How Do YOU Interpret This?

I copied and pasted the information below directly from my BC/BS policy so you can read word for word exactly what it says. Here is my situation. I hope to be having surgery pretty soon in Marietta, GA. The hospital my surgeon uses is "in-network" with my policy. My surgeon, however, is "out-of-network". The way I read my policy is this; After I have reached my annual out-of-pocket maximum ($2,000) then BC/BS should pick up the rest at 100%. BC/BS told me today that is not what my policy states (read it for yourself). They said I would have to pay up to $2,000 for the in-network hospital, and then an entirely seperate $2,000 for the out-of-network surgeon. I swear I can call these people 3 different times, talk to 3 different people, on 3 different days and come away with 4 different answers.   Insurance gurus please help. Or anybody sane for that matter. I'm (almost) not sane anymore.



Out-of-Pocket Maximum
Total amount you pay toward covered medical expenses in one
calendar year (includes deductibles)
$2,000 per person or
$4,000 per family (combined network and out-of-network)

Very confusing indeed!

My policy (I have BCBS of MN) says:

$1,500/person or $5,000/family for In-network
$2,500/person for out of network - no maximum out of pocket for family out of network

So, this means that I could have a maximum out of pocket of $4,000 for the year.

for my family, the out of pocket is $5,000 for in network PLUS $2,500 x # of family members for out of network, so I am best served to pick an in-network dr.

One other thing - my out of network policy only pays a percentage of the allowed amount.  Since the provider doesn't have an agreement with BCBS to reduce fees to an allowed amount, I have to pay any difference over the allowed amount. 

The way your policy is written is very confusing.  Perhaps there is more to the description?

If you log into your BCBS account, there is usually a section that gives you the actual accounting spelled out clearer.

It is very simple.  The out-of-pocket maximum is defined as as a cap on how much the insured will be responsible for paying all covered medical expenses incurred in a calendar year, including deductibles and coinsurance (as in sharing the risk between the insured and the insurer), in addition to regular premiums.  After the cap is reached, the insurer shall pay 100 percent of all medical expenses for the rest of the year.