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Wait. So How Do I Find out if a Specialist Is Covered by My Plan?

A THCB reader in Connecticut writes:

“I’m a pretty level headed person. I’ve been following the Healthcare.gov story in the news and figured it was more of the usual partisan stupidity out of Washington. I decided to do my homework before getting too worked up.

I went on to my state exchange and compared the available plans. Gold. Silver. Bronze. All very logical. I spent some time comparing options and found a plan I liked. So far so straightforward. No complaints. No plan shortage in my state.

The problems started when I picked up the phone and attempted to communicate with a living breathing human being. I figured it would be a good idea to confirm that my OBGYN’s practice is covered. To make a long story short, I have a pretty serious pre-existing condition that could hypothetically kill me. My OBGYN is one of the best in the state. Moving to another practice is NOT AN OPTION.

Knowing how the system works, I called my OBGYN’s office and asked them to confirm that my doctor’s plan was covered. Should be a five minute call. No luck. Sorry. They don’t have the information yet. Probably yes. They helpfully suggest I give the health plan a call. Well, that’s logical, I think to myself.  It takes time for new plans to  about the plans to make it through the system. So I take their advice.

I call the health plan involved and politely tell them why I’m calling and what I need to know.  Guess what? They don’t know either.


In fact, they don’t seem to know very much about their plans at all. And they don’t seem to care very much either. The answer is probably no. If the code isn’t listed, it doesn’t exist. I push. Okay, then. Well, the answer is probably yes.  Now I’m starting to really freak out. They want to sell me a plan and they can’t tell me what I’m buying?? What the hell? The woman tells me to call the state health exchange. These plans are their responsibility.

I call the state health exchange. Surprise. Surprise.The woman I speak with doesn’t have an answer either. In fact, she doesn’t seem to understand why I need to know at all. She starts giving me attitude, then tells me to call my health plan. I am stuck in a surreal healthcare system loop.  It takes no less than eight phone calls and conversations with two supervisors before I finally got a definitive answer. I can see my OBGYN. I’ve also come to a terrifying conclusion: nobody knows anything. And if I push, they say what they think I want to hear. I won’t believe that my doctor is actually part of their network until I actually submit a claim and they actually pay it.

This is not how you fix our healthcare system.”

If you have questions about the Affordable Care Act or your buying insurance on the federal state exchanges, drop us a a note. We’ll publish the good submissions.

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Woolrich Milano San Babila
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jeff Livingston, MD
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As providers in Texas we are having this problem too. We are having trouble confirming which plans we are on. The insurance companies don’t have clear paths for us to become providers listed. Some won’t allow us to join as they are by invitation only. We have managed to get or confirm that we are on five marketplace plans. It is hard because there are doctors like us that want to participate but the insurance companies are not making it easy

Oakley Pas Cher
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Rehearsals are running behind following the death of Acostas much-loved mother in May. “It was very sudden,” he says. “It took me a few days to go back and so I didnt start in the time I should have.”

Joel Hassman, MD
Guest
Joel Hassman, MD

I love the dialogue that giving people who allegedly do not have insurance and are desperately pursing it are more important than those who had it and now risk NOT having it because they can’t afford it, AND, the “and” the left dismisses as quickly as flushing a toilet, won’t be allowed access to these alleged subsidies because of the income level those losing insurance have. Talk about hypocrisy and sheer disingenousness for a group of Americans the Left has basically decided are more likely NOT to be a partisan support to the supporters of the law, who really is… Read more »

alan t falkoff, md, faafp
Guest

Single payor? After this fiasco do you really want the government running healthcare? That makes no sense!

spike
Guest
spike

You’re right, when 1/2 of the government is actively trying to make government fail, initiatives like single payer are impractical. But don’t mistake that to mean governments fundamentally can’t do things. The U.S. Government can’t do things because Republicans are deliberately trying to destroy our government.

alan t falkoff, md, faafp
Guest

What about the family medicine specialists? Those who are going to be challenged to care for the bulk of the public? No contracts have been seen. No fee schedules and companies like United healthcare have de-enrolled thousands of primary care physicians. So what’s wrong with this picture?

Tom Wilson
Guest
Tom Wilson

Hey, look! Another problem that already existed and people are just now starting to notice.

