Question:
Out-of-pocket maximum

I have BCBS PPO. My policy states that in-network coverage has a $100 deductible and a 10% co-pay with an out-of-pocket maximum of $600. Out-of-network coverage is a $100 deductible and a 20% co-pay with an out-of-pocket maximum of $1600. Just today I rec'd one of my EOB's from the insurance. Obviously it contains just a small portion of my total charges. This statement shows the total charges are $10,745.80 and the allowed amount is the same total. There is still question as to whether it will be billed as "in-network" or "out-of-network" as my surgery was 1/13/04 and up until 12/31/03 this facility was "in-network" but at the time of my surgery had not yet signed the contract with my insurer to be in network with this PPO. Regardless, my understanding from HR and the insurance co. was that my total out-of-pocket, even if it were out-of-network would be $1600. But the EOB shows my deductible of $100 and my "co-insurance" amount being $1781.68 - is the EOB a reliable source for the "final" cost, or should I wait on the bill from the hospital? Are these charges "adjusted" in the future to reflect my out-of-pocket maximum or does it look like they will require me to pay more than the $1600? I know to expect more EOB's and such being that I had complications, a second surgery, and a 6-day hospital stay......so it will no doubt be much more than $10,000 - just curious about the maximum out of MY pocket.    — Emijade (posted on February 21, 2004)

February 22, 2004
Your cost should be no more than out of pocket of $600 I had to pay my out of pocket of $850 to the hospital before I was admitted for my Lap RNY. Since, you had surgery and have not paid as of yet...I would not pay till I recieved a notice of payment to the hospital/etc. It would be like pulling teeth to get reimbursed for monies paid to them by mistake, before insurance settled with them. Or call your insurance and ask. These days and times it's our responsiblity to check and know these things in advance. We have to be informed and know what the cost is and what is covered by insurance or we may have many bills to pay long term. Give them a call. I called for everything and knew just what was what when it came to my surgery for Lap RNY and Mammaplasty (9 months post op)in 2003. I didn't want any surprizes! Good Luck.......
   — Hazel S.

February 22, 2004
You 'max' out of pocket out of network could be more than your 1600.. The 1600 max is 'what' the insurance covers. out of network.. If you have charges 'above usual and customary' these will be YOUR responsiblity. If you were charged for a private room when they only pay semi private - these would be 'your' responsiblity. In network 'above ususal and customary is usually 'written off' not so out of network. Hopefully your hospital will 'get in network'.. good luck.
   — star .