<p>“So if you have a heart attack, a stroke or get in a car accident and need care you are going to travel to another country to get it?!?”
-I have 6 implants at $4k each. they are about 30% of that in Costa Rica. And if you are there already, would you travel to the USA if you have a heart attack, stroke? I do not think so…unless you travel in a wooden box, well nobody can escape a wooden box at some point of our lives. BTW, we can only try in this respect and trying cost much more in the USA, I guess, this was my point. Heart attack / stroke will have to be treated at the point of your residency, which BTW might be a vacation travel to some very undeveloped, not civilized location at all, then the sick is screwed…which brings us to the point of saying, that maybe you better off being on your couch in your house located in 15 min. from the hospital. I said on the couch because many heart attack victims are found on the floor where they could have hurt themselves. So be prepared, quit everything, lay on a couch and wait for the hear attack.</p>
<p>This new story brings it to our attention again the accuracy of doctors’ assertions that they won’t see patients whose insurance was bought on the exchange. </p>
<p>This Alameda County woman wanted to see a certain doctor in Santa Clara County, a doctor that she had been seeing. The doctor’s office said that they didn’t take her insurance. The insurer says they resolved the situation, not by making an exception and allowing this woman to see the doctor, but by waving a previously signed contract in the doctor’s face.</p>
<p>No doubt some networks are narrow. No doubt GP would have been facing narrow networks in southern California. But how many of these “I can’t see my doctor” stories are the result of the doctors not knowing what contracts they’ve signed?</p>
<p>emilybee,
I worte that it is amazing how everything is the same, the same slogans, the same actions, the same type of people up there, at different places, different times, 100 years ago, 40 years ago, but nobody is studying history and that is where the problem is. I know that you still do not understand, but I cannot help you with that.</p>
<p>MiamiDAP, you speak multiple languages, dont you? I would like to have that ability. What is your native language? Which languages do you speak?</p>
<p>I have similar issues, but that’s not new – ACA actually seems to give me a better option for dental insurance than before, but the dental policies seem to have a very low annual cap on benefits that makes it unlikely that it would save me money over time. It does seem like a potential way to save a few hundred dollars if I anticipate a specific covered dental procedure in the near future. But that’s consistent with my past experience – I bought dental insurance for my daughter as a child, and then found that it only paid a small fraction of the costs for dental visits and fillings. The only dental policies that seem worthwhile are the dental HMO’s, but then only if you go to their doctors … and it’s always been very important to me to choose my own dentist. </p>
<p>CF, I think that’s sloppy reporting – that quote was in the article last night when I did my own analysis. </p>
<p>Here is what I think happened:</p>
<p>I believe that the medical group in question is included in the new Blue Shield network for PPO’s. I have a BS PPO, and I think that if I wanted to go to that group, I would easily be able to do so.</p>
<p>I know that the BS policy in Alameda county is an EPO --so I think that while the group would be included in a plan bought by patients in Santa Clara County (or, for that matter, San Mateo or San Francisco Counties) – it is NOT included in Alameda because of the EPO thing.</p>
<p>But the insurance companies have been insisting all along that there a process by which EPO patients can request inclusion of an out-of-county doctor. (Similar to what you would do when requesting coverage of a non-formulary network). </p>
<p>So rather than telling the patient that the medical group was not included in the Alameda County EPO, the doctors probably should have told the patient that she would have to contact the insurance company to request inclusion. They didn’t, she didn’t know, hence her attempt to find a provider nearby. </p>
<p>I just think that the news article fails to address or understand that issue – which is quite obvious to me. A truthful (and helpful) article would have included a brief explanation of what an EPO is, and a summary of the process that patients need to follow for approval of secondary network providers. “Secondary” is my word - -not a technical term of art – but I am using it to refer to the doctors that are in the PPO network but not included within the same company’s EPO networks. </p>
<p>Blue Shield is experiencing coverage issues with its Alameda County EPO’s – and I have heard from sources I consider reliable that they will not even offer the policy to some zip codes within Alameda because of it – so my guess is that they are motivated to be quite liberal about granting patient request for inclusion in those cases.</p>
<p>I think the reporter didn’t really understand what BS was saying – and of course the agent or BS spokesperson may have been unclear in speaking to the reporter – but I think BS is saying what I said above – that all the patient had to do was ask and they would have approved the other doctor on her policy.</p>
<p>The other interpretation – that an out-of-county medical group was in the EPO network “all along” – just doesn’t make sense in the context of an EPO. But EPO’s are a relatively new concept with a new set of rules and practices – hence the confusion.l </p>
