Large OOP Max Due/Financing Questions

[momma_missie 30]

I was so excited last night when I was able to attend my Weight Loss Surgery seminar. I loved the staff I was able to meet from the practice and I found out that with a BMI over 50 that BCBS waives the 6 month mandatory supervised dieting. Both were great pieces of information.

Today I called my insurance company to begin asking several questions from the surgeon's office that I needed to have done by the time of my 1st appointment. The end result was finding out that I don't have a $6600 individual out of pocket maximum to pay, but instead I have a $13,200 out of pocket expense maximum I could potentially face because I have a family plan through my employer. I have a co-insurance maximum of $6,000 I could potentially pay. (Which would be applies towards my total out of pocket expense if I surpass this dollar amount.)

I have a 50% co-insurance due for any bariatric procedure and I have a 50% co-pay for the surgery portion of the procedure. So I figure I'll easily be out the $13,200 for the year. Initially I was sad and very angry. Now I have calmed down and am trying to wrap my head around how to come up with this kind of money in order to move forward with my WLS. I plan to call my hospital and surgeons office tomorrow to see if/what they offer in the way of financing, etc.

I was just curious as to what others did that faced a large out of pocket expenses in order to have their surgery. Just FYI I have BCBS of Michigan.

[Sharon1964 2,530]

I would call your insurance company again to clarify the max out of pocket. For many plans, the out of pocket works a little differently.

One person max out of pocket: $6,600

Any combination of more than one person: $13,200

For example, two family members each spend $5,000 out of pocket. The third family member only has to spend $3,200 to reach max out of pocket for the family ($5,000 plus $5,000 plus $3,200 = $13,200). No one single person reached the individual out of pocket, but you met the max family out of pocket.

My plan is similar to yours. I saved my income tax refund, and I've been putting money aside every month (since I started this in November 2014). I figure if the hospital bills me for $6,000, for example, I'll pay them a big chunk and then the rest in monthly payments. My surgeon's office says the hospital usually gets paid first, so since that will meet my max out of pocket, my insurance will pay the entire surgeon's bill (remember, once max out of pocket is met, they pay 100% of everything else).

[momma_missie 30]

I was under the impression that my portion was all that had to be met, because after all, I only had to meet my $500 individual deductible before they started covering my other doctor appointments and such. But BCBS today claimed that I had to meet hte family out of maximum before they would pay. Mind you, neither person I talked to really had any clue about anything. They would just repeat what they were reading off to policy word for word to me. It wasn't helpful at all and they told me my surgeon could call and get more answers than I ever could get.

[CanyonBaby 1,852]

I guess I'm confused. If your out-of-pocket expense is up to over $13,000, what is the total for your surgery going to be? What I mean is, if you are paying that much WITH insurance, this is mighty expensive, it seems to me. I was self-pay, for the main reason I didn't want to wait for the year-long process (I have diabetes, and the complications of it were getting severe) to have the surgery via insurance. My total was about $16,000, and I have a fantastic follow-up care package included with that. I know they jack up the prices for insurance, but if you're going to pay that kind of money out of pocket, why not look into self-pay, and potentially pay less? My surgical team has about a 40 percent reduction for self-pay patients. Just an idea....

[Sharon1964 2,530]

Mind you, neither person I talked to really had any clue about anything. They would just repeat what they were reading off to policy word for word to me. It wasn't helpful at all and they told me my surgeon could call and get more answers than I ever could get.

Call back and ask for a supervisor. Or go to your surgeon's office and sit with them while they call.

[Inner Surfer Girl 12,015]

Does your surgeon's office have an insurance coordinator? If so, make an appointment to sit down and go over all the costs. I went the self pay route because my insurance doesn't cover bariatric surgery and they were pretty clear about the line-by-line costs. Plus, with insurance, they are going to pay a significant portion of your costs in the space between your deductible and your maximum out of pocket.

[momma_missie 30]

I have made an appointment on June 13th do go through a seminar and have a face to face consult with a surgeon at the Barix Clinic in Southern Michigan on June 13th. I can't wait!! They will handle the insurance and help to get me financed to cover the out of pocket of the surgery from my understanding.

Most areas around here is about $16,000 for surgery. I'm still hoping that my deductible will only be $6,000. It would make me feel SOOOO much better and at ease. I'm not giving up yet.

[maggie409 765]

Wow! I am self-pay and my options are between $12,200 and $15,000 in the United States which is all inclusive or going to Tijuana for $3,899 all inclusive which includes a condominium for my husband to stay in while I am in the hospital and some to pick us up and take us back to the airport plus $700 in airfare for a total of $4,599. I have gone with the Mexico option after carefully checking out the facilities and the doctors. Either way, I pay less as a self-pay than you will pay with insurance. Also since I am self-pay I don't have to jump through hoops. I am scheduled for June 15th.

[emilybee 4]

Looks like i will have to pay 50% out of pocket, which is going to cost me alot, i don't have very good credit, i am looking around at financing options too. I really don't fancy going to Mexico, would be scary if i got sick and got stuck there

[momma_missie 30]

@@emilybee Do you have an out of pocket max for the year?? My family out of pocket max is $13,000, but my individual OOP max is like $6600... which doesn't seem too bad all things considered. Good luck to you! The journey to getting to surgery is emotional enough.. surgery itself.. I can't imagine what that day will feel like when it arrives!