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I have individual health insurance and have met my out-of-pocket maximum due to a surgery earlier this year.

I saw my (in-network) PCP this week and was still charged the regular $30 copay. Should that have been waived, will I get a check back, or does it not matter that I've met the "maximum" and still have copays for covered expenses?

Chris W. Rea
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Gary
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3 Answers3

15

Your best bet is to call your insurance provider and ask. Typically copays do not count towards the deductible but do count towards the Out Of Pocket Max. It's probably the case that the PCP does not know that you hit your OOP max and charged the copay as your insurance card instructs. I expect you will receive a reimbursement check from your insurance company, or from the PCP if the insurance reimburses them directly.

TTT
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Generally speaking, under an standard Obamacare plan, you should not have to pay any copays or coinsurance on any essential benefits once you have met your out-of-pocket maximum (Obamacarefacts.com).

In practice, however, there are a few complicating factors:

  1. Did the money you spend so far count towards your out-of-pocket maximum? If you payed for uncovered out-of-network care, or other non essential benefits, your insurance company may not count that towards your maximum out of pocket expenses.
  2. Have all the claims been processed? While you often pay your co-pay at the time of service, the insurance claims process is much slower. Your insurance company may not have caught up with all of your bills, and so have not yet calculated your total out-of-pocket costs so far.
  3. Is your insurance company making a mistake? Be sure to review your EOBs and bills and make sure everything seems to match up and make sense according to your insurance contract. Insurance companies can make mistakes, and those mistakes usually aren't in your favor (at least that is my personal experience). Keep an eye out for possible mistakes, and call your insurance company if you think you have found one.
  4. Even if your insurance company doesn't think you owe a co-pay, your doctor doesn't know that: Your doctor's office probably just bills whatever co-pay they see written on your card. It is unlikely that they can tell that you already met your maximum-out-of-pocket until the claim is processed by your insurance company. If you know you met your maximum-out-of-pocket already, just explain that to the receptionist (or whoever does the billing) when they ask you for your co-pay.

As for unnecessary co-pays you already payed: In my experience, the insurance company will pay the claim without applying a co-pay, and leave it up to the doctor to refund your co-pay. However, you should call your insurance company to verify this. If they do tell you to get a refund from your doctors office, wait until you get the EOB for the vist (which should show you owe no copay) and bring it in to your doctor's office when you ask for a refund.

lzam
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Many of these Dr offices are corporate run. They take the copay not recognizing or demanding you pay it and will get reimbursed when your insurance company pays out. Doing this to multiple people with different copay amounts adds up. They hold this money in a high yield savings account and make a profit iff the money before returning it to you. We, as consumers, pay a lot of money for insurance. There should be protections in place to prevent corporations from doing this.

Carol Neiberger
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