question about max out of pocket and deductibles?
hi, i am just starting my WLS journey. i know that my insurance will pay 50% of costs related to weight loss surgery. the question i have is this: my yearly deductible is $250.00, and the max out of pocket is $2000.00, so does that mean that if my half is over $2000.00 they (the insurance co) has to pay it even if it is more than 50%? i am new to insurance and sooo confused. here is what it says on their website:
the surgeon that i picked and the surgery center that he uses is in network. can some one please explain this to me? thanks so much in advance.
Individual Plan Year Deductible |
Individual Plan Year Out of Pocket |
||
PPO (in-net) PPO (out-of-net) PPO (out-of-area) Lifetime Maximum: In-network Out-of-Network |
$250.00 $750.00 $250.00 |
$2000.00 $4000.00 $2000.00 $5,000,000.00 $5,000,000.00 |
djgsmom,
The first reply to your question was a great explanation. One thing I might add is that you should look for exclusions in your insurance. For example, my insurance has a $1000 deductible and $2000 max out of pocket expense and normally pay 80/20. HOWEVER--with WLS they only pay 60/40 AND it does NOT apply to the out of pocket max. Which means I will pay 40% of whatever the cost is PLUS the deductible no matter what it costs.
Kari