FWIW, I face the same problem and I’m shopping on both coveredca.org and the private individual market (i.e. going around to as many different insurance company websites as I can think of). I finally found a simple solution. I asked my doctor (actually the clinic where my doctor works).

Joel Hassman, MD
Guest
Joel Hassman, MD

As I continue to warn anyone interested in considering this, don’t pay attention to Obama and his hierarchy in DC just reflexively supporting this law and consequences, but, pay attention to who just reflexively defends and apologizes, insincerely mind you, for these said consequences that are so “inconsequential” and “insignificant” I hear Juan Williams say on Fox or any other show he goes on and say those above two words about the MILLIONS of people losing health insurance coverage they wanted to keep, and should, well, I hope those two terms become the real legacy of the Current Occupant of… Read more »

Peter1
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Peter1

“I hear Juan Williams say on Fox”

There’s a couple without a biased agenda. (sarcasm)

Tom Wilson
Guest
Tom Wilson

Millions were losing their coverage before ACA, with no option. People whose plans are being cancelled now can sign up for a different plan.

Seriously, I’m glad for the sudden concern, but this situation is vastly better than the one before, where if you became to expensive to insure, you had no option!

spike
Guest
spike

Shorter version of this blog post: “Wait, you mean Obamacare didn’t magically fix all of the existing problems with our healthcare system??”

David Bynon
Guest

sr, I hear what you are saying. And, like you, I have no faith in Congress to fix the problem. Half of them voted for a law before they saw what was in it, and the other half refused to hear what was in it. Still, I have to believe that what we have is better than a single payer system. I’ve spent plenty of time in Russia, the UK, and the Far East to know what government run and single payer systems look like. We have a better system, albeit way too expensive. I count myself lucky. I grew… Read more »

Peter1
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Peter1

“I count myself lucky. I grew up in a military family and spent 20 years in the military myself. As a child I had great care, on active duty I had excellent care, and today I enjoy good care from our Nation’s VA health care system. It’s not the best money can buy, but it is the best taxpayers should be expected to fund.”

You warn against single pay but extoll VA and military health care – what do you think those systems are? Glad you could depend on the taxpayers for payment of your medical care.

Bobby Gladd
Guest
Bobby Gladd

Single payer. Already pretty much in place. Just finish the job.

Tom Wilson
Guest
Tom Wilson

“Frankly, if I thought our government could provide the same level of care for all Americans that it provides our Armed Forces and Veterans, I’d be all for it. Sadly, it can’t.”

Wait, what? The government can’t provide the same level of care it’s already providing? The VA is beyond single payer, it’s basically our own NHS.

Legacy Flyer
Guest
Legacy Flyer

There is another interesting little twist to this as well. Docs that sign up for certain ACA plans can be stiffed out of 2 months bills. Here is how it works (as I understand it). Patients are allowed to pay their bills monthly and are given a 3 month grace period for non-payment before their insurance is listed as cancelled. But certain ACA plans only reimburse for bills during the first month of that 3 month period. So during the second and third months a patient hasn’t paid, the insurance company will tell a doc that the patient is still… Read more »

David Bynon
Guest

Legacy Flyer, This is not a new issue, and it was not caused by the ACA. It happens with fee-for-service type health care plans. One of the benefits of an HMO is that they use a capitation process to pay physicians and physician groups. Capitation pays for a set number of people assigned to them, per period of time, whether or not they seek care. This is why HMOs focus on preventative care, and why you must go through your primary care physician to get to a specialist. Fee-for-service contracts are different. They bill for each use of service. If… Read more »

Legacy Flyer
Guest
Legacy Flyer

It sounds like you know more about this than me. But ….

What I read was that with non ACA policies, the insurance was only good for 30 days post non-payment or premium but that the ACA extended this to 90 days. That is a significant difference.

Also, if a provider calls to determine if someone has coverage in the first, second or third months after a premium payment has been missed, what does the insurance company say?

sr
Guest

Wasn’t going to comment, but find that I have to. Peter and Cindy, I have no faith in my Congress to fix any of this. I’m not saying to defund the entire ACA, but I really don’t think any of these guys have any idea what’s going, and I don’t trust that they have the ability to fix their toilet with a plumber doing all the work. And I totally agree with Joel – he may have sounded snarky, but I’m guessing that what he really was is frustrated. ‘All doctors should be included in all plans’?? You are kidding,… Read more »