Health Insurance Nightmares

[sandyut]

I am on ACA ins. with Anthem. been with them 3 years, was good enough...till now.

I had cataract surgery scheduled, surgeon is in network and so is his office. He uses a surgery center on the first floor of his building. Surgical center is not in network=DENIED. Surgery canceled. Or I could pay full price, which I will just wait if thats the case.

Broken ankle surgery last March included implants that are now causing issues and need to be removed along with a tendon repair of same ankle. Preapproval at same location as first surgery=DENIED.

Now they are giving me and my surgeons office and bunch of s**t about who and where this next procedure will be done. I was on the phone for an hour and got nothing out of it. The rep was gonna call the surgical centers to see who takes my plan stating "the list on the their website is incorrect". 2 out of the first 3 I called are in-network for orthopedic procedures. My surgeon is not credentialled at the two, but his partner is. My surgeons office got the same run around and ask me to call Anthem and "see what I have to do to get this done". Can you hear me screaming? WTF!

What a joke. I have had implants put in and removed 3 times already. this is not uncommon, but apparently it is with Anthem?

 

[smokerjim]

Got to love it !!!

 

[sandyut]

Got to love it !!!

What a mess. Ive been on the phone all morning and the ins folks barely tell me anything. I learn more reading the denial letter they sent. I asked the rep why it was denied and she wouldnt speak the words...just said my surgeon needed to call them. Which they have.

 

[jcam222]

Not encouraging. I'm on Anthem ACA right now through November. Various reasons I'm going on a Medicare Advantage plan in December and plan on using Anthem. I've looked at others but none have a decent network of providers in my area. I'll be doing the PPO so it gives partial coverage and also has a max out of pocket out of network. Insurance is a travesty in this country and controls treatment of patients over doctors. Total BS

 

[sandyut]

Not encouraging. I'm on Anthem ACA right now through November. Various reasons I'm going on a Medicare Advantage plan in December and plan on using Anthem. I've looked at others but none have a decent network of providers in my area. I'll be doing the PPO so it gives partial coverage and also has a max out of pocket out of network. Insurance is a travesty in this country and controls treatment of patients over doctors. Total BS

I have liked them till now. Honestly, way better than United that my wife is on through MC.

Back on the phone with them. I think the issue is my surgeon isnt credentialled at a non-hospital surgical center and I am not sick enough to need a hospital. It makes some sense, his partner is credentialled at an outpatient surgical center...I think we will be trying that next. Its just a lot of work to sort out.

The other part of the issue is a have what they call their "HMO Pathways plan" which is more restrictive. But you would never know this unless you needed to push the coverage.

I'll be asking a lot more questions to my broker come open enrollment.

 

[sandyut]

After a day of shenanigans...sounds like my surgeon worked some magic and got me approved for the hospital we originally got denied at. Much happier now!

 

[chopsaw]

I hope it all works out . Talk on the morning news was ACA is getting ready to change for a bunch of people by the end of this year .

 

[sandyut]

I hope it all works out . Talk on the morning news was ACA is getting ready to change for a bunch of people by the end of this year .

Very interesting.

Rumors in Colorado were they were pulling all the HMO plans from here. But my daughter is one of the assistant attorneys general and somehow she caught wind that that change is not happening. Guess we will find out in Nov. what options we get.

I would get Anthem again, maybe a slightly more expensive one than the "pathways" but depends on the cost. I think I will still qualify for the fed tax credit. but that remains to be seen...politicians are still not agreeing on that.

 

[BrianGSDTexoma]

So sorry you have to go through this David. I not sure what going to happen with mine. Doctor office was no help! I know my nurse so sent her a facebook message. She not know much. I think that Anthem was maybe one I was hoping they might take? Guess find out open enrollment. I might be screwed!

Edit I just read the ACA premium tax credits are ending this year. Hopefully they will extend it I hope!!!

 

[sandyut]

Edit I just read the ACA premium tax credits are ending this year.

I read up on this. if your MAGI (modified adjusted gross income) is below 4Xproverty level, I dont think the impact is near as significant if the tax credits are dropped. Single person home that is $62,600 for a home of two its $84,600.

I looked up how MAGI is calculated and its a little grey. From what I gathered its your AGI from tax return plus some credits. No idea who has these credits but I dont thing we do. Internet says for most they are very similar.

 

[DougE]

The whole system is f'ked. I'm on a Medicare advantage plan and have a bill for my part of my radiation treatments ........... I'm on the hook for over $2000.00 bucks with me on a fixed income

 

[DougE]

I think what pisses me off more than anything is the fact that If I had never worked a single day in my life, treatment would have been free. That is severely messed up.

 

[Torch&Tone]

Back in July, Congress just barely passed significant (and unpopular) cuts to Medicaid & ACA programs, but actually incorporating the changes into federal appropriations requires more consensus. Since we are well past the deadline for "normal" process, the only options now are a (bipartisan) continuing resolution - mostly kicking the can down the road (again) - or federal government shutdown.

Given the considerable impact of the legislation in question, insurance corporations don't want to make any policy commitments until this plays out (causing more confusion and delay for everyone else) but you can count on them keeping it all as opaque and profitable as possible, no matter what plays out on Capitol Hill. Organize your thoughts on the matter and then call your Senators & Representatives.

