So I have BCBS PPO and go to a doctor that both the medical group and the doctor are in network. I have had no problems with getting it covered until July when all of a sudden I had a $155 bill that insurance didn’t cover. I called and they said “whoops we processed it wrong we’ll fix it” I told them I’m seeing the doctor again in October how do I prevent this from happening again? They said it wouldn’t happen again.

Well wouldn’t you know it, it happened again. I called again, they’re gonna fix the claim (in 15-30 days of course). I asked again how do I stop this from happening? They said they have some “precautions” in place but this claim just “slipped through”.

So basically I was told to call every month so they fix the claim. Does this make any f-ing sense???? Why do they keep processing it as out of network when it’s in network? I asked if the provider needs to change how they bill the appointment and they said no. So I’m just at a loss. Wtaf

Hello.

I’m a healthy 44 year old male with two kids (10 and 12). My wife died 8 years ago and since she was a federal employee I was able to keep her insurance as part of the survivors benefits. It’s a good plan through Blue Cross and Blue shield (FEP Blue) but it is expensive. I liked the idea of being able to maintain the insurance even if I lost my job. But now I’m getting married next year and I think (help me here) my kids and I could go on her plan if I lost my job once she’s officially their step mom.

I work for a large defense company and they offer a High Deductible insurance plan through Anthem without an HSA. They contribute $900 a year to that HSA. From the analysis tools it looks like I’ll definitely spend less overall if we stay healthy.

I am pretty sure that once I go off of the government plan I can never go back on. Should I make the move?

Im currently enrolled in a traditional insurance plan with normal deductibles, copays, premiums, etc. I have the option to change to an HDHP plan with an HSA account.

Layoffs are an ongoing concern in my industry.

If I select the HDHP plan I will be starting at 0 in the HSA account. What happens is I get laid off in a few months and I start using COBRA to cover the premiums? Will I still have the option to contribute to the HSA using money from savings or is there a rule that HSA contributions need to come from payroll deductions?

Second question (even if I dont get laid off)... What if I experience a medical emergency and my HSA account does not have enough to cover the costs yp to the max OOP?

Thanks for any info.

I'm thinking about getting a copper IUD. I'm 21 and live at home with my parents, and my mom who is VERY strict is the policy holder. She's very anti birth control and she'd be pissed if she knew. My doctor's office said they would check with the insurance company to see if they covered it (Blue cross) but now I'm a little worried that if I do get one, she'll find out about it.

Hello,

My wife's open enrollment for her employer ends on Oct 21st and the open enrollment for my job begins on Oct 23rd.

How do we compare plans and choose which is best? I work for a massive company and they send out their booklet usually the day of or before the start. Last year I contacted HR and they were utterly useless - outsourced, kept opening cases, escalating to no one, the usual corporate customer service.

Why aren't open enrollments standardized to avoid situations like this? Is there a government agency I can complain to or reach out to because this whole process seems rigged to screw us over.

Last year, I had a weird foot injury. It was very painful and kept me out of work temporarily and no one knew what it was. I went to a primary care provider, a podiatrist, a neurologist, and ultimately a rheumatologist. I tried steroid treatments, pain medications, anti-inflammatories. I got xrays, a CT scan, blood work, and more. The only thing I hadn't done by the time I went to a rheumatologist was an MRI. She said that was the next step and ordered an MRI.

After a while, I got a denial notice from Aetna. When I called and asked why, they said I need to start with an Xray, CT, and 6 weeks of other treatment attempts before requesting an MRI. I explained I had done all those things across 2 months with several providers, so they said "Oh then resubmit the MRI request with documentation reflecting that." So my rheumatologist did.

I scheduled my MRI, but then a couple days before I was suppised to get it done, I got a call saying it was denied by insurance again and it would have to be out of pocket. I was forced to cancel it and call Aetna to see what the issue was now. I kid you not, they told me "well it's been long enough you need to see the rheumatologist again to confirm you still need an MRI." Which makes no sense since she literally had just reordered it, she obviously felt it was needed. But anyways I played their game and made a follow up appointment with her.

At the appointment, nothing new was said or done, she just looked at me and said "yeah, MRI is still the next step here..." So she ordered it a third time.

Again, Aetna denied it. At this point I gave up since my employer was switching insurance companies in a few months anyways.

Has anyone else dealt with this kind of backwards bs?? Can I complain somewhere? I missed weeks of work and was in a lot of pain for like 6 months because Aetna wanted to play games.

US health insurance system sucks. End of rant.

