Trying to figure out how to schedule a surgery based on coverage changing/prior authorization
I have Empire Blue Cross Blue Shield insurance through my union. You pick your level of coverage at the beginning of the calendar year, and you can downgrade it each quarter (but you cannot upgrade). There are different levels of coverage (for example, C2 is the best level and has a $2000 out of pocket maximum, C3 is the medium level, C4 is the worst level and has a $8000 out of pocket maximum). I’m currently on the C4 plan until the end of the year and don’t have much in my CAPP account that we make the premium payments through. I need a surgery and I have it tentatively scheduled for January. I will be upgrading my coverage for that quarter so hopefully more of the surgery will be covered.
In talking to my doctors office, they have explained that they’re getting prior authorization for the surgery with the insurance company NOW because it sometimes takes several months, and as a result even though the surgery is in January, it will be covered under this quarter’s insurance. However, in talking to a representative from my insurance company, they explained that because the surgery is in January, it will be covered under my new insurance that kicks in on the first of the year. (In talking to a friend they pointed out that if I was in the reverse situation and had GREAT coverage now and shitty coverage in January, it seems pretty unlikely they’d run the January surgery through my December insurance, which is a pretty good point.) I have talked to the company that manages my union’s insurance benefits and they don’t know either way.
I honestly don’t know who to believe or how to get a straight answer. It’s been a rough couple of years for me financially (I primarily worked backstage in live entertainment pre pandemic) but I really need this surgery to improve my quality of life, and it will affect my work schedule less if I get it done in January. It will cost me $2000 out of pocket to upgrade my insurance for that first quarter and I’m hoping that if I have to reschedule the surgery I can do it at the end of that quarter so that I don’t have to upgrade for the second quarter of the year as well but I think that’s what I might have to do. (This is one of the best surgeons in this field and he typically schedules 3 months out, so if I cancel the surgery, and call to reschedule Jan 2 it might not be until March/April).
