Friend's insurance switched, new insurer is refusing to cover

I don't know if Cigna does it, but I know that Blue Shield PPO will do a one-time exception to have something/someone that is Out-Of-Network covered as if it were In-Network. We did it for my Foundation One Testing because F1 is out of network and it's a pricey test (still hope I don't regret using it for that). My oncologist's office has an insurance specialist who told me about it and handled it for me. It's worth her asking about, but one week may not be enough time to get it handled if they do it. And if approved it would only cover that one procedure, it wouldn't apply to any follow-up care with that doctor.

Nancy I looked into the Blue Shield HMO because it was so much cheaper than the PPO, but there were only 3 oncologists anywhere close to me and they were all more than an hour away (several hours depending on time of day and SoCal traffic). I live in south Orange County, CA, not exactly a rural area haha, so I was really surprised to see so few oncologists. It's ridiculous that I would have to travel to another county given how many people live in OC and how many quality hospitals we have here! I'm not willing to travel that far on a regular basis because I've been on IV chemo since Day One, and I have top notch care right here in my backyard. I've had more than 80 medical appointments so far in 2019. I reluctantly made the decision that it was worth an extra $300+ per month to keep my life a little easier.

You are lucky that all of your doctors are in the HMO network!

Nancy I have a Silver plan. I'm a numbers cruncher and for me it works out best to minimize my out of my pocket costs. Are you in CA? I don't know if it's the same in other states but here at the Silver level and above, even though a deductible is listed for the plan, absolutely none of my medical care applies to the deductible. Since I'm Stage IV you can imagine that my care involves a little bit of everything on a regular basis - IV chemo, rads, consults, labwork, tests and scans, biopsies, etc and I have had not had to pay a deductible for any of it. I have to pay the co-pay until I reach the Out-Of-Pocket Max. Since I'm HER2+ I am always on a drug from Genentech (even a chemo like taxol is used with Herceptin) and they have a fantastic co-pay assistance program. My IV drugs are quite expensive so I've been hitting my OOP max by March/April of every year, but the bulk of it has been covered by Genentech's co-pay assistance program (if I time things right - this year we needed to try to fry the cancer to get it to stop spreading in January and I did have to pay a couple thousand toward the co-pay. More typically I might have to pay several hundred dollars toward consults and scans before I hit the OOP max). Once I hit my OOP max early in the year, I never pay another dime toward any of my care for the rest of the year, including prescription drugs. But everyone's situation is different, one really needs to understand what care they are going to need, what drugs they will be taking & if the mfg has a co-pay assistance program, etc. to figure out which plan is going to have the lowest out of pocket costs overall. If it wasn't for Genentech's co-pay assistance program I don't know how we'd do it. We're both self-employed (although I'm no longer able to work, so we no longer have my income) and we have to pay full price for our insurance. I have a panic attack every year when it's time for renewal.

Sorry to the OP for taking things off track. I really hope your friend is able to get her surgery covered in network.

I also want to apologize to the OP as I got this thread off track. Lori yes I'm in San Diego. At this point in my treatment I think an HMO is the better choice for us, but when I was originally diagnosed the PPO made more sense so you sound like you have the best plan for you. I also panic every time insurance renewal pops up as we buy our own insurance as well. Each year blue shield has raised our monthly premium by $300. Outrageous. Best to you

Nancy

Lori my heart goes out to you. You have enough on your plate without having to get screwed by insurance. There are so many things wrong with health insurance in the US. Did you know ambulance service is not covered by Blue shield at all? We found that out when my son flipped over his bike and couldn’t move. Had to call an ambulance and not one cent was paid for. Just that alone was close to $3000 and that’s the cheaper end. Then there was the ER visit, doctor fees and xrays. Since our deductible hadn’t been met we paid for most of it. Anyway it’s a shame that for someone in your situation better options aren’t available. Doesn’t seem like a thing is changing in the near future either. Hugs to you

Just to chime in about Medicare, I have been researching for the past year so that I will know what to expect and from my understanding, we need to buy a Medicare supplement (MediGap) and in that case, the uncovered 20% of our cancer drugs will be covered. In my state, the Gap plans seem to cost around 200 - 400 per month

