Medical Insurance

[dls1]

Brian,
I just went through this thread for the first time, and it seems to me that the solution to your problem is pretty simple to solve. Based on what you've been told the current medical practice that you are a patient of will not be accepting the insurance that you have, effective 1/1/2026. Therefore, you need new coverage starting that date.

The doctor's office stated they will not taking Market Place plans effective 1/1/2026, be it with your current carrier BCBSTX, or any other carrier. They also told you that they will only be taking regular BCBSTX HMO in 2026. The term "Regular" refers to plans provided under an employer sponsored group insurance plan. You have an individual plan. By default, you'll be losing the ability to see your current doctor unless you willing to pay out of pocket for his care and any other care that you may need until you're Medicare eligible.

So, the very first thing that you need to do, and do soon, is to find a new doctor that's accepting new patients. I see that you're in Texoma, TX, did a very quick search, and found the Texoma Medical Center (TMC) and a list of doctors (Family Physicians) affiliated with it, most of whom are accepting new patients. I tried to paste the link to that list but it wouldn't take. Go to TPC's website and you will find the list.

Once you find one or more doctors that may appeal to you, contact their office, confirm that they are accepting new patients, and that you need a new primary care physician (PCP), ask which insurance plans they currently work with, and what plans they will be accepting in 2026. Some may not be certain about 2026 yet, but do your best. Also, the TMC website should show the plans that they accept, an it should mirror the plans acceptable to the individual doctors.

If you have any questions, let me know.

Good luck.

 

[DougE]

Short answer is you're pretty much hosed if you ever worked a day in your life.

Remember that prostate cancer thread I posted awhile back? I'm on the hook for $2300.00 or so after my medicare plan paid their part for the radiation treatments. Been all free if I never worked.

 

[Fueling Around]

Short answer is you're pretty much hosed if you ever worked a day in your life.

Remember that prostate cancer thread I posted awhile back? I'm on the hook for $2300.00 or so after my medicare plan paid their part for the radiation treatments. Been all free if I never worked.

Yeah it sucks for those that actually paid on the plan
That's where a Medi-Gap plan or an Advantage plan are needed to cover the extra expenses.
I don't have either but I get a generous payout from my 401K (that I and my employers funded) NOT welfare or our politicians fat pension.

 

[DougE]

Advantage plan are needed to cover the extra expenses.

I have an Advantage plan through Humana and still got stuck with a 2K bill. Be nice if you could have Medi-Gap with an Advantage plan, but you have to be on the Gov't plan to get the gap coverage.

 

[Fueling Around]

Advantage plans sound really good thanks to mass media commercials listing the pluses.
My wife's agent said to go Medi-Gap. Yes it costs out of pocket and not the "money returned" that many of the advantage plans advertise to lure you to their plan. Comparing both sides her agent recommended BCBS medi-gap. Agents are commission based. Some will direct you only the plans that generate the best commission and from what I have seen they are the Advantage plans

 

[BigW.]

An Advantage plan is similar to your coverage thru work. There are usually co-pays & deductibles. You also need to use certain providers that are in-network. A Medicare Supplement will pay the 20% that Medicare A&B does not pay. If it is covered by Medicare, your supplement will pay. You do pay more per month, but out of pocket is only a couple hundred bucks even for a major health event. And if you travel, your supplement will pay the same as home if the Dr/hospital take Medicare.

 

[jcam222]

Without going into detail I qualify for Medicare a year early. The crap thing is that in Ohio the insurance companies will not sell Medigap if you are less than 65 even though you qualify for Medicare. Forces me into Medicare Advantage to insure I have a max out of pocket limit to protect against catastrophic costs. I'll be buying an Anthem PPO Advantage which at least extends coverage out of network albeit at a higher price. The other thing that sucks is that if you did not take a Medigap plan within 6 months of qualifying for Medicare they are not bound to sell at the lower reasonable rates. There is a bill in the Ohio Senate to change all that but it's been stuck in committee all year. Same bill sat in committee all year last year and never made it to the floor for vote. Overall insurance companies suck.

 

[sandyut]

the whole health insurance deal is an F'ing disaster. I thought it was ok enough till this year. My ACA plan is pushing back on pretty much every preauthorization now. I need two surgeries and both are on hold. Too long of a story to get into the weeds on.

My wife is on an advantage mediare plan with United. Was good for a bit, till they stopped paying claims. she spent hours on the phone with them and providers. They all say its all good, but then they dont pay. A crown too 18 months to resolve.

Then they post record profits...

 

[sandyut]

think about insurance get me fired up!

I need a medication for my heart that my insurance wont pay for till after I have a heart attack. My cardiologist put me on it to prevent one! Its about $60 a month through Cost Plus drugs, about 3X that at the local pharmacy. total BS!

