Yesterday was such a roller coaster of a day. I woke up thinking all was well and we had everything worked out with the insurance and we'd be going to Stanford for surgery. Up. While I was at the park with my kids I got a phone call from UCD Managed Care saying her rep at Health Net is certain that we don't meet the out of pocket maximum and will have to pay 20% of the total bill. Down. She gave me her direct line and asked me to call her. I did later that day and she explained to me that we need to have two members of our family each pay $3500 in order to meet the out of pocket maximum. If we only have one member pay $3500 we keep paying our 20% until the second family member meets the $3500 max. Way down. Laying on the couch, crying my eyes out, what are we going to do, should we just give up DOWN.
Then she calls back half an hour later and says, "I just don't like this, I am going to put my name out there and document that I told you that it won't cost more than $3500 and you take your baby to Stanford for his surgery." Then I'm sobbing on the phone, I can't believe it's possible and I can't take any more of this up and down business. Then I started thinking, that's really sweet that she is willing to do that, but how do I know that just because she told us we could go means we can actually go? So I get out my Evidence of Coverage and read through it all again. And I think she's wrong. I think we really shouldn't have to pay more than $3500 for Drew's surgery. So how many people do I have to talk to, who are the right people to talk to in order to figure this out?! So, here is what it says. Tell me what you think it means.
The select 2 out-of-pocket maximum (OOPM) amounts below are the maximum amount you must pay for select 2 covered services during a particular calendar year, except as described in "exceptions to OOPM" below.
Once the total amount of all copayments you pay for select 2 covered services under this evidence of coverage in any one calendar year equals the select 2 out of pocket maximum amount listed below, no payment for select 2 covered services and benefits may be imposed on any member, except as described in the exceptions to OOPM below.
The select 2 OOPM amounts for this plan are:
one member..........select 2 (PPO) $3500
If 2 enrolled members of the same family have each met their individual out of pocket maximum amounts, then the out of pocket maximum will be considered to have been met for the entire family. No copayment or coinsurance for covered expenses shall be required from any enrolled member in that family for the remainder of that calendar year.
(none of the exceptions to the OOPM applies to us)