I’ve hit my health max out of pocket: what can I access for “free” now?
I had surgery earlier this month, and even after the “discount,” my 20% share of the bill exceeded my max out of pocket. I’ve already spent thousands on healthcare this year, and it’s still February. I’ll also be needing physical therapy soon.
This is my first experience reaching my max out of pocket, as well as my deductible. What is now considered “free” for me? I understand that some copays, like for doctor visits, remain at $20 or whatever my card states, and dental costs are separate.
Are there any preventative services I should schedule that are typically pricey but are now fully covered since I won’t incur extra charges? I’m looking for medically important services that the U.S. healthcare system often discourages people from getting regularly—not unnecessary procedures, but essential care.
For additional context, I might be changing jobs in a couple of months, meaning my coverage will reset before the year ends, so I need to figure this out soon!
I live in New York and have a PPO plan.
Congratulations on hitting your max out-of-pocket! It sounds like you’re navigating the complexities of the healthcare system, and it can definitely be overwhelming, especially with potential changes in your job and benefits coming up.
Once you have hit your max out-of-pocket, most of your healthcare costs should be covered at 100%, including coinsurance and copayments for covered services, for the rest of the plan year. Here are some things to consider taking advantage of while you’re in this position:
Physical Therapy: Since you mentioned you’ll have physical therapy, confirm with your provider that it will be covered in full now that you’ve hit your max.
Routine Preventive Services: Check with your insurance for covered preventive services that usually have no cost-sharing, such as annual check-ups, vaccinations, and screenings (like cholesterol checks, mammograms, or colonoscopies). These are often fully covered under most plans, regardless of whether you’ve hit your out-of-pocket max, but it’s good to confirm.
Specialist Visits: Scheduling visits with any specialists you’ve been putting off (like dermatologists, cardiologists, etc.) may be beneficial. Co-pays should be waived, so you can seek any necessary evaluations or treatments without worrying about additional costs.
Mental Health Services: If you’re interested in therapy or counseling, you could schedule those visits without worrying about the costs since you’ve reached your out-of-pocket max.
Diagnostic Imaging: Procedures like MRIs, CT scans, or X-rays often come with high costs due to copays and deductibles, so if you’ve been needing any imaging, now would be a good time to get that done.
Chronic Condition Management: If you manage any chronic conditions, consider getting additional follow-ups or treatments that you may have delayed.
Annual Screenings/Tests: If you haven’t done them yet this year, consider scheduling annual screenings for blood pressure, diabetes (blood glucose), or other age-appropriate tests.
Since you’ll likely be switching jobs soon, make sure to think about the urgency of these services. Once you switch plans, your benefits will reset, so it’s good to maximize this current coverage while it lasts. Always check with your insurance for clarity on what is covered post-max out-of-pocket and whether any specific services you plan to utilize will incur costs or not. Enjoy the opportunity to prioritize your health without the financial burden!