Lifetime Aggregate Maximum Benefit

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mattwisconsin

Well-known member
Joined
Dec 11, 2008
Messages
199
Location
Green Bay, WI, Columbus, OH, and Chicago, IL.
So anyone out there hit their Lifetime Aggregate Maximum Benefit for their insurance. If so what did it mean to you and what did you have to do for the future.

I am now a little worried because I have realized that mine is rather low at $500,000 and I fear that I could be getting close after seeing some of the bills from the hospital. I am not there yet, but I have only seen about half the bills and I am probably around $300,000. I also know that I will have lots of follow up visits over the next year.

So past stories or suggestions of what to do will be appreciated. One of my other worries is with the pre-existing condition I will always need insurance, but what happens when you hit your Lifetime Aggregate Maximum Benefit from the insurance offered from your employer?
 
What they bill your insurance and what they pay are two different things. Generally, insurance only pays about 65% of the billed amount.

As for the other question, they have to supply you with evidence of coverage at the end of the term.
 
You might find that the expenses over the next couple of years are not even comparable to OHS. However, I do agree that $500K is low as my lifetime max is $5 Million. Can you check with your employer to find out if there are any options or changes they are considering with their next renewal?
 
I know we were worried about this as well with Joe. He did not have a low amount of coverage, but his medical care was astronomical. When he passed away, I received a statement of what the insurance paid just for the couple of months leading up to his death, and it was something like 333,000.00. I had to pay less than 100.00

And this was not for surgery, it was for ICU stays and a myriad of procedures and treatments.

That coupled with his many thoracic surgeries made it huge.

One of our neighbors who worked for the same company and had the same coverage thought he was being funny when he told me that Joe was running the insurance company out of money. Not so funny.
 
Gee makes me want to look into mine. Ross you got the same as me, any info?
 
I have called the rep at my school, who said that she needed to talk to her supervisor and get back to me. She also said that in the time that she has been there, she has only seen one person hit the max and that she assumed they dealt with this on a case by case basis. So I am waiting to hear what they are going to suggest.
 
As Ross said, it's not based on the bill, it's based on what they actually pay. And Ross, 65% is actually kind of high, unless it's a smaller company. When I was on the hospital side of the negotiations in 1997-2001, we were glad to average 50% and from the larger payers, it was more like 35-40%. I think my hospital bill in 1998 was around $100,000, and I believe that the hospital actually got paid around $25,000.

$500,000 is very low though, but I seem to remember that you have a very limited policy. Is this a public school district, and if so, how large are they?

Edit - Wait, I seem to remember that this is a college and you're a grad student, maybe?
 
It is through Ohio State University. In some ways the insurance has been great, but then in others, they seem to have little surprises hidden in there.

I mean it is good in some ways such as there is no deductible for in network providers and there is a $5,000 out of pocket max per year for in network providers. They also cover at 90% for in network. I was pretty impressed with this since my parents have a $5,000 deductible with their plan.

However, they do have a stipulation of not covering surgeries for congenital issues and a $500,000 Lifetime Aggregate Maximum Benefit.

So the insurance is both good and bad.
 
Dyna said:
My lifetime benefit is somewhere north of $4 million. To date they have paid just over $103,000. I don't even have all the bills so wouldn't even know where to start on what the actual charges were. From the ones I have seen I would gather my ins has been paying over 65%.
Click to expand...

Have you looked at your Explanation of Benefits (EOB) from your Insurance Company?
 
Dyna, there are a lot of things involved, including the procedure, the hospital you went to, the type of benefit you have, and the insurance company. Above 65% would be very unusual unless the provider is one of those that doesn't really play the managed care game.
 
Matt:

Is your insurance for students, part-time employees or full-time employees?

My nephew is a research assistant/Ph.D. candidate. He gets insurance from the university, but a different plan from full-time employees.
 
Matt, I'm sure that this has a low life time maximum since it is for students and they typically are only on it for four years or so. I would also think that alot of students may still be on their parents policies as well.

Kim
 
Matt, I don't really have any great advice for you, but you have my sympathies. I was in grad school at NYU when I had my surgery, and my student insurance had a lifetime cap of $150,000 per condition. There was an option to buy catastrophic coverage, which would increase the lifetime cap to $500,000 total (not per condition), but the plan only allowed people to sign up for that option in September. I started school in May and had my surgery when summer classes ended in July, so I was SOL as far as getting the catastrophic coverage. Also, the prescription drug benefit had an annual limit of $1,000. I ran through that pretty quickly. And my surgeon at NYU Medical Center was out-of-network! You would think that one of the most expensive private universities in the country could offer its students more, but no... In any case, my surgery and related expenses came in under $100,000. I feel lucky that I didn't have complications, because I couldn't afford them with that insurance policy!

I'm actually still waiting to get reimbursed by Aetna (four years after my surgery!) because they cheated me and many other students on out-of-network reimbursements. Fortunately, the New York Attorney General's Office investigated them and negotiated a settlement (details at the link below if you're interested):

http://www.oag.state.ny.us/media_center/2009/feb/feb2a_09.html

I am now pursuing another graduate degree at UNC, and I have to say that the student health insurance here is much better- there is no lifetime cap! That was actually one of the reasons I chose this school over some others with stingier insurance policies.

I don't think you should worry too much about hitting the cap on your policy- as others have said, the amount paid by the insurance company is much less than the amount billed by the providers.
 
Thanks for the words of encouragement. I would hope that NYU would have better insurance. I hit my prescription annual max pretty quickly with the 6 weeks of antibiotics at home. It was only $1250 and the first batch cost about $1500. Then I unfortunately had to buy close to $700 in Lovenox. I am on the antibiotics again until next Friday. However for some reason my insurance is covering them directly this time, even though it is a reimbursement policy. I don't understand it but I will take it.
So all this is crazy and confusing but it will all work out. I know that other people before me have been dealing with these bills for decades.
 
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