What, exactly, does "covered" cover?

[rain 2]

Hi everyone, I am nervously awaiting the results of my inusrance company's review of my surgeon's request for me to be covered for a Veritcal Sleeve. I have an Aetna PPO coverage. My documentation is perfect, I have the nutritiionist, doc letters, comorbidities, pshychology letter, etc.... and my doctor and his assitant feel confident that I will be approved. More confident than I feel, anyway!!! My doctor participates in the Aetna PPO insurance plan, so we're all on the same team.

But, in looking through the boards here. I noticed that somebody posted a message saying that "covered" with Aetna means that they will pay 80%. Not sure if this person meant "in network," or "out of network.." but the cost of a VSG in one of the better hosptials of the US, with a top surgeon has to be HUGE... like $25-30,000, I'm guessing. EEEK.. that could leave me stil owing thousands, and I don't have much money at all.

Has anyone here have any idea what COVERED means, money wise??? I was assuming it mean 100%, that they pay for everything but now I am getting nevous that even WITH insurance approval, I couldn't afford the 20% leftover.

Anybody have any experience with this? It's a real emotional roller coaster... as you all know, I've been through so much to get to this point with all they put you through....

Thanks!

[feedyoureye 3,087]

My insurance plan (with WHA) has a high deductible, ($2500 a year) and a maximum out of pocket ($5000 a year) Im pretty sure I have to pay $500 a day for the hospital too... Im planing on having to come up with around $3500. Every plan is different... some WHA plans have complete coverage of the surgery. I hope I'm in the hospital only one day! Call your insurance company and ask....

[weightnomore 8]

Hi everyone, I am nervously awaiting the results of my inusrance company's review of my surgeon's request for me to be covered for a Veritcal Sleeve. I have an Aetna PPO coverage. My documentation is perfect, I have the nutritiionist, doc letters, comorbidities, pshychology letter, etc.... and my doctor and his assitant feel confident that I will be approved. More confident than I feel, anyway!!! My doctor participates in the Aetna PPO insurance plan, so we're all on the same team.

But, in looking through the boards here. I noticed that somebody posted a message saying that "covered" with Aetna means that they will pay 80%. Not sure if this person meant "in network," or "out of network.." but the cost of a VSG in one of the better hosptials of the US, with a top surgeon has to be HUGE... like $25-30,000, I'm guessing. EEEK.. that could leave me stil owing thousands, and I don't have much money at all.

Has anyone here have any idea what COVERED means, money wise??? I was assuming it mean 100%, that they pay for everything but now I am getting nevous that even WITH insurance approval, I couldn't afford the 20% leftover.

Anybody have any experience with this? It's a real emotional roller coaster... as you all know, I've been through so much to get to this point with all they put you through....

Thanks!

Your employer should have given you a copy of your health plan which tells how much your co-insurance and co-pays are. Each company is different. There is not one plan for all Aetna members. It depends on what your company contracts with Aetna for. My husband's plan gives us a choice of either 20% co-insurance or 10%. The premiums are higher, of course for the 10% plan.

[Susanne 32]

Yes, you really have to check with the health plan because your employer can have individual plans considering it is a PPO.

I am with Blue Cross Blue Shield of Michigan. I was covered for the sleeve and in my case that meant:

I pay the first $1,000 out of pocket - that's my deductible and since I didn't have anything done this year, I had to pay the whole amount for this procedure.

After that, I cover 30% and BCBSM covers 70% of the expenses until I have paid a total of $3,000 (this is my health plan, I opted for 70/30 instead of 80/20 - right now insurances have open enrollment, do the math to see if switching into a different plan may save you some money)

After that, BCBSM pays everything.

For me, that mean that before surgery, the hospital wanted a check over $4,000 since it was elective surgery. They said everything else is covered after this.

I addition, I had to pay the little things at Grand Health Partners, my surgeons practice. This was for the behaviorist, dietician, consultations, pre-op appointments, pre-paid post-op appointments, pre- and post-op food and that came to a total of $991.

So, for me, my covered surgery cost me $4,991 out of pocket, including co-pays and everything.

Hope that helps

Susanne

PS: You can always call your insurance, the number is on the back of the card. They should be able to tell you with your member number

[rain 2]

Thanks, ladies, for your information. I will look up what the policy covers. If it is like $5,000 I could probably borrow the money from one of those surgical loan places... I think it's worth it. Buying myself a new life and all...

Much appreciated... Rain

[Susanne 32]

I loaned it from my own 401k so I pay it back to myself with interest, not sure if this is an option for you

[M2G 1,836]

Totally agree that even if someone has the "same" insurance carrier as you, their plan could be totally different.

I had UHC and they cover the sleeve. However, my plan was a high-deductible plan. The basic plan says for our family we pay $5,000 out of pocket (from an HSA) and then UHC will cover 90% and we pay 10% of every bill after we hit our deductible.

So yeah, covered didn't equal free. But it was a LOT less expensive than self-pay. Plus my husband is having the same surgery in Dec. so it made sense to do it after we hit our deductible.

Definitely, call your insurance and get everything spelled out for you...that way no surprises!