retarded HMO question

[Ksandra]

I screwed myself over with something before so I just want to double check (before you ask I already contacted BCBS but the customer service rep was kinda vague).

Ok so I moved almost a year ago out of my service area for my HMO. I wanted to make an app. with the doctor and discovered I was listed out of area (didn't realize the area was so small, oh well). So I switched physicians to my current area. (actually that's when I talked to the rep and she picked one for me).

The change didn't roll over until the first of the month (called rep in march, took effect on april 1st).

So for the past two weeks I've been trying to make an app, at this doctor and idkwtf is up with this clinic. No one ever answers the phone, they are not open weekends, and when I called today their message said "today is thursday april 7th. I am sorry we are closed today."


So anyway, I really don't want to stick to this clinic even if I do get a hold of them because what happens when it's something more serious? (btw SD county doesn't have walk-in clinics or anything). This means though if I switch it won't roll over till May.


So may actually question is if people know a little more about HMOs than I do. If I go to another clinic but that is still in the same service area will I get charged extra because they aren't my primary physician? I know if I'm out of area it does, but not sure if it's different in area.

I can easily get a list from the website of clinics, I just don't want extra expenses if I don't have to.

[clobetasol]

BG medical is way cheaper then your health insurance

[Soa]

If I go to another clinic but that is still in the same service area will I get charged extra because they aren't my primary physician

Yes you will get charged extra for not going to your primary physician, in fact you'll probably have to pay the whole bill. I would pull up a list of providers and call them to verify they'll take you/your insurance then just suck it up till May if possible.

[Ksandra]

that sucks so much, thanks though. Glad I asked lol

[Acturus]

Sorry for the late reply:

You need to know if your member benefits include out of network benefits.

If you have out of network benefits, you can choose a physician outside your network who also takes your insurance, but you will pay more. However, your insurance will still pay some.

HOWEVER, if your HMO plan has no out of network benefits (as many do not), you will be responsible for the full bill you incur.

Not knowing your exact member plan, I can't say for sure, but you should be able to talk more in depth with your BCBS customer service in the hopes that they'll help you choose another gatekeeper physician.

Ultimately, you'll be stuck with this doc's office until you switch with your plan's help.

[Ksandra]

ya after I got the above reply I spent a while on the phone with the reps to figure this out, and they did a 1 time immediate courtesy change to a new doctor and said they were going to investigate the old one lol.

[Khamsin]

What determines whether a company offers HMO or a regular insurance plan? Everywhere I've worked, my insurance worked simply by going to any doctor you feel like that accepts your insurance, and they pay a certain percentage of the cost after your deductible, minus any copays. For some things, it's entirely free (e.g. dentist exam and cleaning every 6 months, or a yearly preventative maintenance checkup with a physician). And some of my past employers have paid the premiums in full, and others have split it with me. But none have made me pick an HMO, which I only hear nasty things about.

[Ksandra]

What determines whether a company offers HMO or a regular insurance plan? Everywhere I've worked, my insurance worked simply by going to any doctor you feel like that accepts your insurance, and they pay a certain percentage of the cost after your deductible, minus any copays. For some things, it's entirely free (e.g. dentist exam and cleaning every 6 months, or a yearly preventative maintenance checkup with a physician). And some of my past employers have paid the premiums in full, and others have split it with me. But none have made me pick an HMO, which I only hear nasty things about.

basically, whatever the company is willing to put in. usually better your rate =the more your company is paying for you to have it. They do it as incentives to get you to work there. Well that and the more people that sign up, the insurance company will give bigger discounts to the company. So usually bigger corporations can have better.

Actually boytoy's company offers ppo as well but we just didn't get it because it costs more and didn't think we'd need it(never had hmo before). You can change it once a year, so ya we'll be changing for next year lol lol.

[Nekio]

The solution to any insurance question is always "call your insurance company". I've been fucked over so many times by offices telling me "yeah you're covered" that I just go straight to the source now.

