Migliaccio & Rathod LLP is investigating whether certain employer-sponsored health plans caused patients to pay more than the federal annual out-of-pocket limit because their medical and prescription-drug expenses were not properly combined or tracked.
Many health plans use one company to administer medical benefits and another company—often called a pharmacy benefit manager, or PBM—to administer prescription-drug benefits. Even when different companies administer those benefits, qualifying in-network medical and prescription expenses generally must be coordinated for purposes of the federal annual out-of-pocket maximum.
Problems may occur when the two systems do not communicate correctly. For example, a patient may pay thousands of dollars for prescriptions, but those payments may not appear in the medical plan’s out-of-pocket total. The patient can then continue being charged for medical care even though the patient’s combined qualifying expenses should already have reached the annual limit.
Similar problems can occur with family plans if a single family member is required to pay more than the applicable individual federal out-of-pocket maximum.
You May Be Affected If:
- You receive health insurance through your private-sector employer, or through a spouse’s or parent’s private-sector employer;
- You paid substantial amounts for both medical care and prescription drugs during the same year;
- Your medical insurer’s website and pharmacy-benefit website displayed different out-of-pocket totals;
- Some prescription payments did not appear to count toward your health plan’s out-of-pocket maximum;
- You reached what you believed was your annual out-of-pocket maximum but continued being charged deductibles, copayments, or coinsurance for qualifying in-network care;
- Your out-of-pocket totals unexpectedly decreased, disappeared, or reset after your employer changed insurance administrators or PBMs; or
- You were enrolled in family coverage and one individual family member paid more than the applicable individual annual out-of-pocket limit for qualifying in-network care.
Does This Apply to Your Health Plan?
This investigation generally concerns ERISA-covered employer health plans. Put simply, you will usually satisfy this requirement if you obtained your health insurance through a private-sector employer, including through your spouse’s or parent’s private-sector employment.
Both self-funded plans and plans insured by an insurance company may qualify. Government employee plans and certain church plans generally do not.
You do not need to calculate your total yourself before contacting us. Your EOBs, medical-plan accumulator, pharmacy-benefit accumulator, and payment records may allow us to determine whether you were overcharged.
We Are Interested in Hearing From Patients Who:
- paid significant medical and prescription expenses in the same year;
- saw different out-of-pocket totals in their medical and pharmacy portals;
- noticed prescription payments were missing from their health-plan total;
- continued paying copays or coinsurance after reaching what they believed was their annual maximum;
- had an accumulator reset after an insurer, TPA, or PBM change;
- paid more than the individual annual maximum while enrolled in family coverage; or
- have EOBs, portal screenshots, pharmacy records, or receipts showing the discrepancy.
If you believe your employer-sponsored health plan failed to properly count your medical or prescription spending toward your out-of-pocket maximum, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or call us at (202) 470-3520.