 

[Fueling Around]

That run around really sucks.
I see that Anthem is a BCBS company, but they offer so many different plans it is hard to choose which coverage you selected. I'm guessing you are on HMO style plan based on finding your approved providers and care facilities.
Call BS if I'm off base.

I was on ACA with a BCBS plan for 6 months until Medicare eligible. The plan was high deductible, but it was universally accepted. Local Broker was very honest and informative. They won't sell you a plan based on their commission over what you need for coverage. They also told me "you get what you paid for" in coverage.

Wife and I have no continual care or major medical history, so that makes it easier for us to get coverage.
She's on a BCBS Medi-Gap plan that is non HMO and non Advantage (another name for HMO). I don't remember the cost, but not unreasonable.
I've been dragging my feet for a couple of years and just on traditional Medicare.

 

[jcam222]

Anthem Advantage plans offer

That run around really sucks.
I see that Anthem is a BCBS company, but they offer so many different plans it is hard to choose which coverage you selected. I'm guessing you are on HMO style plan based on finding your approved providers and care facilities.
Call BS if I'm off base.

I was on ACA with a BCBS plan for 6 months until Medicare eligible. The plan was high deductible, but it was universally accepted. Local Broker was very honest and informative. They won't sell you a plan based on their commission over what you need for coverage. They also told me "you get what you paid for" in coverage.

Wife and I have no continual care or major medical history, so that makes it easier for us to get coverage.
She's on a BCBS Medi-Gap plan that is non HMO and non Advantage (another name for HMO). I don't remember the cost, but not unreasonable.
I've been dragging my feet for a couple of years and just on traditional Medicare.

Anthem Medicare Advantage plans in Ohio offer PPO plans in addition to HMO plans albeit at a higher cost. HMO plan was $0 above the standard a Medicare cost and PPO $46 per month additional. The PPO offers decent coverage out of network and also has a max out of pocket that includes our of network care to protect against catastrophic bills. Also includes prescription plan, a little vision and dental , quarterly over the counter med allowance and Silver Sneakers. I'll be rolling on that on December

 

[sandyut]

I think what pisses me off more than anything is the fact that If I had never worked a single day in my life, treatment would have been free. That is severely messed up.

Could not agree more!

 

[sandyut]

That run around really sucks.
I see that Anthem is a BCBS company, but they offer so many different plans it is hard to choose which coverage you selected. I'm guessing you are on HMO style plan based on finding your approved providers and care facilities.
Call BS if I'm off base.

I was on ACA with a BCBS plan for 6 months until Medicare eligible. The plan was high deductible, but it was universally accepted. Local Broker was very honest and informative. They won't sell you a plan based on their commission over what you need for coverage. They also told me "you get what you paid for" in coverage.

I have the HMO. Not really a big deal till you have something bad happen and need surgeries and such. As I am finding out.

My deductible is like $6500 and max out of pocket is $9500. Maxed out both in March with first surgery. I was hoping to get the cataract surgery covered but not this time.

Ankle surgery #2 finally got approved so Im good for now. Next year is gonna be a whole new ballgame.

 

[sandyut]

Back in July, Congress just barely passed significant (and unpopular) cuts to Medicaid & ACA programs, but actually incorporating the changes into federal appropriations requires more consensus. Since we are well past the deadline for "normal" process, the only options now are a (bipartisan) continuing resolution - mostly kicking the can down the road (again) - or federal government shutdown.

Given the considerable impact of the legislation in question, insurance corporations don't want to make any policy commitments until this plays out (causing more confusion and delay for everyone else) but you can count on them keeping it all as opaque and profitable as possible, no matter what plays out on Capitol Hill. Organize your thoughts on the matter and then call your Senators & Representatives.

This situation is totally F'ed! SO many people will be affected and likely wont be able to afford coverage, then the broken system will become more broken. My retirement income is so low I am hoping I qualify for the credits even if they are cut back. Time will tell.

Medicaid folks I fear will get the worst hit.

 

[DougE]

For the first time in a long time, I'm going to meet with an agent I trust fairly well and review my options before I renew my current Medicare Advantage plan.

The plan I'm on served me pretty well until I developed heart rhythm issues that had to be looked into deeper with a complete workup ........ stress test, echo, visit to an electrophysiologist, etc, and the cancer radiation treatments. I got jammed with a lot of out of pocket expenses.

 

[sandyut]

For the first time in a long time, I'm going to meet with an agent I trust fairly well and review my options before I renew my current Medicare Advantage plan.

The plan I'm on served me pretty well until I developed heart rhythm issues that had to be looked into deeper with a complete workup ........ stress test, echo, visit to an electrophysiologist, etc, and the cancer radiation treatments. I got jammed with a lot of out of pocket expenses.

My wifes advantage plan seems to be ok, when they pay on the first claim filing. Compared to my ACA its FAR better. The issue is United doesnt always pay claims on the first filing and that leads to big PITA, many calls and run around, but eventually they pay. Her hip replacement surgery and all the followup cost $250 ish out of pocket. My ankle surgery cost me $9500 out of pocket.