[Acturus]

What determines whether a company offers HMO or a regular insurance plan? Everywhere I've worked, my insurance worked simply by going to any doctor you feel like that accepts your insurance, and they pay a certain percentage of the cost after your deductible, minus any copays. For some things, it's entirely free (e.g. dentist exam and cleaning every 6 months, or a yearly preventative maintenance checkup with a physician). And some of my past employers have paid the premiums in full, and others have split it with me. But none have made me pick an HMO, which I only hear nasty things about.

HMO versus non-HMO is such an ugly categorization, because an HMO is well-defined by regulation, and non-HMOs are quite simply "it's not an HMO". HMOs are usually better managed, which in turn mean they cost less to the client (i.e. your employer), which means they can afford to pass it on to you.

Ultimately, and I can never say this enough (in work or in my personal life), everything comes down to the member benefit plan. It's less important to know that you have an "HMO" plan than it is important that you know 1) whether or not the docs you want are in network, 2) how far your coverage goes, and 3) what you, the member, are responsible for.

HMOs became an ugly word back in the late 90s as Americans decided that they wanted the freedom to go to any doctor and be seen for the same price. The entire goal of an HMO was to manage a person's care. The PCP was a gatekeeper who was responsible for you as a person, not just you as a headache or you as a cold sore. The PCP would (and still does) coordinate the care of a insured person from first visit, through every referral, and with every follow up.

Truth be told, this is why people in my industry are a little wary of the new "Accountable Care Organization" that's being thrown around as part of the PPACA. It smells like HMO version 2.0.

What sucks is that right now, as they have for the last few years, and as they will continue to have until we fully enforce the new legislation (here in the US), insurance companies have been selling High-Deductible Plans and Limited Benefit Plans, which are not true insurance. HDPs require you to pay out massive amounts of money up front before they chip in a dime, and you still have a premium to worry about. LBPs instead may make you pay little or nothing, but only cover you to $5,000, maybe $10,000, total. Some LBP have coverage up to $50,000 or so annually, but not many.

It's a crappy way for insurance companies to convince small to medium sized businesses that they can give their employees "health insurance" without having to pay "lots of money" to do so.

It's harder to find an employer who has a strict HMO anymore. Most at the very least have POS (point of service) riders that allow for some out of network coverage. But trust me when I say that health plans in general have gotten worse for the average consumer in the last 15 years, not better.

The solution to any insurance question is always "call your insurance company". I've been fucked over so many times by offices telling me "yeah you're covered" that I just go straight to the source now.

Going to the source generally is a good idea, but in all fairness, it's very difficult for many providers to know exactly whether or not they are in a customer's network. Insurance companies have gotten so creative with member benefit plans that it boggles the mind. Not only could you simply not be in network, but your doctor's contract with the insurance company may have so many stupid stipulations that it's not worth it for them to see you. Of course, the poor receptionist at the front doesn't always know that, sees that you have Wellpoint on your card, and let's you see the doctor. Two months later you get slapped with a partial bill for some of those services that weren't approved, and no one cares except you because it's no one's money but yours.

[Ksandra]

The solution to any insurance question is always "call your insurance company". I've been fucked over so many times by offices telling me "yeah you're covered" that I just go straight to the source now.

ya as I said in the op that the last time I did talk to customer service they were kinda vague. In fact, they gave me the impression that I could go to anyone in network (without cost that is). Basically, customer service reps can be idiots too so never hurts to get extra info. XD

[Ksandra]

double postin', but I finally think I got the real story and would explain the conflicting answers. (figured I'd post in case anyone else was wondering)

The way they do it is by medical group not by doctor. So as long as I stay in the medical group I can go to any one of them, but cannot go to a different group even if it's in the same network. That's probably what the first chick meant or something.

If it's like a single doctor's office then I would be stuck just going to him (which is what I had initially). So I guess if you get an HMO make sure you pic someone in a medical group vs. private doctor.