question about max out of pocket and deductibles?

djgsmom
on 4/25/08 4:04 pm - Conway, AR
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:

 

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

  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.
(deactivated member)
on 4/25/08 10:53 pm
Kari J.
on 5/1/08 11:07 pm - Ankeny, IA
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
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