Question:
My insurance covers for out of network services....

My plan states "Plan pays for 70% of next $5,000.00 of covered services after a $300.00 individual deductible is met and pays 70% of the next $10,000.00 of covered services after a $600.00 family deductible is met." At the risk of sounding stupid, what is the amount that I will have to come up with out of pocket. My plan also has an out of pocket maximum that states "After you have reached the maximum associated with the coverage option you elect, (which is above), the Plan pays all further allowable covered expenses incurred in that year at 100%. I am not educated in insurance areas, especially ones that are worded as such. Any information that could be given to me I would greatly appreciate. Thank you.    — Stephanie W. (posted on August 25, 2004)

August 25, 2004
$300 deductable then the 30% of 10,000 which is $3,300. total.
   — star .

August 25, 2004
Stephanie, call the insurance up again and ask them exactly how much you Out of Network, Out of pocket is. They should be able to give you the exact amount. However if the doctor bills over the U&P (Usuall and prevaling) amount then you might be responsible for that amount also, because they are not contracted with your insurance. Ask your doctor if they bill within the U&P amount. If at all possible, it would be to your benefit to try to go to a surgeon that is within your network. This way you will know the exact amount you will have to pay, also it will be much cheaper. If you have any questions still please feel free to send me an email. I used to work for Prudential and Aetna for several years. Good luck to you and God Bless. [email protected] Erin from Florida, Open RNY 5/3/04
   — Erin E.

August 25, 2004
Find out what your out of pocket max is in dollar amounts. Then find out if they are paying the 70% of billed charges or of reasonable and customary. Also while you are on the phone with them ask what their fee max is if you were to go to an in network doc and facility. When you are dealing with out of network providers be VERY careful about knowing exactly what you will be paying. You very well could end up paying over $30k for this if you choose to go out of network.
   — RebeccaP

August 25, 2004
Keep in mind, they will pay 100% of "allowed covered expenses" also known as reasonable and customary expenses, once you have met your deductibles. If your plan is like mine, you are also responsible for all charges in excess of "allowed covered expenses". They are going to base what they pay on what they consider "allowed". Anything above and beyond is your responsibility (at least it is with my policy). I went out of network knowing that I could end up with thousands of $$ in bills but I was lucky and most was covered. Sounds like once you pay $600.00, they'll pay 70% of the first $15,000 which leaves you with about $4,500 plus deductible of $600 PLUS the excess of what is billed that insurance doesn't consider "allowed". They might bill $20,000 but only $15,000 is "allowed" leaving you with the $5,000 difference plus the $4500 plus $600. When it comes to out of network coverage, the out of pocket maximum normally only applies to "allowed" expenses. I know I sound repetitive, but I've seen several people on the boards that go out of network and are shocked and fighting the insurance co & dr.'s because they ended up owing more than they thought because of the out of pocket maximum confusion. Just be sure and check/double check your policy and/or contact your provider to verify exactly how they cover. Good Luck
   — Carolyn M.

August 27, 2004
My PS was out of network, and the only thing that saved me with the 30% that was not covered, was the fact that I have secondary coverage with my husband's plan. They picked up the balance. It is really hard to interpret these policies. I agree---call and ask. I was lucky, that even being out of network, that my PS took the amount (usual and customary) that was paid by both companies. Good luck!
   — Fixnmyself

September 1, 2004
I just wanted to thank everyone that responded to my question. You were all very informative. Thanks again!
   — Stephanie W.