (losing employment, turning 26 and getting kicked off of a parent’s plan, or death in the family.)
  • Changes in income

The Different Documents Required

If you lose health insurance or need a new plan, and you want to use a Special Enrollment Period to shop for a new plan, you will generally be notified of what documents are needed in your Eligibility Results Notice. You will then have 30 days to submit these documents by mail or by uploading them to healthcare.gov. There are different forms of documentation required depending on the life event.

For change in residence you will need to have moved in the past 60 days and have had health insurance at least one day in the 60 days before your move. To prove this, you will need to submit:

  1. Documents proving that you moved, such as rental agreements, mortgage bills, or utility bills, as well as documents proving your new address and the date of your move.
  2. Documents proving you had insurance prior to your move, such as a letter from an insurance company or employer.

For change in household size you will need:

  1. Legal or government-issued documents of an adoption or a birth certificate
  2. Marriage license or certificate.
  3. Divorce certificate.

For loss of health insurance you must show that you had qualifying health insurance coverage in the past 60 days and that you will be losing coverage in the next 60 days. You will need:

  1. A letter from your insurance company showing termination date.
  2. A loss of health insurance coverage letter from your employer.

For change in income, you will need:

w2 form

  1. Proof of a reduction in income which makes your current plan unaffordable for you, such as a past and current paycheck or W-2 forms.

Special Enrollment Period Coverage

After you submit your documentation and prove that you qualify for a Special Enrollment Period, you can get on the Marketplace and pick a health insurance plan. Coverage for your new plan will either begin the first day of the month after you pick your plan or the first day of the second month after you pick your plan, depending on the qualifying life event. Some types of coverage will be active sooner than others; for example, if you have a baby or adopt a child, coverage is retroactive to the date of the birth or adoption, as long as you pick a plan within 60 days.

Need Help?

If you still have questions on how this all works, contact one of our agents. Our highly trained agents will take the time to talk with you, and will go over all of your documents for you as well as thoroughly explain all of your options. Once you are ready to enroll, they will search through all the plans in your area and find the right plan for you, making sure the plan fits your needs and budget. EZ always provides you with your own personal agent, so there’s never any need to worry about bouncing around from agent to agent or getting hassled by endless sales calls. To get started, enter your zip code in the bar above, or to speak to an agent directly, call 888-350-1890.

Can You Get Health Insurance at Any Time?

If you are unhappy with your current health insurance policy, then it might be time to shop for a different plan. But can you purchase a new plan at any time? Yes, and no. For marketplace plans, once the open enrollment period (November 10 to December 15) is over, you generally cannot get a new plan. The open enrollment period for employer-based insurance might be at a different time of year, but you will still only be able to change your plan during that enrollment period. In most cases, if you want to get health insurance or change your plan outside of the open enrollment period, you will need to qualify for a Special Enrollment Period (SEP). SEPs open up when you experience what is known as a qualifying life event. 

Qualifying Life Events

caucasian couple hlding a baby girl in the middle while both are kissing each cheek
You can get health insurance outside of open enrollment if you qualify for SEP such as getting married or having a baby.

You have 60 days to change your plan if you:

  • Got married
  • Had a baby, adopted a child, or took in a foster child
  • Got divorced or legally separated. However, if you do not lose coverage due to divorce or legal separation, then you do not qualify for a Special Enrollment Period.
  • Had someone on your marketplace plan die
  • Changed residence. If you move to a new home in a new ZIP code or county, move to attend school, are a seasonal worker and move between job and home, or move from a shelter or other transitional housing to a permanent residence, you will qualify for an SEP.
  • Lost your health insurance. This includes losing job-based coverage, losing a plan you bought yourself, losing eligibility for Medicaid or Medicare, and losing coverage through a family member.
  • Gained membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
  • Became newly eligible for Marketplace coverage because you became a U.S. citizen
  • Left incarceration
  • Started or ended service as an AmeriCorps State and National, VISTA, or NCCC member

Short-Term Medical Plans

If you do not qualify for any of the life events listed above, all hope is not lost. You can enroll in a short-term medical plan. Short-term health insurance provides fast, flexible insurance with many benefits. These plans can be extended up to 3 years, and you can pick your deductible amount from many options. You are also able to drop coverage without a penalty if you want to change to a long term insurance option. Premiums are lower than ACA health insurance plans, and you get coverage as soon as a day after applying.

short-term health insurance form on a clipboard

It is important to understand that short-term insurance is temporary and not ideal for those who require more comprehensive coverage or have health conditions. Short term plans are not guaranteed-issue, meaning they do not cover pre-existing conditions. They only cover the basics.

Do you qualify for a special enrollment period? If not, are you considering a short-term health insurance plan to hold you over until open enrollment begins? EZ.Insure can help. We offer accurate health insurance quotes based on your specific region, free of charge. That’s right. We will provide you with an agent who will compare all available plans for you, and help you choose a health insurance plan that is based on your health needs and budget, for free. To get your free quotes, simply enter your zip code in the bar above, or to speak to an agent, call 888-350-1890.

Self-Employed? Here’s Your Guide To Getting Health Insurance

Nothing beats being your own boss! If you are self-employed, then you are probably wondering about your health insurance options. Don’t worry, you do not have to break the bank to get a plan for yourself. There are many affordable options.

silhouette of a man looking at a blackboard with 3 arrows pointing in different directions
When you are self-employed, you have different options for health insurance.

Health Insurance Coverage Options

Let’s talk about the options of health insurance for the self-employed. There are different routes to go when looking for the right plan.

