You have a federal plan. Most insurance is state controlled and those require seeing someone in the plan, getting pre-approval for an OOS doc, or for emergencies when traveling.
My friend’s son was at college in NY and broke his foot. He had the surgery done while at home (Colorado) but needed PT when back at school. BCBS would not approve it in NY as it was out of network and not an emergency.
The whole point of a PPO is you’re not as constrained as in an HMO. BC/BS has both. My HMO limits me geographically. A PPO shouldn’t do the same, though there might still be preferred providers and non-preferred providers with different co-pay requirements. But tell me again how our super complicated, for-profit health insurance system benefits us 
(not you, it just makes me crazy my 22-year old or anyone else can’t just get the health care they need)
This is not necessarily the case. I would not assume that a PPO will have a national network or pay the elevated rates for out of network care.
However, many providers have very high list prices, so out of network patients could still face very high costs, even if their PPO covers 60% of what the PPO thinks the price should be (much lower than the provider’s list price).
Not AS constrained but there are still limits. Kaiser is an HMO and you have to stay in network all the time. I have a PPO and live in a major city (Denver) so I have a lot of choices and don’t need referrals for most things but still do for a few (podiatry, PT). Even though preapproval is not necessary, most of my specialists still get preapproval to protect themselves and me from coverage being denied. If I’m taken to a non-participating hospital in an emergency, I can get emergency treatment but not continuing care. For example, Denver Health (big major public health hospital) doesn’t take many insurances, including mine. It is likely an ambulance would take me there if in an accident in their ‘zone’ (Ambulances in the Denver Metro area are in zones with different hospitals in the zone). They even take Kaiser patients there, or OOS people needing care. It is likely my insurance would transfer me if I needed ongoing treatment once the emergency is over. (I used to go there for treatment with a different insurance plan and I liked it, but now can’t go there for ongoing care).
And I can’t just say “I’d rather see a doctor at Johns Hopkins or the Mayo Clinic” if they aren’t in my network (and it’s likely they aren’t). I have a list of providers and not all in Denver are on it and very unlikely OOS providers are on it.
It was a big deal to me to leave the Denver Health system as I liked it but the insurance that they take (Aetna) was a lot more expensive. Some people love Kaiser and others hate it but stay with it because of employer choice of plans. A lot of retired teachers stay with it because their pension plan pays some of the premiums.
I agree that you have to check with the insurer to find out geographic limitations. Sorry that they are imposed.
Seems like Denver Health is a high cost provider, so that any insurance plan with it in-network is likely to be more expensive than other insurance plans. Kind of like Sutter Health in California.
Denver Health is the medicaid/public hospital. I think if they negotiate lower rates with a lot of insurance companies it will change the rates they can get for medicaid reimbursement or maybe billing is more difficult for them? They do take some other insurances but not Humana or United health who are the other two (with Aetna) medicare advantage plans I can choose from. They take non-medicare advantage medicare plans like BCBS, but not Kaiser, United, or Humana. Kaiser here doesn’t have its own hospitals but uses about 10 around town (used to be only 2!), but not Denver Health.
I had Aetna my first year and was at Denver Health. When I switched, I had to switch all my doctors. I’m not going back now, and that’s the reason I didn’t pick Kaiser this year - no more switching if I can help it. I liked having all my doctors in one place and I liked having MyChart for record keeping. I now have doctors all over the place and about 7 electronic charting plans. Much more work for me.
We have some of H’s doctors in multiple different health systems. Fortunately, most of them are some form of EPIC, so many of them can see each other’s records, even if they are in different systems. There are a few of his providers who are NOT in the same system and it’s more cumbersome. We had to ask the folks from the ER in NYC to send his records to his internist locally, so she can follow up with the contrast CT they did. Both are EPIC but she couldn’t view the CT and the hospitalist asked that she follow up. We had to fill out paperwork to get the records sent.
Most of my providers can see the records of the other providers, even though they are in different hospital systems. I have given permission to the different organizations to see one another, so they can see most of the EPIC records but not all sometimes. I have docs in CA and in 2 different medical systems in Honolulu. Fortunately, they are all on EPIC.
Epic MyChart is an example of network effects creating market pressure in favor of monopolization, since there are conveniences for both patients and providers for being on the same system as a large number of other providers.
Obviously, monopolization of the electronic health record market can result in higher costs becoming embedded into health care, as well as creating a bigger target for those trying to crack electronic health records.
I am already getting messages about shipping for different medicare supplement plans to not even july. But that said, we did just get a premium notice increase.
I went to a different PCP a few years ago (TWO different online systems). In May my PCP left the group, but I was transferred to another with first appt in Aug. Got an email yesterday that she’s leaving the group too! For a lot of reasons it is time to change, not the least of which this group is now owned by Amazon, I get notices about my test results from Seattle from doctors and nurses who are clearly NOT reading my records, and the pharmacy is run out of Seattle or San Francisco and I’ve never heard of these doctors so when the pharmacy has a question, I can’t answer it and I have to go through the online system to get an answer.
