Question about out of pocket

[sabrinamena 3]

I was approved by my insurance (BSBCIL), but now I am very confused about what part of the cost I will be responsible for. My deductible is $750. Coinsurance 75/25. Out of pocket is $7,150.

When I spoke to the surgeon's office they said for example if I had surgery that day since I had not met my out of pocket that the hospital would ask for the entire $7,150. Which is a little (a lot) more than I was expecting.

I was under the impression that I would be responsible for the deductible, and then 25% after that until it reached out of pocket max?

Please help me understand!

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[blessedgirl80 3]

Have you met any portion of your deductible? It should be any unmet portion of your deductible and 25% of the contracted rate for that procedure not to exceed your out of pocket maximum . I would find out what the contracted rate is. Some policies have hospital copays etc. Hopefully your out of pocket Max isn't that high.

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Edited January 23, 2017 by blessedgirl80

[sabrinamena 3]

No my insurance started over with the new year. My out of pocket is $7,150. I think the surgeon's office isn't telling me something right. Also, my deductible doesn't count towards the out of pocket. I've never had to deal with insurance other than my usual yearly PCP and obgyn so this is all like a foreign language to me.

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[blessedgirl80 3]

Right the deductible doesn't but if you paid any copays that should count. Once u find out the contracted rate u will have a better idea. Try getting the procedure codes from your doctors office and call the insurance company. I don't want to give u any inaccurate information.

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[Monasmle 90]

I have highmark BCBS, and when I log in online I can see my policy and get estimates based on my insurance for the cost of any procedure. I'm not sure if BCBS IL has it, but they're the same company so they might. They had bypass and band as options, but not sleeve, but I'm sure bypass is close to sleeve. The estimate included EVERYTHING, hospital surgeon, blood work, ekg, etc. And depending on the hospital it shows the different prices. It was crazy to see how one hospital the bill was 27k-30k, and the hospital I'll be doing it at is 13k-17k. It also explains the breakdown of what your total estimate might be.

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[sabrinamena 3]

Yes I tried the estimator but my insurance approves on a case to case so it won't show the price after insurance.

Our website isn't very helpful at all!

Thank you guys for replying!

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[olamae 16]

Sounds like to me you will owe the entire deductible if not met $750 then you will owe the entire amount of the out of pocket $7150. So being the procedure is well above $7900 then you will owe that entire amount. The contractual rate is what the insurance agrees to pay the hospital. Sucks they don't include the ded in the out of pocket.

[Mandybb 183]

I have United Healthcare with a $6000 family max out of pocket and a $400 deductible. I had to meet the $6000 out of pocket max + $400 deductible before they would pay 100% for my surgery. After my out of pocket was met then they paid 80% and I paid 20% until that last $400 deductible was paid. I waited to have surgery until Dec 29th to have them pay 100% because I couldn't pay everything upfront.

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[hmills653 365]

I have a $3100 deductible. I pay 100%of any medical costs each year until I met that deductible. After that, I pay 10% and my insurance pays 90%. My yearly out of pocket maximum is $5000. So once I reach $5000 I pay nothing else. This includes the $3100 I pay for deductible and anything else until it reaches $5000. Hope that helps.

[courtneyd 59]

On 1/22/2017 at 8:50 AM, sabrinamena said:

I was approved by my insurance (BSBCIL), but now I am very confused about what part of the cost I will be responsible for. My deductible is $750. Coinsurance 75/25. Out of pocket is $7,150.

When I spoke to the surgeon's office they said for example if I had surgery that day since I had not met my out of pocket that the hospital would ask for the entire $7,150. Which is a little (a lot) more than I was expecting.

I was under the impression that I would be responsible for the deductible, and then 25% after that until it reached out of pocket max?

Please help me understand!

Sent from my iPad using the BariatricPal App

You will pay your deductible of $750. Then your insurance starts to help pay, that's when your co insurance kicks in. So you're responsible for $750 plus 25% of the total cost up until $7,150. You will not pay more than that towards your health care (your deductible is sometimes put towards your out of pocket, that depends on your plan).

With such an expensive surgery, I would be prepared to pay all $7,900 out of pocket (depending on if you've met that elsewhere so far this year). When the hospital calls to tell your your benefits, you can ask for a payment plan and they will usually work with you on a down payment, especially since your insurance is going to cover so much of the surgery.

[crystalrae 16]

I have highmark BCBS, and when I log in online I can see my policy and get estimates based on my insurance for the cost of any procedure. I'm not sure if BCBS IL has it, but they're the same company so they might. They had bypass and band as options, but not sleeve, but I'm sure bypass is close to sleeve. The estimate included EVERYTHING, hospital surgeon, blood work, ekg, etc. And depending on the hospital it shows the different prices. It was crazy to see how one hospital the bill was 27k-30k, and the hospital I'll be doing it at is 13k-17k. It also explains the breakdown of what your total estimate might be.
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I have the same insurance. What is your out of pocket expense?

[Monasmle 90]

18 minutes ago, crystalrae said:

I have the same insurance. What is your out of pocket expense?

My out of pocket is $300 deductible, which I've already met with the sleep study.

[crystalrae 16]

Yeah I'm thinking mine is fully covered too but I had other insurance at first and they said they cover [emoji817] as a secondary but I lost the other plan so hopefully it pays [emoji817] as the primary too

[courtneyd 59]

I have the same insurance. What is your out of pocket expense?

An out of pocket max is different than a deductible. Make sure you call your insurance company so you have a full understanding. I would just hate for you to get a bill and be shocked.

[bcl1628 26]

Did you ever get an answer to this?

I have Highmark of DE. My coinsurance max out of pocket is $500. But there's also a "total max out of pocket" that's like $7k. According to the Highmark glossary, the coinsurance counts towards meeting the total out of pocket costs of $7k. What ridiculous terminology! Did you find out what your out of pocket is going to be?