School Me On Insurance And Co-insurance For Gastric Sleeve Surgery

[OilSooner 23]

So, I have been to all of the pre surgery appts, and have a tentative surgery date of Jan 12th (yay me!), but am wondering how "co-insurance" works on my insurance (Aetna POS II). On the website, I show a $200 deductible ($91.83 remaining) under just my name, and $600 deductible for family (oddly $91.83 remaining here as well).

Then, it shows $4000 for coinsurance ($3981.99 remaining) for the family, and there is no co-insurance showing under just my name. My wife and daughter are on my insurance as well. I am the account holder though.

Does this mean I will have to pay $3981.99 for my surgery when I go to the hospital?? Its odd that only $18.01 has been used on coinsurnace, because I have had MANY claims from all of the psychiatrists, nutritionists, pulmonologists, etc.

Its all very confusing.

How does co-insurance work? If I have to have $4k when I check into the hospital, do they take a payment plan, or do you have to write a check right before they will admit you?

Thanks in advance for all replys!

[Wheetsin 714]

Coinsurance is the same as a percentage plan. E.g. 80/20 where your plan pays 80% of the costs and you pay the remaining 20%. This only applies after your deductible is met. So if your deductible is $1000 and you have a $5000 procedure:

• You pay deductible (assuming it's not already met): $1000
  
• Plan pays 80% of remaining charges ($4000): $3200
  
• You pay 20% of remaining charges ($4000): $800 (assuming that's below your out of pocket maximum).
  

That assumes you haven't yet paid against your OOP maxmum. On major medical there's usually a coinsurance cap, after which the plan pays 100%.

As for individual vs. family, what type of plan do you have?

This is quicker than me putting it in my own words:

Individual Deductible Family Plans

Some family insurance has separate deductibles for each individual and then a family deductible limit. For example. a plan might have a $5000 deductible for each family member and a $10,000 deductible limit for the whole family. What that means is that any given individual in the family must reach $5000 in covered medical expenses before the health plan begins to pay. Also, let’s say that this family has 3 individual members and that the total in family expenses exceeds $10,000, from this point on through the end of that calendar year all family members will have been deemed to have met their deductible. Statistically, only one family member usually has major medical expenses in a given year, so the individual deductible plan is generally recommended.

Aggregate Deductible Family Plans

Some family health plans have one deductible for the whole family. For instance, a plan might have a $10,000 deductible for the family and each family member’s covered medical expenses are combined to meet the $10,000 family deductible. Statistically, only one family member usually has major medical expenses in a given year, so the $10,000 family aggregate deductible is usually harder to reach. We generally recommend family health plans with this type of family deductible, but there are situations when an aggregate deductible is preferable, for instance a large family would have a greater chance of meeting the family deductible with no single individual accounting for $5,000.

HTH

[OilSooner 23]

Thanks!

Does anyone know how much the surgery costs?

[Wheetsin 714]

Do you mean to pay out of pocket?

[OilSooner 23]

No. I am wondering what the cost is that insured people have to pay (I assume self pay people pay less). I am trying to figure out what my out of pocket expense might be. I have approx $100 left on the deductible, then have 10% coinsurance after deductible is met. So, if the surgery is $25000, I'll probably owe about $2600 out of pocket.

So, I am wondering what the surgery generally costs for insured patients (in Oklahoma if that helps) so I can calculate my part.

[Wheetsin 714]

It's going to vary drastically by surgeon, and even by hospital/facility (for surgeons who do procedures at more than one location.)

For example, my surgeon's self-pay cost is $12,000 for lapband or sleeve. That's start to finish. Compare that to about $38,000 they charged my insurance company (for my lapband - different procedures, but let's assume comparable costs). When my father had his lapband I think insurance was billed about $43,000. A friend of mine who had one had a complication and her bills topped about $100,000. VERY VERY VERY few plans around today would require you to pay 10% of $100k.

Some surgeons use PAs, some don't. Different surgeons have different surgeon fees (and hospitals, and anesthesiologists, and...) Some keep patients overnight, some do not. Most procedures go smoothly, some do not. Etc. That's all going to impact cost.

In addition to your deductible and coinsurance, you should have an "out of pocket maximum". Do you know what yours is? You should not have to pay 10% coinsurance of any amout, sky's the limit. E.g. if your plan has a 2k OOP maximum, you would not pay the $2600 you've estimated above, you'd pay no more than $2k total. You also need to determine if your premiums count toward OOP. Usually they do not, but I have seen some plans where they do. That makes a big difference. From your numbers above I'm guessing yours does not, but call your provider and check.