This is from Medicare.gov

https://www.medicare.gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigap

You can look at the cost of Medigap plans in your area and what they cover, here:

https://www.medicare.gov/medigap-supplemental-insurance-plans/

Plan F was the "best" that covered everything but that is going away for new applicants next year, the next best one is supposed to be Plan G

It's important to note that federal law does not require companies to sell Medigap policies to anyone under 65, and you can be denied coverage due to your pre-existing condition. There are some states that require companies to sell at least one type of Medigap policy to people under 65 (doesn't say it has to be a Plan G), but if you don't enroll during the 6-month Open Enrollment period you can still be denied if you don't meet underwriting guidelines. Even if you are approved for Medigap coverage, the company is allowed to charge whatever it wants and can make you wait 6 months before coverage kicks in (look-back period), which would really suck for those of us who are Stage IV. California Medigap plans for people under 65 are extremely expensive compared to what someone who is newly eligible due to turning 65 would pay.Face it, if we're Stage IV they know up front that our annual medical expenses are going to be astronomical, it's a no-win situation for them.

Anyway, it's important for people to know that they need to check on the laws in their specific state.

Lori - for people who are 65, I don't believe you can be denied medigap (supplemental) coverage when you first become eligible. If you switch to an HMO plan (advantage) and then want to switch back to traditional medicare, then yes - you can be denied based on health information.

I've been on traditional medicare and a medi-gap policy for 10 years. I can't begin to tell you how pleased I have been. Like Yoga, once I pay the premiums, the only thing I pay is the yearly deductible for Part B ($183 last year) and a reasonable hospital deductible if I'm an inpatient. No co-pays, no partial pays, nothing. Medicare pays 80%, my medigap policy pays the 20%. I do have friend who choose traditional medicare w/medigap but elected to have the initial yearly deductible paid and she pays a $10/20 co pay for every visit. Not sure that one is available any more but she thought she was saving $ since she never had doc visits.

There are no limits to what traditional medicare will do - up to and including hospice. They don't pay for long term care, but you have to have a separate personal policy for that anyway. You can see any doc you want. You don't need a gate-keeper or a referral. You can call up any specialist & make an appointment. I went through 3 cancer surgeries, reconstruction, two different sets of chemo, radiation, herceptin for a year - and on & on. To date I have never been refused any test or service, or been turned down for anything, or paid one dime over the yearly deductible.

Weighing all that against an advantage plan - for me it's a no-brainer even if the HMO plans do pay something for dental & vision.

I realize I'm fortunate to have this coverage and so sorry for those who don't have decent medical insurance.

Lori - so sorry for my mis-reading. Based on your details I read in another thread, I'm also sorry you're going through such hell with insurance & costs. Not to mention the cancer itself.

It gets more complicated - the "outpatient" drugs like Ibrance are covered under a Part D plan not Medigap. The infusion drugs are covered under Part B plus Medigap (or Medicare Advantage).

Part D drug plans *I think* are available in all states to under 65 SSDI recipients and some Medicare Advantage plans will include Part D. But the issue there is that Part D does not cover 100% (or even close) to your drug costs. Some states have additional programs for elderly and disabled Social Security recipients but these are income tested and the income limits may be pretty low.

It certainly does suck that we have to forego the benefits that we contributed to during our working lives in order to maintain insurance coverage and it is crazy how inadequate Medicare pharmaceutical drug coverage can be.

But for some people under 65, Medicare could be preferable to an exchange plan, depending where you live and what plans are available to you.

Hi yoga, yes, we qualify for the "compassionate allowance" as it is called and it looks like some or all lung cancers are also on the list. Here is the link to the Social Security admin. website so you and she can investigate further:

https://www.ssa.gov/compassionateallowances/conditions.htm

Remember too, even when we qualify for SSDI we have a two year wait to qualify for Medicare if we're under 65. So she would still have to arrange for some type of insurance coverage.

Let me also add, I've made a few calls to Social Security to ask questions and they're quite helpful, although there is a long wait on hold to actually speak to someone.

Olma, thank you so, so much!!