Question:
How much should I have to pay?
I have Cigna PPO and I was wondering how much I should have to pay out of pocket for surgery. My plan pays 100% after co-pays and deductible for in network providers. My surgeon and hospital and all the pre-op doctors are in network except the psych. According to my plan Dr. visit co-pays are $15 my deductible is $50 and inpatient hospital is $100. The way I am understanding this is I should only have to pay $150 total for the surgery and $15 for each doctor's visit. One thing that worries me is my plan says there is an out of pocket maximum of $1,500 excluding deductible and co-pays. So how can I owe this ammount if they pay 100% after co-pays and deductible. I am having a hard time with money right now and really want this surgery and can come up with the deductible and co-pays but can't be out much more than that. Also my plan covers 50% for out of network outpatient mental health so I should only have to pay half of that bill, right? Thanks in advance, — Marjorie F. (posted on October 8, 2002)
October 7, 2002
If you are reading the policy right, sound like the $150.00 is it. I would
just call your customer service # on the back of your card and ask.
— Sharon H.
October 7, 2002
Nothing ever seems to work out that way. I have the same insurance. There
are hidden charges for instance you will be getting blood tests which your
insrance will cover all but $.49. Crazy huh? If everything is in network
your bill will be low. If not the Dr. can charge whatever they want and
Cigna will ONLY pay thier normal charges. If Cigna says it is normal for a
Dr to charge $100, for a psyc eval and your out of network guy charges $200
Cigna pays $50 and you pay $150. But it will not be alot. Good Lux
— Robert L.
October 8, 2002
ARe you certain that these are your co-pay percentages and deductibles? If
so, you have a great PPO Plan, most plans are 80/20 or 90/60 plans, seeing
a 100% plan is pretty remarkable. I would definately double check
w/customer service or at least review your policy veery carefully.
The Out of Pocket Maximum refers to the most you would have to pay before
your plan begins to pick up 100% of the charges, the Out of Pocket maximums
are different for In Network and Out of Network Doctors - be sure you check
on that as well. Also, when you're in the hospital, you may not always be
seen by IN Network doctors, so that's another "hidden" charge to
be on the look out for, that and lab work, the lab may not always be part
of the network either. Just because a facility is part of a participating
network, not all the doctor's that work there are part of the network -
ESPECIALLY the Anesthesiologists, they pretty much work on their own.
Unless you have an HMO, you never really know up front what your out of
pocket expenses are going to be! With that in mind, check carefully to
ensure what your plan covers. Keep in mind that IN NETWORK are paid at a
perecentage of a negotiated rate - doctors are contracted to accept the
insurance carriers payment as payment in full - they cannot balance bill
you! OUT OF NETWORK doctors are paid at a percentage of usual and
customary charges (they base that amount on what other doctors in the area
charge for the same/similar procdures), they WILL Balance bill you for what
the insurance didn't cover, they pretty much want payment in full for the
amount billed.
— Rosario T.
October 8, 2002
I have Cigna PPO. Check your policy to make sure it is the same, but I had
to pay $1,250.00. That was my out of pocket maximum for everything. BE
CAREFUL!!! Make sure everything is in your network. If it isn't, call and
tell them to cover it in network. I called before surgery to inform them my
hospital was out of network and they said it would be covered in network.
now they are saying it is out of network. So just gets names and such of
people you talk to. I am in an appeal right now trying to get my insurance
to cover my hospital as in network. If you have any questions, please feel
free to e-mail me.
— sammygirlwpc
October 9, 2002
original poster here:
Yes my plan is 100% for in network. The out of network amounts are 80/20
,deductible $200, out of pocket maximum $3000, inpatient hospital is 80%
after $250 per admission. The anesthia I think is out of network but I was
told by someone that they pay in network if performed at an in network
hospital and pay out of network if performed in an out of network hospital.
And the lady at insurance said if we approve the surgery that includes all
related charges. I haven't been approved yet but am in the process and just
want to know upfront what kind of hidden charges I might encounter before I
go through with this.
— Marjorie F.
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