Insurance Question

Ok I have a question I hope someone can answer.  I have bcbsm and my deductible has been met for the year.  So my responsibility is 20%.  My question is for Roux-en-Y Gastric Bypass surgery what would is a rough estimate of what I would be paying out of pocket.  I am seeing Dr. English from Marquette MI.  I asked my ins. before what I would be looking at and this was before my deductible was met and they said $1700.00 no more than that.  But typically this kind of procedure is around $25000.00 and 20% is $5000.00.  I really am sick now because I don't have that much.  Can anyone give me an idea if I am right on this. Thanks!

Most insurances have what is called a stoploss or out of pocket max.  What this means is that  your 20% responsibilty reaches a certain point - BCBS would pay at 100% of the approved amount. 

Example:   A person has a 500.00 deductible.  After that deductible has been met, your clais are paid at 80% of the approved amount with a 20% coinsurance.  The 20% coinsurance is the patient's responsibility.  When their 20% responsiblity totals 1200.00 the claims are now paid at 100% of the approved amount for the remainder of the year.  Your total out of pocket for the year is $1700.00.   The 500,00 ded and the 1200 stoploss or coinsurance maximum. 

If your doctor does not participate with BCBS, you will be responsible for any balance between the doctor's charged amount and the BCBS approved amount. Call your customer service department. Ask them - 1.  Is Dr. English a participating physician?                      2.  What is your out of pocket coinsurance maximum.                       3.  How much of this out of pocket coinsurance maximum is remaining. 

The answer to #3 will be what you owe. 

If you have any other questions, let me know. 

Thank You so much.  My doctor is in the network for my ins.

I had BC when I had my surgey and I payed a little under 500 and that was with the ppo options.  Plus If the hospital and doctor participates with BC they are agreeing to take what BC pays with a contractual write off.  So your copay will be under the max allowed amount.  Tricia