Question: Does the Maximum Out-of-Pocket of $6,350 include total cost to the consumer for any given care or is it limited to the insurance company's "negotiated rate" for a given treatment? In other words is the patient stuck with the costs above and beyond the negotiated rate and if so, will that cost go towards the "maximum out-of-pocket" or will it not?
Answer: The out-of-pocket maximum of $6,350 for covered expenses in a calendar year is based on the negotiated or contract rate. There is no patient responsibility beyond the contract rate for in-network expenses. Out-of-Network coverage has a higher out-of-pocket maximum and the patient is responsible for charges beyond the contract rate.