Need Advice Regarding Out-of-network Benifits For Upcoming S Posted: 04-01-06 19:24pm
I am scheduled for surgery on 4/11/2006 at
the hospital for special surgery in nyc.
Everything is out of network including my
surgeon.
I have guardian healthnet for insurance
and my benifit break down is as follows:
copay
information (the amounts and
percentages are what I am responsible
for)
------------------------------------------
-------
office visit copay
in-network $5
out-of-network 20%
my out of
poket maximum is $1200 for out of
network with a $200 deductible.
The policy defines out of poket
maximum as
individual out
of pocket maximum the maximum
dollar amount generally includes
coinsurance / deductibles and copayment
for which the member is reponsible in a
calendar year. Once satisfied, no
additional copayments, coinsurance or
deductibles will be required for the
individual member for the remainder of the
calendar year.
the policy defines hospital
inpatient services copay as
hospital
inpatient services copay inpatient
services in a hospital are covered,
subject to the scheduled copayments.
Some plans, however, charge a flat dollar
amount or percentage of the inpatient
admission copayment. Benefits for
hospital care are limited to the
hospital�s most common charge for a
semiprivate (two-bed) room. If the
member elects to have a private room, the
member is responsible for any amount over
the semiprivate room rate, plus the
copayment called for by the plan. If the
participating provider group (ppg) or
qualified physician has authorized a
private room as medically necessary, the
member has no financial responsibility
beyond the required copayment.
i am prepared to pay the $1200 dollar max
because I set up my flex plan for that.
My real concern is having to pay anything
above and beyond that. Is the out of
pocket max the only thing I need to worry
about? Can I get hit with more
expenses?
Please give me your advice regarding the
matter...
