BRCA carrier is being forced to chose HMO

Sahar

Hello,

My mom is a BRCA1 carrier. She was diagnosed in 2010 with DCIS. She underwent a lumpectomy and radiation by a very reputable NCI center in Los Angeles county. She is now forced to change her insurance to an HMO model. As you know, in HMO model you don't have the ability to go wherever you want. You have to go wherever your HMO sends you. The problem is that the NCI that my mom has been going and receiving all her follow ups/surveilance  is not part of any HMOs. If she changes her plan and moves to HMO, she will lose access to this NCI center. We asked for exemption but it was denied. Now we are going to appeal it. Personally I think having BRCA gene increases the risk of recurrance and developing a new cancer and carrier should have access to any new trials/treatments that are available at NCI centers which could not be available in other places. Additionally, with such elevated increased risk, services should be available immediately if needed. Person cannot wait to go through the HMO process such as referrals/authorization, challenges with finding necessary treatments/specialties within the HMO network, etc. So these are my reasoning that I will be using to make our appeal case but I would like to get more opinion to build our case stronger. Thanks for your input.

Chickadee

It seems you would have to prove that this HMO is not capable of providing the expected standard of care. Is there only one insurance choice?

Sahar

There are 2 choices but both are HMOs. Unfortunately.

bak94

Is she being forced to change insurance because her company changed insurances or specifically because she has the brca gene?

Sahar

No the change had nothting to do with the gene. Some Medi-Cal enrollees are mandated to change to Medi-Cal HMO and my mom is one of them. This is a state initiative unless you prove that it is not safe for your condition to transition to HMO. 

peggy_j

I'm sorry to hear this. Who is forcing her to change? If this sounds fishy to you, there are national orgs that help cancer patients with legal issues who may be able to help. 

Sahar

It is actually the state of California. Probably to manage healthcare cost.

peggy_j

CA has a consumer advocate for health insurance. I called them about a year ago and the person I spoke to was surprisingly knowledgeable and helpful. Maybe they'll have tips on how to prove that it would be unsafe to switch. It was a *.gov website, perhaps this one.

http://insurance.ca.gov/0100-consumers/0020-health-related/0010-consumer-provider-complaints/ 

Sahar

Thanks Peggy_j, I'll try it.