Horizon BCBS NJ Out of network benefits question

[Wolfy]

I saw in the sticky thread that BCBS does cover GRS. All I'm looking for is Top surgery with a surgeon in my area. I've already had the consultation but my insurance at the time wouldn't take it. I have insurance through my dad now and he has out of network benefits. The Dr office said they will work with me to try and get it covered. I have to call them when the insurance lady is in.


I was wondering usually how much is out of network benefits? (like what % do they usually cover)
Are they going to deny me for surgery based on it being a double mastectomy? or does it have to go in a certain way?
How can I go about calling my insurance and asking them questions about surgery coverage?
Any other insight would be helpful because I'm not sure how to go through with all this on my own.

[FTMax]

This should be in your plan. It's going to vary by what plan you have - you'll need the plan name and the group number associated in some cases. The insurance lady in your surgeon's office should know how to word the request to have it accepted. And you can always (and should) appeal if they say no the first time. Insurance companies almost always say no the first time.

My plan (also BCBS) doesn't have trans exclusions, so all transition related procedures fall under the surgical benefits. In-network coverage is 100% minus copays, deductibles, etc. Out-of-network coverage is 70% minus copays, deductibles, etc. Once you hit the out-of-pocket maximum, they cover the rest.

As an example, the surgeon doing my bottom surgery is out of network. I'm responsible for copays and deductibles, and any additional fees that don't exceed my out of pocket maximum. This amount includes what I'll pay in copays and deductibles. My out of pocket maximum for an out of network provider is $6k. So the most I will spend for medical treatment in a calendar year is $6k. After that, insurance pays 100%. That is why I am hoping to get as many stages in as possible before my insurance rolls over

When you talk to them, see what other things they cover. Many plans have travel benefits if you're having to travel for surgery, and some cover home health aides for post-op recovery.

[Wolfy]

This should be in your plan. It's going to vary by what plan you have - you'll need the plan name and the group number associated in some cases. The insurance lady in your surgeon's office should know how to word the request to have it accepted. And you can always (and should) appeal if they say no the first time. Insurance companies almost always say no the first time.

My plan (also BCBS) doesn't have trans exclusions, so all transition related procedures fall under the surgical benefits. In-network coverage is 100% minus copays, deductibles, etc. Out-of-network coverage is 70% minus copays, deductibles, etc. Once you hit the out-of-pocket maximum, they cover the rest.

As an example, the surgeon doing my bottom surgery is out of network. I'm responsible for copays and deductibles, and any additional fees that don't exceed my out of pocket maximum. This amount includes what I'll pay in copays and deductibles. My out of pocket maximum for an out of network provider is $6k. So the most I will spend for medical treatment in a calendar year is $6k. After that, insurance pays 100%. That is why I am hoping to get as many stages in as possible before my insurance rolls over

When you talk to them, see what other things they cover. Many plans have travel benefits if you're having to travel for surgery, and some cover home health aides for post-op recovery.

Hi Max,

I called up my dads insurance and they do have an exclusion policy and denied me over the phone (since they never got the request in the mail) They told me I can write a letter to the Board Of Trustees since my dads insurance is union based.

I called up the insurance under my mom and they dont have out of network benefits, but if the dr sends in the request to the insurance they can possibly cover it once it gets accepted. But my moms insurance is my secondary while my dads is my primary, so I will probably have to drop one of them. It's a really hard decision to make for me.

Am I able to go through with my moms insurance and if it gets accepted I can then drop my dads insurance? or the only way to properly find out is dropping one or the other insurance?

[FTMax]

See if you can email them or mail them a letter and get that response in writing (unless you recorded the phone call). If they have trans exclusions, you may be out of luck.

You can have multiple insurance policies. Most people don't because it's expensive, but if your mom has you on her policy, why not use it? If your dad's plan has already said they will not cover surgery, trying with your mom's should be your next step. I don't think you'd need to drop coverage on your dad's plan in order to have your mom's plan cover it. This site gives a good breakdown of what you might encounter with multiple plans:

http://www.netquote.com/health-insurance/news/more-than-one-health-insurance-plan

My advice would be to have your surgeon submit a pre-authorization to your mom's insurance company.