Damocles & Max

Previously, I wrote about the possibility that I might meet Max this year.

After looking a little more closely at all the numbers, it appeared there was a chance to avoid it.  If we pay for my orthotics out of pocket, and if nothing unexpected happens in the next two months, we could barely squeak in under the limit.  Those are pretty big ifs.

There’s something comforting in knowing that the insurance company says, “Amount charged against lifetime benefit limit:  zero.”  When nothing has reduced the limit, I feel like there’s no limit.  It’s as if insurance will always be the safety net to cover anything that might occur.

I don’t feel that way any more.  There is a limit to what insurance will cover.  It’s like a huge sword hanging over my head; the smallest thing could bring it crashing down.


Would I be better off paying cash the rest of the year to avoid hitting the annual out-of-pocket maximum?  Sure, it would cost a bit right now, but in the long-run, if things get really bad, it could save me thousands of dollars.

I’ve talked to our insurance plan administrator.  Co-pays don’t count toward my annual out-of-pocket-max.  Prescription meds don’t count.  My annual deductible doesn’t count.  A lot of things don’t count.  Of the $2200 that I’ve paid out of pocket so far this year, insurance only counts $912 of that amount toward my max.

The rules change once I’ve met my out-of-pocket maximum.  When they’re looking at the benefit limit, they count every penny they’ve paid on my behalf this year.  All those numbers that didn’t count toward reaching the annual limit?  Now they matter.

I could make myself crazy trying to figure out a way to control these costs.  I could pay cash for the rest of the year to avoid having my lifetime benefit reduced by $11K.  In the end, though, I have to take this the way I decided to face RA: one day at a time.

It would take 99 more years like this one to blow through my million dollar lifetime limit.  The chances of my living another 99 years are mighty slim.  Therefore, I’ve decided that insurance will pay for the rest of this year.  I’ll enjoy the slight reprieve while insurance picks up 100% of the tab instead of just 80%.

If, someday in the future, I end up on expensive biologics (isn’t that redundant?), and have that lifetime benefit reduced even further, I’ll deal with it.  In the meantime…

Meet Max



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