Saturday, April 26, 2008

Just when you think it's over...

It's not.

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.

Out-of-Pocket-Maximum-Select 2
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 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)


Jennifer Herring said...

Hi Andrea,

I'm sorry that you're having to deal with all of this insurance mess. I agree with you though. The way it reads to me is that once the $3500 is reached for an individual, you can't be charged anything else for services for that individual. The two members of the family thing is only talking about a FAMILY maximum. Once two members meet the maximum, you can't be charged for services for anyone in your family. I don't see why she would think that affects the individual maximum at all.

I hope you get the answers you need soon! I'm praying for you...


Kathy said...

I'm sorry Andrea....and I'm NO help with the all BLOWS my MIND!! But...I hope you do find definite answers and you can just relax until surgery comes...the worry about your son is enough...
I hope you can put this all out of your mind, enjoy your kids, husband, and this wonderful weather....worry again on Monday. (easier said than done..huh??)
For me...I'd just have the surgery...and let the bills come. They could bill me ALL they wanted..and i'd pay them a big fat $5 a month for the rest of my life!
Oh...I just can't get started on makes my blood boil and I get too's better to think about the good things!

Shannon said...

Hi Andrea
We have a similar out of pocket arrangement. Ours is $3000 per person if it is just an individual insured. However, as with yours... if there is a whole family insured then you have to pay double the individual co-pay.

Unfortunately, I think that is what it means on yours so the notation on your file from that agent is important!

If a family is insured you have to have two people (ie $7,000) paid before the family out of pocket max is met.

We paid that in both the years Wren had surgery and it can be paid off slowly. I felt it was a good deal considering the bill was about $200K.


Anonymous said...

Hi Andrea,

I think the girl you talked to realized her mistake and thats why she called you back, and was maybe saving face. I also think that if you have to pay 7K, its still a lot better than 200K, and it can be paid off slowly. In all of my experience it isn't the individual, but the hospital that figures out your insurance for a procedure. What is Stanford saying?

Anonymous said...

You have a church family that can help as well. Have the surgery and let God take care of your family emotionally, physically, AND financially. He will!!

Our Family said...

Well, I just read the comments that agree with BOTH situations, so now I don't know. When I read it myself before reading anyone else's interpretations, I thought that you were out of luck. However, it just doesn't make sense that you would have to wait until another family member reaches $3500 before insurance takes over the rest. Here's an idea....someone in your family needs to create a "minor" medical mishap, to the tune of $3500 or the next 25 days...AND, remember the comment that your church, family and friends are behind you. Insurance companies bargain with the hospitals all the time, you can too!

Samantha said...

Oh Andrea...I am so confused reading through all this now...but the one thing that I am pretty sure of is that it will not be more than $7000...however, I still think that the $3500 is the maximum. I think that this is all ridiculous! These insurance companies make me so angry...they write things that they cannot even understand and it adds all this ridiculous stress and pressure to the parents who only want their babies well. I am so sorry...I hope that someone at that darn insurance company figures things out so that you can focus all your attention on that adorable family.

Heart Hugs,

The Portas said...

I like the comment about just letting God handle the financial side, too. It looks like you won't have to pay more than 7k (but most likely 3.5k is more accurate), and things will work out. I'm so sorry for the emotional turmoil this is causing you. Sending you lots of hugs!!! It will all work out! xoxoxo

Andrea said...

Just to clarify, since this is the PPO portion of our plan, we don't expect to have a second family member spend $3500 on anything. If it was a difference of $3500 or $7000, it wouldn't be that big of a deal. But it's a difference of $3500 or 20% of the total bill, which could be $60,000 or more.

Shannon said...

If Drew is the only one who is going to approach the OOP Max then I agree that after that is met you should have no further bills from Drew's care. You should only be liable for $3,500.

We talked to our insurer at length about this and there should be a manual that spells this out in even more detail than they give you in the consumer version. You can ask for a copy if you need it.

I have had two plans with these terms but yours is phrased in a rather obtuse manner. The principle is that no family should have to pay the OOP max for more than two individuals.

It does not seem that you pay more than 2X OOP max (eg the 20% overall).

In our case we paid twice because Wren had his first surgery in December and the next procedure in January (great timing) and I had delivery charges meeting my max in Dec too. PLUS Josh had an appendectomy in June. So, we paid our family max of $6,000 and then WRens max of $3,000 for 2007.

We paid no more for Wren in 2007 BUT I had to pay 20% when I had some tests run because we had not met the full family max on anyone else.

Does that make sense?

In short, I agree that you should only have to pay the $3,500! BUT
I would ask for that in writing (fax, email etc) to allay anxiety.

Shannon said...

PS. Andrea
I just remembered that our case was made so much easier to deal with the insurer by asking our insurer for a CASE MANAGER.

They offer this to people with ongoing, chronic or severe medical conditions. It is to streamline the preapproval and billing process and to give you a single person to speak to.

We were told to do this by someone online and it was great advice. Our insurance "contact" manager called me monthly and was proactive in assisting. She definitely had the insurance company's interest at heart and we had to contest some decisions but we had good information on hand when we needed it.

Perhaps your insurer offers this too?