How can there be an actuarial value of X% AND an out of pocket cap?
Say I buy a plan in the exchange with a 70% actuarial value and I have an illness that costs $50K to treat. The insurance company has to pay for $35K of that. Say I have an out of pocket maximum of $5k, according to whatever bill is passed. How's that gonna work? Does the insurance co. just eat it and them pass the costs along in premium/subsidy increases? Anyone know?
If you have a cap, you pay your part up to that, then the insurance company has to pay the full freight. Of course, they also dictate to the provider what the full freight is.
2. Yep, and with a 70% MLR. By tightening the caps and doing away
with pre-existing restrictions as well as premium increases, the MLR will go up a little but not to the 80-85% required once you add in the mandated. Which means that the insurance company will have to lower their premiums in order to maintain the required MLR.
5. It's not my situation at all. I'm unemployed and uninsured.
I'm just trying to figure out why there are different actuarial benefits to plans when there are going to be set out-of-pocket limits in a subsidized plan.
6. You pay up to your cap. Either the insurance co eats the balance or
negotiates an arrangement with the provider for discounted payment. That happens now the only difference is that most out of pocket caps now are higher than they would be after passage of either house or senate bill.
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