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Covered California Q&A

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.

What is Maximum-Out-Of-Pocket Based On?

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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.

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