  • Marketplace– If you work as a freelancer, run your own business, or self-employed without employees, then you qualify for the Individual Marketplace. There are a variety of different plans you can choose from, but you can only enroll during the annual Open Enrollment Period, unless you have a qualifying life event. When you fill out an application, you will find out if you qualify for premium tax credits and other savings, which we will further elaborate on later. 
  • Private Insurance– Private insurance has plans that provide good coverage at an affordable rate. Private insurance companies have many plans to choose from with a variety of coverage and costs. You can find a plan tailored to your needs and budget.
  • SHOP Marketplace– If you own a business and are looking for coverage for yourself, a spouse, or have an employee, then Small Business Health Options Program (SHOP) Marketplace is the way to go. Enrolling in a SHOP plan offers small business or non-profit a Small Business Health Care Tax Credit.

Marketplace Savingsafrican american hands holding a small white piggy bank

Now back to those savings we talked about earlier. When you fill out a health insurance Marketplace application, you will estimate your net self-employment income. The premium tax credit or reduction qualifications rely on the year you’re getting coverage, not the prior year’s income. You will have to estimate your household income for the year and submit it. During the year, you can change your estimated income if the income changes. 

If you qualify for the tax credit, you are allowed to deduct 100% of your health insurance premiums for your adjusted gross income every year. 

Tips On Choosing A Plan

caucasian woman n a sundress with a laptop on her lap and a notebook on the seat next to her.
Before choosing a plan, make sure to do some research, so you pick the best plan for your situation.

There are a lot of different plans you can choose from, both on the marketplace and through private health insurance companies. You can choose a high deductible plan with lower monthly premiums, and benefit from an HSA account. You can choose a low deductible plan with higher monthly premiums, or even a catastrophic plan. Whichever you choose, make sure to compare plans to choose the one that meets your needs and budget. 

Comparing plans and their prices can take a long time, and can be frustrating. The most important tip when choosing a health insurance plan is getting expert advice from an insurance agent. EZ.Insure offers highly trained and knowledgeable agents all around the U.S. that specialize in their region. You can speak to one of our agents, and they will do all the comparing of available plans for you and provide you with the quotes. It comes at no cost to you, which is a win! You get free help, and get directed in the right path to save money, double win! To speak to an agent by emailing [email protected], or calling 888-998-2027. No gimmicks, no hassle, and no cost. Just simple, free health insurance quotes.

Turning 26? Your Guide To Getting Health Insurance

The time has come. You made it to 26 with health insurance coverage through your parents. But now your birthday is approaching  and are getting kicked off your parent’s health insurance plan. You may be wondering if you can stay on your parents’ health insurance longer. The answer to this is, unfortunately, no. You will get kicked off the plan at

Birthday cake with canles "26" on it lit.
When you turn 26 years old, tjere is a deadline for your hralth insurance. You will have to get your own plan.

either the end of the month that you turn 26, or at the end of the year.  Its inevitable, but where do you start?

The Options

If you are employed, then you can join your company’s health insurance plan if they have one. Another option is to hop on your spouse’s health plan if you are married. If none of these options apply to you, then your only choice is to get your own health insurance plan. Those options are:

 

  • Long-term Plans

 

When you turn 26, you qualify for a special enrollment period for Obamacare, also known as the Affordable Care Act (ACA). You also have the option of getting private insurance in which licensed health insurance agents are able to create a policy that is unique to your specific needs using a full spectrum of different insurance companies. It is important to shop around because these plans are sometimes cheaper than the marketplace insurance plans. Long-term plans offer more comprehensive coverage. These plans help manage day to day expenses and are convenient for those that require routine medical work, such as medication, lab work, and inpatient/outpatient services. Major medical health insurance complies with the ACA requirements which means it provides the ten essential health benefits.

Essentially, when you are over 26 years old and are no longer on your parent’s plan, then a major medical plan is best if you are looking for coverage of pre-existing conditions, and need routine medical work , such as medication,

Two signs that say short-term and long-term on them pointing in different directions.
The two options for health insurance are short-term and long-term. Short term plans do not cover pre-existing conditions, only the basics.  If you need comprehensive coverage, long-term is best.

lab work, and inpatient and outpatient services. Major medical health insurance complies with the ACA requirements which means it provides the ten essential health benefits. These ten essential benefits are: ambulatory patient services, prescription drugs, emergency care, mental health services, hospitalization, rehabilitative services, preventative and wellness services, laboratory services, pediatric care, and maternity and newborn care.

 

  • Short-Term Plans

 

Unlike long-term plans, their short-term counterparts do not need a qualifying life event to enroll. Short term health insurance provides fast, flexible insurance with many benefits. These plans can be extended up to 3 years, and you can pick your deductible amount from many options. You are also able to drop coverage without a penalty if you want to change to a long term insurance option. Premiums are lower than ACA health insurance plans, and you get coverage as soon as a day after applying.

It is important to understand that short-term insurance is temporary and not ideal for those who require more comprehensive coverage or have health conditions. Short term plans are not guaranteed issue, meaning they do not cover pre-existing conditions. They only cover the basics. 

When you consider purchasing health insurance, you have to think about how much you want to pay, the coverage provided, and which term length is best for you. It can be quite overwhelming when you embark on this new journey. EZ.Insure can help. We will provide you with a highly trained agent within your area that can provide you quotes and plans from all the different health insurance companies in your region. To get started, enter your zip code in the bar above. Or to speak to an agent call 888-350-1890, or email [email protected]. We will go over everything with you and help you decide if this plan best suits your needs. If it does not, then we will direct you to other plans.

Speak with an agent today!
Get Quotes