HMO Plan - OON Doctor - what is Covered?

[sman]

You can call me Cait .....................

So I no longer have to refer to you as Master?

 

[somarco]

So I no longer have to refer to you as Master?

That was supposed to be our secret.

 

[sman]

That was supposed to be our secret.

Well this is embarrassing

 

[kgmom219]

Well this is embarrassing

I just threw up a little in my mouth

 

[sman]

I just threw up a little in my mouth

You should go see your pediatrician for that.

 

[AllenChicago]

My experience with HMO's is this.

Outside of an emergency, any services rendered or prescribed by the non-par doc are not covered.

Also, no "discounts" for the doc or any prescribed services even if those providers are in network.

In the past you could beg forgiveness and sometimes the carrier would approve the ancillary claims but this is a different world.

It's ............... Obamaworld .

For 2016 HMO plans, I'm seeing that only the hospital Emergency Room is covered, not Urgent Cares. Wasn't this reversed 2 years ago, when the emphasis was to use Urgent Care, instead of the (more expensive) Emergency Room?

 

[somarco]

For 2016 HMO plans, I'm seeing that only the hospital Emergency Room is covered, not Urgent Cares.

It has been that way for as long as I can remember (medical emergencies covered OON, non-emergency only covered if par provider).

Even if you go to the ER for non-life-threatening "emergency" claim will likely be denied by your carrier.

 

[AllenChicago]

It has been that way for as long as I can remember (medical emergencies covered OON, non-emergency only covered if par provider).

Even if you go to the ER for non-life-threatening "emergency" claim will likely be denied by your carrier.

Understood Somarco. What I'm saying is that the E.R. is incentivized over Urgent Care for 2016. In 2014 and 2015 things were reversed.

Example of BCBS HMO: (Out of Network)

For 2015:
E.R. = $500 Copay + 20% Coinsurance
Urgent Care = 20% Coinsurance

For 2016:
E.R. = $1,000 Copay + Deductible + 30% Coinsurance
Urgent Care = Not Covered

All of a sudden, health insurers (at least this one) wants insured members to visit the E.R.. I remember in the 2014/2015 BCBS training video how the company wanted to keep people away from the E.R., and visit Urgent Care instead. It's now reversed.

No big deal, cause most everyone on the new 2016 PPO's and HMO's will eventually be screwed if they go out-of-network anyway. (No more max OOP when OON)

 

[kgmom219]

Understood Somarco. What I'm saying is that the E.R. is incentivized over Urgent Care for 2016. In 2014 and 2015 things were reversed.

Example of BCBS HMO: (Out of Network)

For 2015:
E.R. = $500 Copay + 20% Coinsurance
Urgent Care = 20% Coinsurance

For 2016:
E.R. = $600 Copay + Deductible + 30% Coinsurance
Urgent Care = Not Covered

All of a sudden, health insurers (at least this one) wants insured members to visit the E.R.. I remember in the 2014/2015 BCBS training video how the company wanted to keep people away from the E.R., and visit Urgent Care instead. It's now reversed.

No big deal, cause most everyone on the new 2016 PPO's and HMO's will eventually be screwed if they go out-of-network anyway. (No more max OOP when OON)

AC....do the benefit summaries say Urgent Care is "not covered"? Thats a massive shift and doesn't correlate with actual cost. I would ask for clarification.

 

[AllenChicago]

AC....do the benefit summaries say Urgent Care is "not covered"? Thats a massive shift and doesn't correlate with actual cost. I would ask for clarification.

Here's a copy/paste from the BCBS HMO SOB. Formatting stinks, but you can see that OON is Not Covered.


Urgent Care: 50% coinsurance Not Covered

Must be affiliated with member's chosen medical group or referral required.