Maximum benefits defined

[vzguyme]

We have reached our maximum paid benefit for a particular treatment. It was our understanding this is a paid benefit, meaning that after the maximum has been paid out, we will have to pay going forward, however the payment amount(s) will still be the insurance contracted rates.

Our medical insurance (the most popular one out there), is now stating that the contracted rates do not apply after the maximum benefit has been reached. Is this true in the cases of maximum paid benefits, which in our case is a lifetime maximum on the policy.? To us, it seems like this is at the convenience of the health insurance company. We would think that at a minimum, we should be receiving the contracted rates.

 

[STIBROKER]

Our medical insurance (the most popular one out there), is now stating that the contracted rates do not apply after the maximum benefit has been reached.

Let me guess......you are on a USHEALTH plan........

 

[vzguyme]

nope. bcbs. i'm in the northeast, where I don't see many folks with ushealth around here.

 

[STIBROKER]

nope. bcbs. i'm in the northeast, where I don't see many folks with ushealth around here.

but bcbs does not have maximum's..........

 

[vzguyme]

we do. we have a lifetime paid maximum of $4k for this treatment. We met the maximum and now they've even stopped adjusting the charges to the contracted rates.

They sent us a note in the mail stating: "Once the $4,000 paid lifetime maximum is exhausted, no additional benefits will be available; including the contracted rates."

I would just like to know if this is normal...to stop adjusting to contracted rates.

 

[STIBROKER]

we do. we have a lifetime paid maximum of $4k for this treatment.

not seeing it......here it is......
https://www.horizonblue.com/sites/default/files/2019_plan_guide_english.pdf

 

[vzguyme]

is there a similar guide for bcbs nebraska? we reside in nj, but have bcbs through our employer.

the treatments are for fertility treatments & medications

 

[Yagents]

Most policies have maximums on certain medical conditions. Even obamacare. You have no idea of the plan he owns.

 

[leevena]

We have reached our maximum paid benefit for a particular treatment. It was our understanding this is a paid benefit, meaning that after the maximum has been paid out, we will have to pay going forward, however the payment amount(s) will still be the insurance contracted rates.

Our medical insurance (the most popular one out there), is now stating that the contracted rates do not apply after the maximum benefit has been reached. Is this true in the cases of maximum paid benefits, which in our case is a lifetime maximum on the policy.? To us, it seems like this is at the convenience of the health insurance company. We would think that at a minimum, we should be receiving the contracted rates.

There is no standardized approach to this issue, but I doubt very much if the contracted rates would extend to you in this situation. The provider is aware of the limitation and would more than likely have limited the discount to the $4000 limit. Not a convenience for the carrier, they could care less.