<p>GP, under what circumstances do you imagine that DStark’s currently healthy NY son will suddenly need to be “hospitalized” for “non-emergency” care?</p>
<p>Here’s my state info on Anthem and their networks. Info from largest state paper and from my industry monthly magazine. Anthem is the state’s largest provider with market share greater than 60%. There are 4 providers for ACA for my state, but what you can buy depends on your county. For my county, there is ONE. Is this typical? In 2010, 17 companies offered coverage. Indiana’s rates are in the 10 highest in the country on the exchange.</p>
<p>Anthem has signed on 50% fewer hospitals and 40% fewer doctors. Here’s the really scary part for me. The state’s 3 largest hospital systems are IU, St. Vincent’s and Franciscan Health. In the last 5-7 years, they have bought up virtually everything everywhere. In the Indianapolis market these 3 systems have 79% share. I’m not sure that extends across the state, but I believe it would be close. NONE of these 3 systems are in the Anthem market. I’m several hours away. Everyone in my locale has heart surgery at St. V’s in Indy. Leading children’s hospital is IU. These critically ill people are absolutely (I believe) not going to receive commensurate care at community hospitals.</p>
<p>People say if your hospital/dr doesn’t have the expertise/whatever for your condition/care, you will be granted an exception for out of network. It’s not that easy. At all. We’ve had the diseases where you fight insurance for decades for.every.claim. </p>
<p>I see a real problem looming if 79% of the market is now forced to community hospitals. They must be jumping for joy. Too many people don’t care because they have employer insurance and this is all too complicated. CC is not your average person. I think something has to give in that equation.</p>
<p>I don’t know Calmon, but are you advising him to take the chance.</p>
<p>You want to get in an argument with Anthem about what is emergency vs non-emergency care while you have a 6 figure bill hanging over your head.</p>
<p>Just to clarify my discussion with my agent and the Anthem supervisor. The issue which they are trying to resolve is whether a provider in an EPO region is automatically in network for a PPO region or does that provider have to have a PPO contract for 2014 ACA-compliant plans in addition to the EPO contract with Anthem. In other words, is this a blanket rule or is it determined individually for each provider. Hopefully, I will know tomorrow. This is a huge issue for me.</p>
<p>Ok…</p>
<p>[Anthem</a> Blue Cross :](<a href=“http://www.anthem.com/wps/portal/ca/popcontent?content_path=shared/f1/s0/t0/pw_e206382.htm]Anthem”>Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More)</p>
<p>I have no idea what is going on…</p>
<p>I just talked to two people at Anthem…</p>
<p>One said I was covered at UCSF in network.
The other said I was covered at UCSF out of network. That would mean out of pocket maximum would be 15,000 for an individual… 30,000 out of network.</p>
<p>Stanford would be in network.</p>
<p>The link has the list…if you live in an area covered by a ppo…you are in network in all the areas that have ppo plans. </p>
<p>Areas that have epo plans are out of network. </p>
<p>Emergency care is emergency care. Whatever that is… A broken leg is emergency care.</p>
<p>I have no idea if what I was told is true.</p>
<p>All of this makes me want to join Kaiser. :)</p>
<p>Yeah, it is very confusing. My agent says no one is really sure of anything at this point. I am going to get all representations from anyone connected to Anthem in writing. I am leaving nothing to chance.</p>
<p>The problem with out of network is the balance billing issue. That could be a huge amount of money.</p>
<p>I guess this is where my anal personality comes in handy. I am going to get to the bottom of this if it is the last thing I do.</p>
<p>I don’t think they have Kaiser in NY. ;)</p>
<p>
</p>
<p>That’s the difference between PPO and EPO. An EPO is essentially and HMO – I think the only difference is that you do not have to get a referral from an assigned primary physician before seeing an in-network specialist.</p>
<p>Dstark, the link you posted to Anthem leads to the print outs for provider networks – in very small print at the bottom there is a date. At least for my area, that date is 10/24/13, so I’m looking at a list that hasn’t been updated in more than 5 weeks.</p>
<p>FWIW, if I lived in SF, the UCSF medical facility would not be my first choice for most medical treatment. Way back when I do remember taking my son to the UCSF emergency room after I slammed the car door on his finger – but we lived quite close, so that would have been the nearest facility. (They provided appropriate smashed-finger care.) </p>
<p>But for other stuff the preferred facility has generally been California Pacific, which is a Sutter affiliate (and iffy about Anthem coverage - they don’t like Sutter’s prices). I do know that the SF General Trauma Center is staffed by doctors from UC Med.</p>
<p>Well…the link is what Anthem gave me today.</p>
<p>I have been unimpressed with Anthem for a very long time.</p>
<p>And people are against single payer. Lol.</p>
<p>Is Kaiser really in NY?</p>
<p>I signed up for a plan at Anthem. I have 30 days to change my mind.</p>
<p>It’s a problem dealing with individuals at the insurance companies. They all firmly believe that they are correct, and they can be absolutely and totally wrong.</p>
<p>I had two separate people at Anthem convincingly tell me that my son should not sign up for health insurance at his company, because he absolutely is covered under my plan right now…and my plan was probably better than anything he could get for himself.</p>
<p>Then a little while ago, they sent everyone an email declaring that children over 23 aren’t covered until Jan 1st, so you’re on your own till then.</p>
<p>Now I don’t think he can even get health insurance with his company, that time has passed. He turned it down because they said he was covered. I just have to pray that he doesn’t need anything until after the first of the year, or if it does, they decide he wasn’t eligible for insurance at work anyways. All because the people at Anthem were so dead sure that they were right, and I actually believed them.</p>
<p>The interactive provider tool on the Anthem website is supposedly working but my agent says it is totally screwed up.</p>
<p>So, I got this postcard in mail today. First off, I have not been a patient with them for more than 20 years.</p>
<p>It is from Cedars: </p>
<p>If you have non-employer provided health insurance, be aware that if you didn’t choose your plan carefully, you and your family may not have coverage for Cedars-Sinai when you need it most. </p>
<p>There is contact information to learn more. </p>
<p>Interesting.</p>
<p>I looked it up: </p>
<p>
</p>
<p>
Nice pun :D</p>
<p>
How is that legal? The coverage through age 26 provision of ACA went into effect in 2010.</p>
<p>I thought you had employer coverage, and that your employer self-insured?</p>
<p>Busdriver, </p>
<p>Did you drop him from your coverage?</p>
<p>Calmom, I didn’t even realize it. It must have been subconscious.</p>
<p>“How is that legal? The coverage through age 26 provision of ACA went into effect in 2010.”</p>
<p>They weren’t required to allow a child to stay on a parent’s policy until age 26 if the child had access to their own health care plan at work, no matter how poor it was. Unfortunately.</p>
<p>I believed my child could stay with my coverage regardless of access to healthcare at work, because they were so firm that he could. And I wanted to believe it.</p>
<p>dstark, I think you have until Dec 23 to change plans in order to guarantee coverage Jan 1.</p>
<p>No samurai, I didn’t. I assumed he could stay on until age 26 like they told me, so I told him not to get any from his work. Now I don’t know if mine will cover him at all, at least for the next 28 days.</p>
<p>I do not see why he wouldn’t be covered, if you did not remove him - at least until he does have a plan, anyway.</p>