Well, it turns out I did get home with a reasonable amount of time after my mother’s cancer treatments, but then I had to deal with… insurance issues. Like, “Once you’ve reached your out-of-pocket maximum, do you have to pay the copays for doctor’s visits?” I have called the health insurance company, pored over the insurance information and documentation, went online to look at evidence of coverage and am STILL not sure.
Originally the insurance agent told me that my mother would not have to pay anything, including copays once she reached the out-of-pocket limit. But then she got a bill for doctor’s visit copays after she’d reached her yearly cap (which happened after only one month of her chemotherapy regimen; it’s that expensive!). So I called the insurance company direct and was told that doctor’s copays are not applied toward the out-of-pocket limit and she would have to pay the bill and any subsequent copays. Okay.
So we went in today and told the receptionist that we were mistaken and my mother was supposed to pay the doctor visit copays even though she’d already reached the cap. The receptionist thought that was weird and suggested I talk to the Oncology center’s financial advisor. The financial advisor also thought that was weird; in fact she’d never heard of such a thing and asked me to bring in the EOB (Explanation of Benefits) for what she thought were the doctor visit copays my mother had been billed for.
But the dates she gave us were after the ones on the bill…
I am utterly bemused by the lack of clarity in the language used in the Summary of Benefits. Under “Important information” it says:
$XYZ out-of-pocket limit.
There is no limit on cost sharing for the following services:
- Doctor office visits
- Chiropractic Services
So… From this I gather that “no limit on cost sharing” means that you must continue to share the cost without limits. Which means doctor visit copays do not apply to the oopl and you do indeed need to keep paying the doctor office copays…
Later on in the charts, they list items that are included in the out-of-pocket cap. “Doctor office visits” is not on the list but “physical exam” is. When you look at “Physical exams” it says there is no copay for a routine exam, of which you may receive only one per year. Why list physical exams under what can be applied to the oopl if you don’t have to pay a copay for them? In “Physician Services,” they tell you all the rates of copays for various types of doctors. But in many of the other categories, after they tell you the various copays they state, “you will pay these amounts until you reach your out-of-pocket limit.”
By which I deduce, again, that you must continue to pay doctor’s copays or they would have said “you will pay these amounts until you reach your out-of-pocket limit,” after the listings of the various doctor types of copays…
Are they being deliberately obtuse or is it just me?
On a brighter note, my mother is doing very well with her treatments. Today was the last full treatment and the end of the sixth cycle. She looks good, she’s feeling well, her pain is vastly reduced, and her appetite has returned. We now wait three weeks during which she’ll get a bone scan. Then we’ll go back for “maintenance” treatments with the chemo-lite drug that supposedly has no side effects… At least that’s his plan now. We won’t know for sure until the scan comes back and we see him again. But for now it looks like we might have a three-week break.
I say might because the one thing I’ve learned in all this is… you never know what a day might bring.