<p>Dental insurance has always been expensive and really not worth it. There are really very few procedures which even come close to costing what most medical procedures cost and few people go bankrupt for lack of insurance. </p>
<p>Not to poo-poo the cost of implants, for example, but I am close to $15K retail for my two+ month medical issue for which, after diagnosis, the treatment is a medication I need to take every day, likely for the rest of my life, which costs $1.94/month. I also need PT once a week for 6 weeks. But getting to this point was very expensive and there wasn’t even a hospitalization or surgery involved! </p>
<p>My dental is lumped in with my medical insurance. Have no idea what the breakdown between the two is. My H and son both go to an in network dentist and they pay nothing - everything is covered. I go to an out of network dentist and it’s $150 every 6 months for a check-up and cleaning and I get reimbursed about 30% Xrays once a year add more. I needed a crown a few years ago and it was $500 out-of pocket, if I recall correctly - after my insurance covered their portion. If we didn’t get dental insurance we wouldn’t purchase it on our own. </p>
<p>I don’t think that the woman complaining about the change in her policy is a scammer – I think that she just didn’t understand the benefits she was getting, particularly the maximum out of pocket. She was paying $1000+ a month for a policy that seemed to cover her expenses 100%, and so she was happy with that and rationalized that the policy was worth it. Then she gets a plan with a $500 premium and 20% copay – the lower premium leads her to suspect that “there’s got to be a catch” – and she doesn’t know or realize that the copay is limited by the out-of-pocket maximum.</p>
<p>She contacts her congressman, and rather than getting help she is exploited for political purposes. (“Help” would have been an explanation of her out-of-pocket maximum, as well as inquiry as to whether there are some real concerns, such as whether medication she needs is covered, or whether she will need to see any specialists who are not in her plan’s network.)</p>
<p>I do think that some people really don’t get the math behind the insurance or understand terminology like “copay”, “co-insurance”, “out-of-pocket maximum” – etc. So I can understand a patient feeling panic and being fearful of change. It’s just that she would be better served by having someone answering her questions rather than asking her to be the poster girl for a political attack ad. </p>
<p>Thanks, calmom. Let me see if I can restate this to clarify my understanding.</p>
<p>This patient bought an EPO, an exclusive provider organization health plan. Whereas a PPO will pay the entire cost of the subscriber’s health care if they choose a preferred provider, and some percentage if they choose another doctor, an EPO pays nothing if the patient goes out of network. And the Stanford doctors are out of network for this plan, because they are not even in the same county as the patient.</p>
<p>So when the patient went to the doctor, the doctor correctly said they were not in the patient’s plan. However, as soon as the patient asked Blue Shield if she could see this doctor, Blue Shield said OK. Blue Shield isn’t worried about the Stanford doctors overcharging, because Blue Shield already has other contracts with those doctors (a PPO plan for Santa Clara County people, for example) that include provisions so that Blue Shield can also send Alameda patients over.</p>
<p>This is a complicated situation and I don’t blame the patient for not understanding it. But I was under the impression that a reporter’s job was to clarify complicated situations. If you, calmom, could explain it so I could understand it, the reporter could also have explained it.</p>
<p>Yes, CF - that is how I understand it as well. I also am not completely clear on what an EPO is, but I think it functions like a hybrid between HMO and EPO. An HMO typically limits the patient to one primary care provider, with the patient needing a referral in order to see any specialist. The EPO allows the patient to see a specialist or choose to rely on multiple primary care providers, but has a more restricted network to choose from with generally is also tied closely to the geographic area. </p>
<p>I don’t know the specifics as to how the BS EPO works in Alameda county - maybe I am mistaken and they do include some out-of-county facilities without the need for a special request – but that certainly would be something I would want to clarify when talking to an insurer about the EPO. This EPO vs. PPO issue was the subject of considerable discussion between GP and DStark on this thread, though the focus was on Anthem rather than BS. But I think it was very clear at the end of the discussion that DStark could buy an Anthem PPO in Marin county that would give him more freedom to choose doctors throughout the state than the EPO that was available to GP in his own county. (I personally am very uncomfortable with the EPO model and would probably choose a Kaiser HMO plan over an Anthem or BS EPO if that was my only choice, but that could be a result of my own misconceptions.)</p>
<p>Emilybee , because your defense of Obamacare would be a lot more credible if you did. I wonder how your experience with a chronic disease would have gone with an Obamacare plan. </p>
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