Help with insurance lingo

Hello all!
I am interested in having gastric bypass surgery, but I am confused with the way my insurance works.  My hubby's insurance has recently changed, and now our deductible is $10,000! Well the good thing is that it does cover weight loss sugery. My question is this (and I'm sure it may be a stupid question):  When will I have to pay this, and who do I pay? Is this an amount that I will have to pay BCBS, the hospital, or my surgeon? Can I be billed this amount after surgery, because I don't have this kind of money. I'm so completely loss. Any and all answers will be greatly appreciated, but please explain it to me like i"m a 2 yr. old, lol.

Thanks!!!

It is definately is not a stupid question. You will not have to pay this to BC/BS. It will have to be paid to your providers. Since you are still early in the process, my guess is that it will be paid to the providers that do your pro-op testing, i.e. psych, labs, your surgeon, as well as some for your actual surgery. The providers MAY require that you pay it before you have the procedure since it is such as large amount.

If you don't already have a copy of the plan, get one ASAP (his employer has to provide this). Then, take a GOOD look at your policy so you can determine the following:
 
Is it a HDHP (high dedcutible health plan)? If so, does your hubby's employer help to cover some of the deductible through an HSA (health savings account)?

Are there some services covered before the deductible (this could be possible with several types of plans)?  Also, do you have to pay a percentage after the deductible is met?

Is there a limit as to how much the insurance company will pay towards WLS (aka WLS Cap)?

Is there a MOOP (maximum out of pocket) for the policy and how much is it?

You definately need to read all services so you know exactly what to expect so you can be prepared.

Good luck!!!

Thank you so much for your response and insight. This was very useful information. I do know that once my deductible is paid that I don't have any copay, and everything would be covered 100%. I just have to come up with a way to pay the deductible.

Wow.. and I thought my $5K ded was bad!

You know, if you don't have your heart set on bypass but a sleeve instead, it would actually be cheaper to go to Mexico. :o/

Sleeves ROCK!

Thanks for your response. I'm not really set on having gastric bypass, but I'm a little nervous about going out of the country.  How was your experience in Mexico? I didn't know if it would be worth it, with paying for airfare, hotel fees, etc.  About how much did you end up paying including all expenses? 

I had to pay a near 8k by the end of my surgery in co pays.  However some of the funds were eventually refunded.  The healthcare process is definately a maze these days.  Keep in mind deducting expenses from your taxes as that was a help to me.  Perhaps the facility or Dr. would consider a payment plan?  Deductibles can be for any other health needs that can be applied to it per insurance specific regulations.  Best of luck to you!!

Much to say here regarding MX and bypass. ;o)

Bypass, it's a trade off. You'll lose the same with bypass as you will with a sleeve, statistically speaking. The trade off is faster weight loss with bypass in exchange for a lifetime of malabsorbing nutrition. You'll only malabsorb calories for 6-24 months but you'll malabsorb nutrition forever. With bypass you have high risks for vitamin deficiencies, reactive hypoglycemia, and dumping, you also risk bowel obstructions for life. About 3 years post op bypass you are seriously metabolically challenged so losing a pound 3 years post op is not like losing a pound today. And in the end you have to follow a sleeve diet to maintain anyway. So is the trade off worth it?

Bands are horrible surgery types, sleeves are the safest surgery type long term, bypass is great for people with severe reflux not caused by obesity or a hiatal hernia, and DS provides the best weight loss long term.

Sleeves... it removes Ghrelin produced by the stomach and Ghrelin is what tells your brain you are hungry. Most sleeved people don't experience hunger often. About the only time I do is if I eat a lot of white carbs. Then the blood sugar spikes cause hunger. But otherwise, I might experience stomach hunger a few times a year. Bypass requires lots of labs, sleeves require far fewer labs since we don't malabsorb.

Bypass folks often times dilate their stoma. Food acts like a water slide down their esophagus, through their pouch, and into their small intestine, they are always hungry and since they aren't malabsorbing anymore the regain starts. Since they are metabolically challenged they have a hard time losing that regain.

Sleeves... perfect restriction forever, your pyloric valve isn't stapled off so you have a fully functioning smaller stomach minus the Ghrelin.

Mexico... much to say about that. There are really great doctors and bariatric butchers in every country including MX and the US. See this:

http://wasabubblebutt.blogspot.com/

Those are examples of US and MX surgeons that are questionable.

This is why research is critical regardless of who does your surgery in any country and you do it this way:

http://wasabubblebutt.blogspot.com/2010/03/researching-mexican-or-us-sleeve.html

I went to a fantastic surgeon and a fantastic hospital. I had my band there and then I revised to a sleeve there. I'm having my plastics done at the same hospital as well.

You just want to avoid Tijuana and Juarez, they are too dangerous and really, IMHO there are no good bariatric surgeons in Tijuana or Juarez anyway. When the US, MX, and Canadian gov'ts warn about Mexico it is not the entire country they are warning about, it's very specific cities.

You know, most of the popular MX surgeons have more experience than most US surgeons. They have been doing bands for 10 years longer than US surgeons, they were saying years ago sleeves are the way to go. US surgeons were drinking Allergan's kool aid and they were just sure bands were the way to go. Turns out the MX surgeons were right but they've been doing stand alone sleeves longer than US surgeons so of course they had experience with both.

I can't speak for all the doctors in MX but my surgeon... there are no hotel fees. He keeps you in the hospital until you are okay to go home. Two nights for bands, three nights for sleeves, and a week or so (I forget if it is 6-7 nights) for bypass. I don't know how long he keeps you for DS. You arrive the day before your surgery for pre ops and then you do go to a hotel the night before surgery. That's included in the package price and the doctor's driver provides ALL transportation from when you arrive in San Diego, from hospital to hotel, from hotel to hospital, and from hospital to the San Diego airport. So, no transportation costs once you arrive in San Diego.

I paid more because back in the day it cost more! ;o) Today it is $8750 and figure in a $250 airfare ticket. You are talking $9K for surgery in a US inspected, Joint Commission Hospital.

http://www.jointcommission.org/

My surgeon has done well over 1000 sleeves, thousands of bands, around 500 bypass and I don't know how many DS. His stats are great. My sis is considering a sleeve and I won't let her go anywhere but my surgeon.

There is much to research regardless if you stay locally or travel. My surgeon is my personal pick, that's why I went to him! ;o) But he's not the only good surgeon in MX, there are about three that I would personally go to.

So how was my experience? I had perfect surgery twice and I plan on having two more perfect surgeries for plastics. At the time I lived in Phoenix and so my surgeon was driving distance for me for aftercare with a band but there is no aftercare for sleeves.

My surgeon is a proctor surgeon, meaning he travels the world one week out of every month teaching other doctors sleeves and bypass. He was previously a proctor surgeon for US docs when the band was approved in 2001.

BTW, regardless if you have surgery in the US or MX don't forget, all your expenses are tax breaks if your income qualifies. ;o)))

OMG!!! That was some really good info! Thank you for breaking everything down for me, I needed that. So after reading your post, I'm really considering looking into doing this in MX. I was a bit scared to even think about getting surgery done there, but after reading what you wrote, I'm really excited, and the price is considerably cheap. Thanks again!

There are some seriously fantastic surgeons in Mexico. I have had surgery twice in Mexicali and will do my plastics the same.

Just do your research, don't pay high deposits, before paying the deposit get it in writing if it is refundable or not. Pay your deposit with a credit card when possible. That holds true for the US or MX.

A sleeve is a great procedure for MX because there is no after care, you have surgery and you are done.

If you check out the link in my sig you can see how to research surgeons.