MaxCapOne cool thing about my medical insurance policy is that whenever the annual out-of-pocket maximum for the calendar year is not met, the amount counted toward the lifetime benefit maximum resets to zero.

I’ve never met the maximum.  I don’t want to.

Most of my life it has been easy to avoid Max.  I was hoping to continue the trend, but I’m afraid that maybe our time has come.  Based on my last EOB, I’m $90 from my annual out-of-pocket maximum.

In truth, I’m closer than that since I don’t have EOBs for my last two trips to the lab and will need additional bloodwork in December.  My share of labwork (obviously) depends on which tests are ordered.  A couple times it’s only been $7; once it was $37 (and once my 20% of the cost was nearly $300 (gulp) but those tests shouldn’t have to be repeated).  All this means that with labs alone, I might be able to avoid Max.

But I was measured for custom orthotics, which cost $400.  My share will be $80, and that (combined with three trips to the lab) will put me over the annual limit.

This presents a problem.  Once I’ve exceeded the annual out-of-pocket maximum, insurance looks at how much they’ve paid on my behalf and accrues money toward my lifetime benefits limit.  While I understand that from a business standpoint, it makes sense to limit how much money the insurance company will spend on any one person, when we’re talking about the cost of taking care of my health – making it possible for me to walk, breath, and take care of my family, it terrifies me to think that at some point the insurance company could refuse to pay even one more cent.


2 thoughts on “Max

  1. And that’s why health care insurance reform is so desperately needed. No one should ever be forced to face disease, disablement and pain without hope of help. Most of us could never afford, in our wildest dreams, the outrageously expensive tests, drugs and appliances for RA (and other autoimmune diseases) which make our lives liveable. No one should be forced into poverty because of illness. But that’s what many of us face with our current health care system.

    I hope that serious reform comes soon.

  2. I know our system in Canada is a bit different than yours, but that fear of being without the care, or in my case the medication, we need rings true for me. I’m not certain I’ll always be able to access Enbrel, or any other medications that work for me. It’s something I’ll always have to think about when I plan for my future.

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