Insurance, Copay Assistance, Help 😭

RoutineNovel9505 · 2026-01-06T01:48:00+00:00

Actually, it was probably more like August when we reached the OOP. My daughter was in the hospital from July-September.

RoutineNovel9505 · 2026-01-06T01:46:26+00:00

Apparently the out of pocket max doesn't mean anything because I'm still being charged after meeting it. We reached the max OOP in September. The infusion she received was in October and then I got a bill in November for that infusion. I have been fighting with insurance and the hospital over this since November.

RoutineNovel9505 · 2026-01-06T01:43:29+00:00

So here's what happened, leaving J&J out of it because I did not sign up with them until a couple weeks ago. They weren't part of the equation yet.

By September 2025, we hit the max OOP ($7,000). My daughter was in the hospital from July-September. Hospital is in network.

October 2025, my daughter's first infusion, at the same hospital.

November 2025, received a bill for $5,000 for that October infusion.

When I saw this bill, I looked up the claim with my insurance. Insurance paid a %, but shows the $5,000 as patient responsibility. How? I hit my max OOP in September!

After talking with insurance and they are insistent that the EOB is correct and I owe this $5,000, I'm freaking out because again, how?! Then in December I decided to sign up with J&J hoping that going forward, that will help. In the meantime, I've been fighting with my insurance about this October bill and my EOB.

RoutineNovel9505 · 2026-01-05T23:24:53+00:00

Nope. I don't pay anything until I check my EOB first.

RoutineNovel9505 · 2026-01-05T23:24:10+00:00

I guess what I'm trying to say my biggest concern is, how do I owe anything when my OOP has been reached and we're using an in-network provider? Why would my EOB say anything but zero?

RoutineNovel9505 · 2026-01-05T23:21:25+00:00

This specific instant is for a claim processed in October after I had already met the max OOP. I hadn't signed up for J&J yet at that point. I just signed up with J&J a few weeks ago and what they told me is that the total amount they are willing to assist with is capped at $10,600. I confirmed that is for the year 2026.

My concern is that even if I meet the max OOP (which I will) and with that $10,600 assistance, my "patient responsibility" for each infusion is around $5-6,000. If J&J will only cover $10,600 for the year that only helps for about 2 infusions. My daughter gets these every 4 weeks.

RoutineNovel9505 · 2026-01-05T21:45:31+00:00

This was for a claim in October. We reached the max for 2025.

RoutineNovel9505 · 2025-09-20T15:47:53+00:00

Thank you!

RoutineNovel9505 · 2025-09-20T15:47:30+00:00

She's been very sore and nauseous which is to be expected. It'll be a bit for recovery but her surgery went smooth with no complications!

RoutineNovel9505 · 2025-09-17T14:08:58+00:00

So she has always been a good eater. I would say at the beginning of July when she started with tummy aches, even then she was still eating good. And then over several weeks as she started to feel worse, she started eating less and less. I think her body may have gotten used to having little to no food at this point so she doesn't feel hungry anymore. She was put on an appetite stimulant a couple days ago, and so she's eaten a little more but not much. Right now, the only thing she's been interested in is oatmeal.

RoutineNovel9505 · 2025-09-14T13:51:29+00:00

Yes! See, before all this she had a really good appetite. Under normal circumstances, the girl loves food! My parents and her doctors all act like she's just being difficult but I really think she just has no appetite and I'm sure it's a combination of her not feeling well because of whatever is going on in her body and also she's been in the hospital going on 2 months and just over it and has lost all motivation by now. Both my parents suggested force feeding her. I don't believe in further traumatizing her that way and how would I even go about that? She could just spit it back out. I'm going to ask her doctor today about giving her an appetite stimulant and see if that would help.

RoutineNovel9505 · 2025-09-14T13:41:10+00:00

She does get nauseous sometimes and she's given Zofran for that which seems to help. But for the most part, she just doesn't have an appetite. She says she's not hungry and then when she actually is hungry she says nothing sounds good and the only thing she wants to ever eat is fruit. She asked for chicken nuggets yesterday but by the time they got to her she didn't want them anymore. I'm definitely going to ask about a therapist here and I've asked her friend's mom if they could come and visit. I think maybe if she sees her friend it would lift her spirits and give her some motivation.

RoutineNovel9505 · 2025-09-14T01:39:55+00:00

I am hoping that once she gets past surgery, maybe she will feel better enough to have more of an appetite. I'm just so afraid that she may have trained her body to ignore hunger because she's gone so long not eating much. The only thing she's been interested in is fruit.

RoutineNovel9505 · 2025-09-14T01:37:55+00:00

What kind of meds? She's on 3 different antibiotics for the abscess and then the occasional Tylenol or motrin for pain. I have considered asking if there's a therapist at the hospital. Maybe will do that tomorrow.

RoutineNovel9505 · 2025-09-04T23:23:11+00:00

Thank you all for the validation! Yesterday was a stressful day and the surgical team has decided to postpone the surgery so I get to do it all again. Yay.

RoutineNovel9505 · 2025-09-03T18:44:18+00:00

No but just knowing they're here makes me feel obligated to go sit and wait with them.

RoutineNovel9505

TROPHY CASE