“Separate plan service providers may impose different levels of out-of-pocket limitations”
That doesn’t even make sense. The medical side has its own out of pocket, which has nothing to do with any level of anything on the pharmacy side. Is the policy out of pocket max determined individually per provider, or is it aggregate?
I’d like to see a Navigator Of Excellence prune through that fine print. Right after they put down the bong.
Seems like they are writing the unwritten.
Different medical insurance policies have different organizational structures coordinating between 7 to 20 entities, each with massive relational databases to operate in the industry. (e.g. within one regional healthcare system commonly accessed service providers in an outpatient surgical procedure might include: Patient, Dr., Dr’s Group, Pharmacy, Lab, Admissions, Insurance Provider, Radiology, Anesthesia, Emergency Room/Trauma Center, Ambulance, Physical Therapy).
Different plans group those services in different fashions based upon local economies of service. Any two or more of those groups may also engage in “co-pay” systems.
The clause seems to be allowing all the different plans to implement their operations in their own fashion, but failing to recognize their ‘granting’ of that freedom, might be encroaching upon the contractual relationships between service providers within their systems.
I haven’t seen a model showing the difference in ACA and the relationships in standard healthcare systems.