Deducts and OOP Max

icogburn

I apologize if someone has posted this before. I tried searching and didn't find anything.

Before starting TTC, I checked my insurance benefits. Diagnosis and testing are covered. My HSG and sonogram were denied by the insurance company even though they approved prior.  I only paid $50 at time of service. They are citing the need for more medical records. Before I begin the clomid and other sono's...does anyone know how the deductible and OOP work?

Here is my understanding...I will have to meet the deductible for anything that isn't considered a copay or under normal coverage?  Once that is met, the insurance covers based on the coinsurance amount. The deductible is split in and out of network.  (I'm staying in-network) So....if IUI and IVF are not covered, would they fall here?  Once the max is met would the insurance start to cover them?  Lord, I think I just confused myself more.Thanks for any light you can shed on this. 

Twinkie0612

IntuitiveBlue:

Here's my understanding of how insurance *generally* works.  Your situation may be different.

Example:  Let's say I have coverage for testing, but not for treatment.  My deductible is $500. I go to an in-network doctor, and have my preliminary blood work done.  I pay a $20 copay at the appointment.  The doctor bills my insurance $250 for the office visit and blood draw.  Because he's in network, that gets reduced to $100.  Because I have a $500 deductible, I owe my doctor $100 (but not more).  Until I reach the $500, I have to pay his bills, then my insurance company will take over.  Copays don't generally count toward your deductible. Once you hit the deductible, then insurance will cover at the coinsurance rate. Let's say that's 80%.  If I go to do another round of the same blood work, and it's billed to the insurance company the same way, then insurance pays $80 and I pay $20, up to the out-of-pocket max amount.  No treatment costs count toward either the deductible or the out-of-pocket max.

Hope that helps. 

This is a good explanation.  It boils down to you have to meet your deductible before your coinsurance kicks in, during this time you owe 100% of the bill. Once you meet your deductible, your insurance will start paying a portion of the bill.  If you meet your OOP max, your insurance will cover your costs at 100%.  

Anything that is specifically listed as not covered, will not be covered whether you meet your deductible/OOP max  or not.

Svenny1011

PP described it well. If it explicitly says treatments are not covered, then no, the deductible does not apply. Everything billed for IUI, IVF, etc will be totally out of pocket for you. 

My insurance is the same - diagnosis is covered once I meet my deductible, anything treatment that is used solely to get me KU isn't. Now, I was told on the phone that all my lab work would be paid OOP until I met my deductible. However, when I looked online today, my insurance covered it all, even though 3 people there told me differently. You just never know with these folks.....

icogburn

Thank you all. You have been extremely helpful.