Increasing out-of-pocket expenses or patient financial responsibility is one of the biggest trends happening in healthcare today.

Struggling to keep up with their financial responsibility, patients are becoming more cost-conscious as insurers pass the risk to them with high-deductible health plans.

According to a recent nationwide survey by Healthcare Insider, 56 percent of US adults are worried their out-of-pocket healthcare costs would lead their household into bankruptcy when they get ill.

The survey also revealed that the top reason patients skip healthcare is because out-of-pocket expenses are too high, and they could not afford it (32 percent).

Healthcare affordability and out-of-pocket patient costs have been in the spotlight during this pandemic when everyone may need access to healthcare.

Many patients acknowledge the need to be able to access healthcare at least when they are feeling Covid symptoms.

However, health insurance out-of-pocket maximums have been increasing each year.

Health insurance plans set their own out-of-pocket maximums but have an upper limit on how high out-of-pocket costs can be which is imposed by federal regulations.

For the 2021 plan year, the maximum out-of-pocket or upper limit is $8,550 for an individual and $17,100 for a family.

In the recently published final Notice of Benefit and Payment Parameters for 2022, this upper limit increased to $8,700 for an individual and $17,400 for a family.

For perspective, this new out-of-pocket maximum in 2022 is 37 percent higher than it was in 2014.

What is an out-of-pocket expense / maximum related to healthcare?

A health insurance plan’s out-of-pocket maximum is the total amount you would have to pay in a plan year. These are medical expenses that aren’t reimbursed by your insurance.

Once you spend enough to reach your plan’s maximum in a given year, the insurer will then cover 100% of your medical bills.

Out-of-pocket costs include:

  • deductibles – the amount you need to pay before your insurance benefits kick in;
  • copays – small flat fees that you pay on the spot each time you go see a doctor, fill a prescription, visit a specialist, go to the emergency room, etc.;
  • coinsurance – the portion of the costs of a healthcare service that you pay after you’ve paid your deductible, but before you’ve met your out-of-pocket maximum.

The out-of-pocket limit doesn’t include:

  • out-of-network care/services
  • monthly premiums
  • cost of services your plan doesn’t cover
  • costs above the allowed amount for a service that a provider may charge

In essence, your insurer starts covering a portion of healthcare costs once you hit your deductible, and then covers all costs after you reach your out-of-pocket maximum.

If you receive care outside your plan’s network, the out-of-pocket maximum can be higher, or it can be unlimited.

Therefore, it’s so important to seek care in your plan network, because you’ll have lower out-of-pocket costs.

If you receive care out of your plan network, the costs will not count toward your in-network out-of-pocket maximum.

Patients need cost estimates and price transparency

With higher financial responsibility, healthcare consumers are demanding more transparency in relation to healthcare pricing.

Patients now turn to price transparency and comparison tools before a procedure or surgery to plan accordingly.

On January 1 this year, a new regulation took effect requiring hospitals to post payer-specific negotiated rates for 300 services. This move helped open the dialogue between patients and physicians about the cost of their care.

While this is helpful, patients still won’t know what they’re paying out of pocket due to in-network and out-of-network billing complications.

What patients really need to understand is what the impact to their portion would be from copays to their deductible.

Providing transparency into the true out-of-pocket costs helps patients navigate payment options before receiving care.

How can patients pay for out-of-pocket expenses?

Patients know they need to access healthcare, but they cannot always afford to do so.

Cost estimates open the opportunity to discuss resources and start the conversation early on if patients can’t afford the expenses.

A comprehensive solution to this dilemma is to provide a payment plan, which allows patients to spread payments out over a longer period and make medical care bills more affordable.

If patients can’t afford to pay the balance, they might need payment plans and financing options.

Healthcare facilities need to work with a partner that provides patient financing allowing patients the flexibility to customize payment options to fit their needs.

Providers need to look for a partner that allows for a 100% patient acceptance rate like Mnet’s PaySUITE. This would mean that all your patients can get access to financing options.

To help the patient further, payment extensions should also have zero percent interest and no credit checks. This offers your patients more time to pay their bill regardless of the remaining amount.

A payment solution that accepts a variety of payments, including mobile pay and text-to-pay, is also crucial because it improves the patient experience and allows people to pay using the tools they already love.

As patients navigate an economy crippled by the COVID-19 pandemic, they need all the flexibility and financial options they need to get access to needed healthcare.

This is where your facility can really make a difference in patients’ lives.

About Mnet

We believe every patient deserves a helpful, transparent, easy-to-navigate financial experience in healthcare.

Mnet is the premier revenue cycle management & technology provider to the surgical industry. Mnet provides customized patient-pay solutions to surgical hospitals and ambulatory surgery centers. Mnet Health partners with over 900 surgical facilities nationwide and is the preferred vendor to the leading ASC management companies in the US both directly with and in support of centralized billing offices.

Mnet’s tailor-made brand, PaySUITE, is a white-labeled payment technology platform that helps surgical facilities, and their providers grow their business by helping patients pay. Mnet’s patient-pay solutions significantly increase self-pay collections while creating a better financial experience for patients. For more information, visit