Can anyone help me understand my insurance policy?

[sleepyjean 0]

I found out on Monday that my company is switching to Blue Cross from Healthnet. I was pursuing the band at UCLA but they don't do banding anymore. So I'm back to square one. The company has only given us until Thursday to get our paperwork in and I am tearing my hair out. I can't find another medical group that offers banding. I have to choose between HMO or PPO and I need help understanding the PPO stuff. I'm trying to figure out if I go with the PPO, what I'd be looking at cost-wise for banding.

I know what a deductible is and the annual out of pocket max, but I don't all the stuff with the percentages and how that applies to the out of pocket max. Are those percentages something that I'd have to pay on top of everything else? Does anyone understand this stuff? Wah!

Here is the information they gave me.

annual deductible - $500

out of pocket maximum - $4,000

office visits - $30 copay for 12 visits (after 12, it becomes 45% of the negotiated fee)

other professional services (diagnostic, labs, xrays) 30% of negotiated fee after annual deductible

hospital inpatient facility services - 30% of negotiated fee after annual deductible

hospital inpatient professional services (physician, anesthesia,etc.) - 30% of negotiated fee after annual deductible

[Lynn B 0]

OK I'll do my best - the difference between and HMO and PPO is with an HMO you need to get your PCPs referal to see a specialist or another doctor. With a PPO (at least mine) I can go to any doctor I want. As long as he is "in network" all I pay is my copay. I currently have BCBS MA PPO and do not have a deductible (I guess that depends on what plan your company opted for). All routine and office visits for "in network" are $25, ER visits - $100.00, Outpatient surgery $150. - Inpatient surgery $250. If I went to an "out of network" doctor it would basically be like a 80/20 plan - insurance would pick up 80% of the bill and I would be responsible for the rest. All in all I love my PPO - I paid $250 for my band surgery (plus the program fee of $500) and $25 for each of the 3 pre op appointments...Oh and $100 for the psych eval which was not covered.

So it looks like once you meet your deductibel (the first $400. worth of services) you pay co pays and 30% of the remaining bill until you hit $4000. for the year - after that everything is free. So if they are going to cover your surgery you are probably looking at paying the $4000.00 in that year. Does your company offer a medical savings account? If so and you know that you can get approved for surgery you may want to take advantage of putting the max away (tax free) to help cover your sugery costs.

Good luck - I hope I helped a bit.

My employer is changing ins in January and the new plan kinda sounds like yours - you have a $200. deductible so first appointment you basically pick up the bill - after that they pay 90% of all future in network charges - I pay a copay plus the 10% balance.

[Alexandra 55]

Jean, Lynn is right in that your out-of-pocket maximum (OOP) is the MOST you would have to pay in a calendar year for any services received. Deductible is paid first, and then you pay 30% of the rest until you have paid out $4000 total. You may want to clarify whether the deductible is included in that OOP; sometimes it's not presented that way.

Your HMO may be open-access--that is, it may also not require referrals. The only real difference between HMOs and PPOs these days is that with an HMO there is NO option for out-of-network coverage. You must stay in the network to receive benefits.

Good luck!

[sleepyjean 0]

Thanks so much you guys! If I went through my HMO, I'd only have to pay $250, but what's the point of that if I can't find anyone to do the surgery?

I think I can suck it up and pay the $4000, I was just really afraid of getting hit with unexpected costs. $4000 is a lot of money, but I can put it away in flex spending and it's a tax deduction too I think.

One more quick question: we haven't received the info on the flex spending program. How does that usually work? Do you set aside a lump sum or is it a deduction each pay period? I want to have the surgery in Jan or Feb and I won't have that much set aside by then.

[Lynn B 0]

For my Medical Savings plan you specify the amount that you want to put in the account - say $1000.00. They take $19.23 out of your check each week but you acctually have access to the whole amount committed (in this case $1000.00) on the first day (for me that would be Jan 1. when benifits re up)

Good luck!