Blue Shied Deductible

[shaeluv 16]

Wondering how much people are paying out of pocket for surgery with Blue Shield- I am looking at the plans and am so confused by the coinsurance etc... any advice appreciated!

[prettyCali916 299]

Hi! I don't have blue shield but I work in the health insurance industry. Some Blue Shield plans are HMO so those plans have no deductible or coinsurance, just an office visit copayment if that. It all depends. If you have coinsurance that means you have a PPO more than likely. Let's say your hospital bill is $10,000, your deductible is $500, you have a $4000 out of pocket maximum and your plan is an 80/20. Assuming you are starting with nothing paid towards your deductible, you have to meet that first. So that's $10,000 minus $500 leaving $9500. Then you are responsible for 20% of what's left. That's because of the 80/20 we mentioned before (which could be 90/10 or something else even). So you now owe 0.20*9500. That is $1900. So you have to pay that on top of your $500 deductible for a grand total of $2400. The insurance company then pays the rest of the bill. If you ever get to the point where you have met your deductible and paid $4000 out of pocket cumulatively over a year, then anything after that would be covered at 100% by the insurance company. Until the end of the year that is, then it starts all over again.

Hope that helps!!!

[MrsRP 36]

It really depends on coverage. Your best odds are to call the customer service number on back of the card give them your policy number and what procedure you are having. They will be able to give you the exact co-pay you will have.

[Sharon1964 2,530]

Are you looking to purchase insurance, or do you already have insurance?

Edited to say, never mind, I just saw your other post. Give me a few minutes and I'll get back to you.

Edited December 15, 2015 by Sharon1964

[Sharon1964 2,530]

Here are the contracted amounts for my surgery with Blue Shield of California in Fresno County. The fee schedule in your county will be different, but not by a huge amount.

Hospital - operating room plus two nights' stay: $10,288.00

Surgeon's fee: $1,267.94

Anesthesiologist fee: $778.77

Labs inpatient: $84.74

TOTAL: $12,419.45

For the sake of simplicity, let's round it off to $13,000. The only time the total cost is going to matter is if it's less than your out of pocket maximum. And remember all these numbers are for a calendar year; you don't want to start the process in November or December.

Blue Shield Bronze 60 PPO: Deductible of $6,000 per calendar year, out of pocket max of $6500 (including deductible). This means you are going to pay $6500 for your surgery (and all the preop stuff) then Blue Shield is going to pay everything after that.

The silver plans are similar to the bronze plans, with a $6250 to $6500 out of pocket max. That's going to be your total.

The difference really comes with the gold and platinum plans. They have no deductible and a lower out of pocket max. The platinum plan has a $4000 out of pocket max, so that's going to be your total.

Now, I don't know what the premiums are for your age and zip code. But let's say the premium is $100 for the bronze and $500 per month for the platinum. And let's say it's going to take you 6 months to get all your testing and preop stuff done.

bronze: $100 premium per month x 6 months = $600, plus $6500 for your out of pocket max means you'll be paying $7100 total.

platinum: $500 premium per month x 6 months = $3000 plus $4000 out of pocket = $7000 total.

So with these numbers, you don't get more for your money with the "better" plan (platinum) - they're about the same. If you go longer than six months, the differences are greater.

7 months: bronze $7200; platinum $7600

8 months: bronze $7300; platinum $8200

If you keep the plan for the whole year (and you may be contractually obligated to do so, I'm not sure:

12 months: bronze $7700; platinum $10,600

Remember these are examples only as I don't know what your premiums would be.

Now we focused on the out of pocket max because you're planning surgery. If you're looking at plans for regular day-to-day health care, there are other factors to consider to determine what's best for your situation.