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May 6, 2010 9:36 AM   Subscribe

I'm scheduled for major surgery. Fortunately, I have insurance. Unfortunately, I don't understand it. What's this really going to cost me? What does it mean for my other medical expenses for the rest of the year, both routine and emergency?

The deductible is $500. The out of pocket maximum is $3000. There are copays, like $50 for each PT visit, $50 for each specialist visit, $30 to see my GP. A whole bunch of services are listed at 20% on the Summary of Benefits.

I expect bills from: the surgeon; the anesthesiologist; the hospital; the hospital doctor; physical therapy in hospital, at home, and later at their location; occupational therapy in hospital and possibly also at home; nurse visits at home. All of these are in network. I expect the total bills to be somewhere around $70,000, but the amount that Anthem pays and that the providers accept as full payment will be considerably less than that.

Once I leave the hospital, when I've met the $3000 out of pocket maximum, if I need to see the physical therapist at their office, do I have to pay the $50 copay each time I darken their door? What about when I see the surgeon 6 weeks post-op - do I have to pay him another $50 copay? What about later in the year when I see my endocrinologist about unrelated issues, do I pay him $50 for every visit? What if the other hip gives out and I need another surgery - is that free if it happens in 2010? Am I well and truly done paying for doctors in 2010? Are there any other financial surprises lurking around the corner? What else do I need to know?

This is in Kentucky. The insurance is Anthem. I try to google and I get definitions but no big picture explanation.
posted by acorncup to Work & Money (10 answers total) 1 user marked this as a favorite
 
There are so many variables in so many policy types that there is no way anybody here can answer your questions. Have you tried contacting Anthem directly? Copy and paste the following into your browser for information as to how to contact them, toll-free right there in Kentucky.

http://www.anthem.com/wps/portal/ahpfooter?content_path=member/ky/f5/s5/t1/pw_m010378.htm&label=Contact%20Us
posted by Old Geezer at 9:41 AM on May 6, 2010 [1 favorite]


Is there a limit on your copay and does the copay contribute to the out of pocket max? You will have to contact Anthem to get a better idea of the copay vs no pay and if that 20% goes on anything you need to contribute towards.

I have a similar policy via a competitor. Son was in the hospital in Jan. We reached the out of pocket max by then. The only thing I pay is $20 copay for routine visits. I believe if he gets other services then no, I'm not paying anything since it reached the out of pocket/deductable max.

Good question.
posted by stormpooper at 9:48 AM on May 6, 2010


Does it make sense to ask the insurance company? Ultimately you might want to get a written approval of costs and consequences if the situation really is unclear.
posted by oxit at 9:53 AM on May 6, 2010


Is your insurance through your employer? If so, I would go speak to the benefits person in your Human Resources department. The person who answers the phone at Anthem is probably not going to be well-versed in your specific policy and, even if they are, sometimes insurance companies are not the best at providing you with information over the phone because they're worried about giving the impression that they will pay for things they may end up not wanting to cover.
posted by something something at 9:56 AM on May 6, 2010


You will want to add "pathologist" to your list.
posted by 6:1 at 10:27 AM on May 6, 2010


IME, you keep paying copays since they are separate and not included in your "out of pocket" amount or applied to deductibles. But other expenses should be paid at 100% once you've met your out of pocket.

Also IME, the customer service reps at the various insurance companies we've been insured through have been very helpful at walking through this kind of stuff with me when it wasn't clear.
posted by not that girl at 10:58 AM on May 6, 2010


Should have specified: YMMV. That is how it has worked with every insurance we've had, but we haven't had every insurance, so yours could be different.
posted by not that girl at 11:00 AM on May 6, 2010


In my plan, co-pays, co-insurance, and deductibles all go toward the MOOP. So you would never pay more than $3000 in one year, no matter what.

Except for meds. There is no cap on the prescription co-payments.

Honestly, until I read some of the other answers, I thought this was the case for all health insurance plans. Maximum means Maximum, right? Silly me.

Check with your insurance carrier.
posted by SLC Mom at 1:16 PM on May 6, 2010


The doctors office should be able to give you an estimate based on your insurance policy provisions. Call them and ask for it. They can go one step farther and submit an estimate to the insurance company who will then apply all their black magic formulas to it and give you an out of pocket estimate.
posted by COD at 1:39 PM on May 6, 2010


I work in benefits in Kentucky and I currently administer 2 Anthem plans.
Disclaimer, though: I'm not your benefits person, and I'm not familiar with your plans.

Here, though, are the most likely answers to your questions given the information you've provided and assuming you have a standard Anthem PPO plan:

Once I leave the hospital, when I've met the $3000 out of pocket maximum, if I need to see the physical therapist at their office, do I have to pay the $50 copay each time I darken their door?
Yes

What about when I see the surgeon 6 weeks post-op - do I have to pay him another $50 copay?
Probably not, but it's a possibility. Ask if you'll be billed for an office visit, or if this is covered in the expenses you've already paid for the initial consultation & the surgery itself.

What about later in the year when I see my endocrinologist about unrelated issues, do I pay him $50 for every visit?
If he bills Anthem for an office visit, then yes.

What if the other hip gives out and I need another surgery - is that free if it happens in 2010?
This depends. When does your plan year start? If you're not sure, think back to the last time the plan changed (rates went up, deductible went up, etc.). When was that? That likely was the start of your plan year. Some plans run on a non-calendar year (for example, a plan year from July 1 - June 30) but their deductibles and out of pocket maximums run on a calendar year. So, you could meet a deductible twice in one plan year, in that example - once from July 1 - Dec 31, and once from Jan 1 - June 30. If your plan year is the same as the calendar year, then you will have met your deductible for 2010. Keep in mind, though, that you may have a separate deductible for in-network and out of network charges. Even if you meet the in-network deductible, you could still have a separate out of network deductible to satisfy if you begin seeing out of network providers.

Am I well and truly done paying for doctors in 2010?
No. You'll still have co-pays, and if you see any out of network providers, you may have another deductible and out of pocket max to satisfy.

Are there any other financial surprises lurking around the corner?
Most likely not, unless either a)your deductible resets before your plan year renews; or b)you begin using out of network providers.

What else do I need to know?
Do you have a friend or relative who understands how claims are processed & paid? If so, and you're comfortable with them seeing your health information, have them look over your Explanation of Benefits (EOBs) that you get after the surgery. They may find errors that you would not.

Good luck - the word of benefits can be tedious and hard to navigate. Feel free to memail me if you've still got questions. Your plan is probably very similar to the ones I administer.
posted by pecanpies at 6:31 PM on May 6, 2010


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