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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Out-of-Pocket Maximum?

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Question: Nobody at Covered California can tell me what my out of pocket maximum would be. The website says 2250 per my income and plan choice, but when I call Healthnet directly they told me my out of pocket max could be up to 12K if I go out of network. Nowhere is any of Covered CA does it state that. What is the right answer?

Answer: Apparently your income makes you eligible for an Enhanced Silver Plan with an out-of-pocket maximum of $2250. That's a great deal. If you are smart about utilizing your benefits, you should never have an out-of-network bill of any kind much less have to worry about the out-of-network annual maximum, but the Health Net rep was right, you would have to spend $12,000 out-of-pocket before you are covered 100% out of network.


FYI, just got my Blue Shield PPO online, I could not determine its max out of network copay until after submitting my binder payment. That’s not how it’s supposed to be, but CoveredCA somehow allowed PPOs to leave the out of network caps off the SBC template.

Anyways, Blue Shield’s PPO out of network maximum on my Silver plan is $5,250. Reasonable, but could be lower.

Hopefully next year CoveredCA will require SBC’s to state the maximum out of network cost for PPO plans. Not holding my breath for that, however.


Check-out the third-party quoter quotes (like HealthConnect). Out-of-network benefits are listed there for all the PPO plan carriers.

Maybe Anthem will provide benefit summaries at some point…

Blue Shield and Health Net have been kind enough to publish them already.

Cigna’s out-of-network benefit deductibles at $12,500 are laughable; essentially making their plans in-network-only plans.

I’m not sure I agree with Michael’s assessment of Blue Shield’s out-of-network benefits being the lowest, because you can’t even find any information on Blue Cross’s out-of-network PPO expense coverage even on the Anthem site.

Everything else stated is accurate. Sadly, until the PPACA came along and overturned the apple cart, even PPOs did not operate in the manner we will see in 2014 and beyond.

Now, I would like to point out how there is BLATANT MISREPRESENTATION of health care coverage on the CoveredCA website. When you point to each and every health plan in the “Preview” section, you receive a floating window that says, at one point,

“Yes, you can go to doctors, hospitals or other providers ‘outside the network.’ I you do, that usually means your care will cost you more than if you went to an ‘in network’ provider.”

TO the unsuspecting consumer who has no knowledge of insurance, this would lead a person to believe they can see any doctor, go to any hospital, get any benefit they want, and might have to pay a little more to get it.

Nothing could be further from the truth. Those of us who are licensed agents are supposed to know that.

You’re never covered 100% out-of-network.

Health Net’s annual out-of-pocket maximum for it’s PPO Silver plan is $12,700. Yet, this is of only an “allowed amount.” Any out-of-network provider charges for services at costs above the carrier-defined ‘allowed amount’ would be your responsibility. Therefore, there is never 100% coverage for out-of network services; in fact there is no annual dollar cap for all out-of-network charges above the ‘allowed amount.’

Every Covered California Silver plan with each carrier, or Gold plan with each carrier, or Platinum plan with each carrier, or Bronze plan with each carrier is identical with regard to in-network benefits for each respective metal tier plan. However, for carriers which offer PPO plans, plan benefits do vary between each carrier’s out-of network benefits.

Blue Shield offers the lowest PPO out-of network benefits in comparison to other carriers which offer PPO plans.

Remember, in-network benefits are identical for each respective metal tier plan with every Covered California health insurance carrier, yet PPO plan out-of-network benefits vary significantly with each carrier.

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