Can someone tell me about Max-Out-Of-Pocket?

[FatButNotHappy 0]

I recently found out my insurance Aetna, will pay for bariatric surgery. However, it isnt cheap.

I have an $1100 deductible and they will pay 80%. My max out of pocket is a whopping $4000 (on my husbands plan, i believe it is $1500 max and that $4000 is for our whole family--so, YOUCH!)

So, my questions are: Does that $1100 deductible count in the $4000?

Also, would 20% of the surgery equal up to $4000? could it potentially be less than the $4000 max-out-of-pocket or should I just assume that I will be paying $4000 for this surgery? OR--would it really be $5100 if the deductible isnt inlcuded in the $4000?

Thanks a lot.

Stacie

[Mojo08 0]

Hey there,

You are lucky to have an insurance plan to cover the cost! I paid $15 000.00 out of pocket and have to travel 4 hours for fills and follow up at my expense...worth every penny though!

Good luck!

[Sue Magoo 71]

Stacie:

Insurance plans vary tremendously depending on what the employer selects with their provider. You really should call the number on your insurance card and ask them.

By the way, usually if you have $1,500 max out of pocket, and your family out of pocket is $4,000, then the $1,500 would apply to each person individually until the $4,000 family cap is met.

Please get clarification from your insurance representatives.

Best wishes to you. I love my band!

Sue

[KyBandChick 3]

I have an $1100 deductible and they will pay 80%. My max out of pocket is a whopping $4000 (on my husbands plan, i believe it is $1500 max and that $4000 is for our whole family--so, YOUCH!)

So, my questions are: Does that $1100 deductible count in the $4000?

Also, would 20% of the surgery equal up to $4000? could it potentially be less than the $4000 max-out-of-pocket or should I just assume that I will be paying $4000 for this surgery? OR--would it really be $5100 if the deductible isnt inlcuded in the $4000?

Read your benefit book. My insurance out of pocket max does not include my co-pay or deductible and the amount for the max is for the individual or the family. I too have Aetna and my benefit book is pretty clear.

If your surgery were lets say $15,000 then your would subtract your deductible (15,000 - 1,100)=13,900*0.2=$2,780+1,100=$3,780 out of pocket cost. If the surgery cost were higher you shouldn't have to pay more than $4,000. I am not an expert but I believe that is how it works.

[FatButNotHappy 0]

OH, i am on my plan by myself. I didnt add the rest of the family to the plan because the only reason I got it at all was for this surgery. So, my individual cap is $4000. Boo.

I tried to find the info on Aetnas web page, but i can find anything about co-pays for each visit (nutritionist et al) but would those appts go into the OOP or the deductible? I am sooo confused. I have already called the insurance company and i am still confused.

Do the co-pays (for the dr visits) go to the deductible and do those go to the OOP?

The insurance lady at the surgeons office was confused too because she said i had a $1100 deductible, then i had to pay the next $4000 and only THEN would they pay 80%. Boy was i depressed after she told me that. I am glad i called Aetna and figured out she was wrong. :cool: After the $4000 they pay 100%.

Another question is....if you go to an OUT of Network doctor, is the max OOP still the same? I know they only pay 60/40 instead of 80/20....but if the max OOP is the same, then i would really like to see Dr. Curry (cincy ohio) who is not in my network.

Edited January 10, 2009 by FatButNotHappy

[dlmyvette 12]

WOW....I can understand that concern. However, I would have rather paid 4K than 14K. The only thing I do know is that I'm glad I did it. I had my surgery almost 2 weeks ago this Tuesday and I've lost 16 pounds. That is what I LOVE!!!!

Good luck!

-Yvette

[Band_Groupie 3]

I don't know if this will be any help, but I called my insurance yesterday so I can tell you what mine is (as someone else said, call yours again and if you're getting confusing answers ask to speak to the reps. supervisor). I have Highmark PPO Blue (BCBS). I have no co-pay, my deductable is $250 per individual and $500 per family. All my Dr. visits go toward this deductable (PCP, Psych, NUT, surgery, etc.), so my first few visits each year, no matter who they are with I get huge bills until I've reached that $250. After that I pay 10% of everything (again no matter who I'm visiting, up to my max which is $1000 per individual and $2000 per family (the $250 deductable IS included in my $1000 max). After I reach $1000, I'm covered 100% up until 2 mil.

