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%

Emergency Room Copay
In-Network $50
Out-of-Network $50

Urgent Care Center Copay
In-Network $50
Out-of-Network $50

Specialist Copay
In-Network $5
Out-of-Network $50

Rehabilitation Therapy Copay
In-Network $5
Out-of-Network 20%

Allergy Copay
In-Network $5
Out-of-Network 20%

Mental Health Copay
In-Network $5
Out-of-Network 20%

Outpatient Services Copay
In-Network $0
Out-of-Network 20%

Hospital Inpatient Services Copay
In-Network $0
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.

Please give me your advice regarding the matter...

Thanks

John

No matter what you read on the net, I suggest you take your policy to the out of network hospital and also talk with the surgeons office to make sure there are no surprises. You are not the only or first one who has asked them the same questions. And ,your insurance company can also answer these questions. Good luck.

No matter what you read on the net, I suggest you take your policy to the out of network hospital and also talk with the surgeons office to make sure there are no surprises. You are not the only or first one who has asked them the same questions. And ,your insurance company can also answer these questions. Good luck.


What questions should I ask? Would they give me anything in writing?

One thing to be cautious of is that when your carrier says they will pay 80% of out-of-network charges, it usually means that they will pay 80% of the "usual and customary" charges, meaning the rate that they deem acceptable for the services rendered. If you happen to see a provider who charges a higher rate, then you will pay your deductible, 20% of the usual and customary charges, AND any excess charges if the provider bills at a higher rate than what is considered U&C. Example -- Let's say that the bill for your surgery is $10,000. You pay your $200 deductible, which leaves $9800. Your portion (20%), would normally come to $1960, but since your max out-of-pocket is $1200, that's all you should have to pay. However, if your insurance carrier says well, the usual and customary fee for this surgery is only $8000, so we will only pay 80% of that amount, then the out-of-network provider would come to you for the difference, which in this example is $2000. You might be able to find out from your insurance carrier's Claims department, especially if you are able to obtain procedure codes for whatever you're having done. You could call and ask what is considered U&C for those particular procedures, and compare this with what the out-of-network provider charges for those same procedures, to estimate whether you'll get hit hard with excess charges. You really have to be careful with out-of-network services because your plan appears to cover so much of it, but that's not always the case. You don't get the write-off of excess fees that you would if you were using an in-network provider. Hope this helps!

I would first call the hospital and ask them what network they belong to, then tell them the name of your insurance company and that you are out of network. If they say o.k. I would call Guardian and tell them you are going out of network and ask them to explain how your maximum out of pocket, out of network works. If they verify just ask for the name of the person who you talked with. The only thing in writing you will have is a copy of the policy, but it sounds like you are protected. If this is major, I would go to an admissions clerk with my policy before going in to the hospital to make sure. But, that would be unusual as iou have a valid contract if your premiums are paid. The major problem in situations like this or major treatments are that the individual did not make full disclosure on their application. good luck!