Searching for a new doctor is not fun.
We have great health insurance but when H’s PCP abruptly left the practice with no warning, we had to frantically search for a new one. Some were booking appts more than a year from the day we called IF they even accepted new patients.
We were very lucky my internist had her office call us after they had hired a new internist and offered H an appt that wasn’t too far in future. Sadly that PCP left in a few months (HI too expensive), so H had to switch to a new PCP but they were able to offer him appointment with the replacement. While we were at it, we scheduled D as a new patient too and had her scheduled when she is in Honolulu for holidays. She’s thinking of moving back to HNL and we want her to have a PCP here. Plus she sometimes has extended visits in HNL.
I definitely would not want the system where the pharmacist and MDs involved in your care are remote and don’t know you and aren’t paying attention to YOUR records—very scary stuff!
And beware the post-merger implications.
At my last physical, the PA asked “are you having any side effects from the long term use of XYZ"? I said “I took XYZ for 10 days about 15 years ago when I was in the ER after an accident, how is that long term use?” She was apologetic, said that the practice had been “rolled up” into a much larger medical system, various systems had merged helter-skelter, and that the staff could no longer see which medications had been prescribed by them and which ones had been prescribed by other providers.
yikes. She rolled the screen over to me, and there it was– my medical history going back two decades, a big block of text, and the only line in red was “Prescribed Oxycontin”. As if Oxy is the only medication that warrants attention….You would only see the allergies if you scrolled down and paid attention until the bitter end….
Yes, one really needs to pay attention and be one’s own advocate and/or have someone with you to help. H honestly can’t remember and is grateful I now accompany him to all appts. Allergies need to be front & center and not buried in the record!
NYC has five different med school-hospital-health care systems, all allegedly nonprofit and at least three use some form of EPIC-MyChart. With permission of the patient, providers in each system can access the records of the others. Despite bull@#$% about lower cost with mail pharmacies, I use an independent pharmacy where the employees and pharmacists know me and deliver for free. I have them add a tip via my saved credit card but I hardly ever need that service.
I’ve had the same wonderful pcp since 2019 and she probably won’t retire until I am long gone. She makes great referrals, even outside her network if it takes too long to see an in-network doctor.
My current Medicare Advantage plan allows me to see PCP and get diagnostics for free with low or no (!) copays for meds and $35 to see a specialist. So I’m good.
We THOUGHT we were good when H had a new PCP after his original one that he had for decades retired. She was young but she got grumpier and grumpier and then one day in April, she just stopped working with no notice to patients at all and no option to have someone takeover care. Then H had another young PCP and she was great but after a few months, she decided HI was unaffordable for her with the poor reimbursement rates, so she left after a few months. We have our fingers crossed that her very young replacement will last at least as long as mid-80s H needs her! D (in her mid-30s) said this is her first provider who is younger than she is! She’s a friend of nephew’s fiancée–they attended local instate med school together and she’s coming to wedding of nephew and fiancé! This is H’s 3rd PCP in 12 months!
If there is a Medicare only thread, please let me know but the one I found was closed. Is anyone that is currently on Original Medicare with Supp G or N considering the High Deductible Plan G or N? I wasn’t aware of this plan before (maybe it’s new) but before I start searching for providers for my existing G plan, thought I’d see if anyone could share info they know about the High Deductible Plan G or N. It sounds like a great plan if you don’t have annual issues (I have an endoscopy every year but this still looks like it would be less expensive than regular G). The concern with current Supp G or N is the rising costs that pile on top of each other year after year vs. $50 flat monthly premium with a $2,950 deductible. Has this been around before?
It’s been around. It’s a good deal, and a lot of people are switching. I would choose G-HD over N-HD simply because costs are $0 after the Part B & G-HD deductibles. N may have ongoing costs. Google Giardini Medicare for videos and other information.
H & I have chosen to stick with G for a couple reasons. G-HD isn’t that much less expensive in our area than G. We can’t change back from G-HD to G without underwriting, but we could change from G to G-HD easily down the road. Most importantly for us, after seeing the reality of medical bills as our parents aged, we want our medical bills as simple as possible down the road.
Thank you. I was putting it on a spreadsheet and trying to decide if it made sense. Then I looked at the 2024 HD cost was $2800. 2 years later, it’s up $150 to $2950 so that seems a higher rise than my regular Plan G is rising. Also I don’t want to risk not being able to get back on regular Plan G. My husband will go on Medicare in January or February and we “may” look at the HD for him, still iffy about it. Does the HD include the Part B deductible or is that in addition to it?