So the bottom line for me is I'll reach my $250 deductable with other Dr. visits long before my surgery. Let's say I only reach that and haven't done any 10% visits...so now I've got $750 left toward my max. My surgery will be way more than $7,500, so I know that paying my 10% I'll definitely reach the $1000 max.

Perscriptions-Keep in mind the prescription part of my insurance policy is totally different, so you'll have to plan this into your costs as well (even if all you need is pain killers to go home with).

Copay- In the past I've had plans like Aetna with a co-pay and in those plans the co-pay would also go to my deductable/max.

Out of network- on the plan I'm on now, if I go out-of-network ALL the rules change, my deductable, my percentage, my max, everything...I would end up with most of the costs. I've read people have gotten pre-approval to go out-of network from their insurance co. (usually because there is not a doc in their area), but be really careful with this if you try it and make sure you have pre-approval for both the Surgeon AND the hospital bills as these are totally seperate (I've seen people have pre-approval for the surgeon and then get stuck with the huge hospital bills).

Again, write down what you think you know and call your insurance co. again. If you can supply them with estimated bills (ie. "My surgeon will charge $$$ and the hospital billing person told me to estimate $$$$") then the insurance rep. should be able to tell you exactly what your costs will be.

I hate insurance...good luck!

[Band_Groupie 3]

Oh, and always write down Date, Time, and Name of the insurance rep. and what they told you. You may need it later if there's a problem.

[susan1961 0]

FBNH: If it's just you you should only have the individual max out of pocket, not the family max of $4000. Usually the deductible IS part of the max. Good luck with all this.

I spent nearly $20K out of pocket and consider it money very well spent!

[FatButNotHappy 0]

FBNH: If it's just you you should only have the individual max out of pocket, not the family max of $4000. Usually the deductible IS part of the max. Good luck with all this.

I spent nearly $20K out of pocket and consider it money very well spent!

Oh, the $4000 IS the individual max. Can you believe that? Pretty crappy, huh? I work for a big, nationwide corporation in the HEALTH CARE business. I would think my insurance would be better, especially after reading on here how great other's coverage was.

A year ago, I was willing to figure out a way to self-pay. I decided I would wait to see where I landed my first job to see if the insurance would cover it and YAY...it does.

[burtonfeather154 0]

I have a $2000 out of pocket max and a $200 copay. I have to pay $2200 on Tuesday. Still ouch, but I put mine in my health care spending account.

Good Luck

[Kyha 0]

Hi there,

I too have Aetna. But my company's plan is the Aetna POS Open Access II. My max out of pocket is $2,500 annually. I have a $500 ded. My Aetna plan covers 90% for both outpatient and inpatient surgery at a in-network hospital.

For my coming surgery on Jan 22, 2009. I was told to bring $1,500 (this includes my $500 ded). If I pay my portion upfront, the hospital will give me a 25% discount.

By the way, the hospital billing Aetna $10,500+

Thank you

K

Oh, the $4000 IS the individual max. Can you believe that? Pretty crappy, huh? I work for a big, nationwide corporation in the HEALTH CARE business. I would think my insurance would be better, especially after reading on here how great other's coverage was.

A year ago, I was willing to figure out a way to self-pay. I decided I would wait to see where I landed my first job to see if the insurance would cover it and YAY...it does.

[KyBandChick 3]

When it comes to insurance it really has nothing to do with your plan name and everything to do with what your company is willing to pay and how they have set up their plan. I have different out of pocket max for in network and out of network ($2500 in and $7500 out). I am going to an out of network Dr but my surgeon office told me only their fee ($4,000) is considered out of network (as he only accepts 1 insurance company) and the hospital fee is in network so I get 50% of the Dr fee and 80% of the hospital.

[Cate18 0]

I definitely agree with the post above me. What the insurance company covers, according to my doctor, is not what my husband's company policy regarding LapBand is. So although they say it's covered, the stipulation with my husband's company specifically is that they cover only 50%.

Their policy with the 50% I have to pay is that it is NOT included in the deductible. If the people answering your call at your insurance company aren't being forthright be sure to ask to speak to a supervisor. You're spending enough money so that they can clarify for you !