 

[BrianGSDTexoma]

Man there is a lot to this! I decided to just until open enrollment and hope I find a decent plan my Doctor will take then in March start trying to figure out this Medicare for June.

 

[sandyut]

Man there is a lot to this! I decided to just until open enrollment and hope I find a decent plan my Doctor will take then in March start trying to figure out this Medicare for June.

I think you said you have a broker? they are free and can be very helpful wading though this for both ACA and Medicare

 

[BrianGSDTexoma]

I think you said you have a broker? they are free and can be very helpful wading though this for both ACA and Medicare

Yeah but not yet used them. I messaged to tell them what going on but no reply?

 

[Ishi]

the whole health insurance deal is an F'ing disaster. I thought it was ok enough till this year. My ACA plan is pushing back on pretty much every preauthorization now. I need two surgeries and both are on hold. Too long of a story to get into the weeds on.

My wife is on an advantage mediare plan with United. Was good for a bit, till they stopped paying claims. she spent hours on the phone with them and providers. They all say its all good, but then they dont pay. A crown too 18 months to resolve.

Then they post record profits...

This is why I went with A&B Medicare plan plus G plan.
Before my wife passed she had many thousands of dollars and all was paid except 260$ a year deductible.

 

[sandyut]

Yeah but not yet used them. I messaged to tell them what going on but no reply?

Lame I hate that. The ones I have used respond year round. One emailed me back saying that till open enrollment there wasnt much to discuss. Which makes sense...sorta. Shew was more lakey and I chose a different one.

But I called my current broker about rumors my HMO plan was being canceled and she answered and confirmed a couple weeks ago.

 

[dls1]

Man there is a lot to this! I decided to just until open enrollment and hope I find a decent plan my Doctor will take then in March start trying to figure out this Medicare for June.

Brian,

Maybe I wasn't clear enough in my prior post, but if your current doctor isn't taking any ACA Market Place plans as of 1/1/2026, there isn't for you to "find". As such you and your current doctor will be parting ways, and you need to find a new one that accepts a plan acceptable to you.

 

[Jonahind]

Finding a doctor that takes your specific marketplace plan can be a real headache. I remember when I was between insurance plans for a while and had to switch PCPs, it felt like every call was the same: “Sorry, we don’t take that plan.” Eventually, I had to settle for a doctor who wasn’t my first choice just to keep my meds going. Honestly, the process felt even trickier because some doctors dropped certain plans mid-year, not even at renewal, and it was hard to keep track of who took what. I started using a broker after that, and it really helped cut through some of the confusion. https://premierpmi.co.uk/wpa-health-insurance/ They explained which plans were most accepted in my area and gave tips about what to watch for with HMOs versus PPOs. If you’re ever looking for options outside the typical US marketplace, info about WPA health insurance shows how some brokers in the UK provide help comparing different private health plans, which can be a good model to follow for getting unbiased advice.

 

[lihat]

Are your meds unaffordable without the insurance? When the ACA first started, it was affordable. Within a few years the price the gave me was literally over $3,000 a month in premiums with a high deductible. I had to go back to uninsured. I didn't stop going to the doctor or taking what meds I was on, I just paid out of pocket. The doctors/providers around here all had an automatic 50% for self-pay, about what they would get with an insurance claim. GoodRX and other discount systems can sometimes slash the price of drugs to lower than the insurance sets them. Harris Teeter (grocery and pharmacy) actually started using a different discounter and saved me even more money. It was more affordable than insurance premiums even before they skyrocketed back then. We dont get a dime in subsidy, so, nothing free for us...

On the medicare thing, definitely get with one of those places that provide gcc medical report check guidance. My wife did that and they really helped her navigate the complexities. If you dont have an expert help you, you can end up leaving a heck of a lot on the table. She got an excellent setup and we have never have a problem with services. My employer provides a $300 stipend towards my current policy and takes the rest of my payment out before taxes, so, not a bad deal right now except my deductible and MOOP is high. But that was my choice to keep the premium lower.

You don’t need to find a new PCP just for the Marketplace application. Since you’re turning 65 in June, you should focus on enrolling in Medicare during your initial enrollment period (around 3 months before your birthday). Once Medicare starts, that will replace your Marketplace plan in most cases. Your current doctor may still be able to see you under Medicare even if they stop taking Marketplace insurance.

 

[DougE]

You don’t need to find a new PCP just for the Marketplace application. Since you’re turning 65 in June, you should focus on enrolling in Medicare during your initial enrollment period (around 3 months before your birthday). Once Medicare starts, that will replace your Marketplace plan in most cases. Your current doctor may still be able to see you under Medicare even if they stop taking Marketplace insurance.

I'll also add that you should see an agent who specializes in Medicare options as you enter into this. They will see that you get the best plan that meets your needs.