Hi!

    I just went through a situation that I'm not sure I understand so hoping I can get some guidance from the community.

    I have a plan with BCBSIL with:

    – $1,000 deductible

    – $3,000 max out-of-pocket

    I have an ER bill for which the patient responsibility is $2,500, from which:

    – $1,000 went to deductible

    – $1,500 was my coinsurance amount

    BCBSIL is saying that my max out-of-pocket amount to date is only $1,500, when I expected the amount to be $2,500 (which would include deductible + coinsurance).

    BCBSIL actually had my spending for max out-of-pocket as $2,500 but they say they'll adjust it because there was an error.

    Their explanation is that the deductible and max out-of-pocket are 2 different buckets and what you paid to reach your deductible is not included in your max out-of-pocket bucket.

    I don't see any mention of this in my policy, and from previous experience with a different insurance company, the deductible amount counts towards your max out-of-pocket.

    Any help on this would be greatly appreciated as I'm not sure if I'm wrong here or if there's a misunderstanding on BCBSIL's side.

    Deductible + max out-of-pocket question
    byu/emerinohdz inInsurance



    Posted by emerinohdz

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