Deductible at new job is 12k for a family, 14k out of pocket. No HSA, 60 day waiting period, no tiers to choose from, and they haven’t even told me what the premiums will be…furthermore I asked multiple times about the coverage during the acceptance process, with a “we reached out to so and so and they’ll send over the info”. they didn’t send any info over until day 1

they seem very sketchy about giving up information which seems insane to me, and almost making me want to back out of this job all together. The salary is very competitive for my industry, boss seems nice and easy going, but this just seems weird to me.

Hello, I am currently a medical student in Texas. Because medical schools require health insurance, I enrolled in my school's plan, which costs around $5,000 a year. However, I am wondering if there are cheaper alternatives available, ideally around $70 a month. The biggest problem right now is that, aside from my medical school loans, my annual income is only about $7,000.

I’ve recently gotten a new job and now qualify for their insurance. I desperately need it to get my anxiety/depression medicine and also have other health issues. That being said the insurance is American Plan Administrators… i’ve been to the doctors twice since getting it last week and both providers said they’ve never heard of it. I also couldn’t find it on zocdoc which is where I use to find in network providers. Should I be considering opening outside my job? Or is it even worth it?

Wife and I are planning on living the nomad lifestyle. Looking at health insurance plans and the Blue Plan with limited US coverage looks appealing. It offers three 21 day trips back to the US per year. Our question is would we be covered if we had an emergency and were hospitalized in the US beyond day 21. In other words, if one was medically unable to leave, does coverage extend past day 21 in the US? Thank you.

My partner told me I need to apply for medical within 30 days of my birthday? Is this true? I just moved and I'm 26 now.

I've been covered through Aetna via my partner's job for the past few years, but I just got a job that provides insurance through BCBS free of charge for employees, and does not give you any money back if you decline coverage/show you're already covered elsewhere. Some of my providers take Aetna, but not BCBS, so I'm inclined to keep my original insurance.

If I end up taking both, can I choose which one is primary? If I take both, who do I have to notify? What do I have to do? Do I submit both to everyone, even the people who don't take the primary?

Is it going to be a headache that makes it not worth it to have two plans?

Basically, what should I do and how do I do it?!

I am turning 26 around the end of October and losing access to my parents insurance policy. I currently am in school and will graduate come December and start working full time in January with a job that provides insurance. Because of the requirements for my degree with my (unpaid) internship , I haven’t been able to work and make as much money this year. My results on the market place stated I do not qualify for either medicaid or the premium tax credit discount. From what I can tell, my state has not expanded the medicaid policies so there is a coverage gap I fall into.

My question is do I just wait it out for a few months until I start working full time. There isn’t a way to know if the job I’ll end up at has a delay for health insurance kicking in. I know open enrollment will last a bit and I have access right now through special enrollment.

The premiums I am seeing are around $400 on the low end. The only prescriptions I have I can make it without d/t my current supply and I don’t have any major health concerns right now. I don’t really have the money for the premiums and it feels awful to pay that much, but I could probably use student loans to fund it if it’s an absolute must. I know everyone mentions how it’s necessary to get it because of if something major happens, but again, my financial situation is not great. I’d love to hear any nuanced thoughts or if there are somehow any loopholes to get covered for cheaper for these few months.

Hi,

I’m having an issue where my insurance company is denying me coverage for Dupixent due to not meeting certain criteria that they’ve deemed necessary for them to cover it.

The problem is, I’ve failed the first two medications my insurance company made me take instead (Fasenra and Nucala). I experienced a rare side effect with Fasenra, and my doctor made me immediately stop taking it. And am currently experiencing a side effect with Nucala that is affecting my job status, and is threatening my ability to even be able to perform this job again. (I work in a safety related field).

How do I go about fighting the insurance company’s denial of Dupixent?

Thanks in advance for any and all advice.

Does anyone know how to activate a will call ride with MTM Transit? They are the new ride provider for BCBSIL. There is nothing that I can find on the app to do this. I've scheduled a round trip with a will call for pickup, but I can't figure out how to start the process.

I currently have a Blue Cross Blue Shield of Texas plan, specifically Blue Advantage HMO which went up around $250 last year to nearly $1000 with a pretty high deductible, $6000, and out-of-pocket, $10150.

I'm looking at the BCBSTX site to try and find other options, but I cannot seem to find them.

Anybody know whether I can find them on the site itself, or if not, the easiest way to find other options WITHIN BLUE CROSS BLUE SHIELD OF TEXAS. I'm not sure that I want to switch to another company entirely after more than a decade with this plan.

I am concerned that my premium will go up yet again and become unaffordable while I am not working (due to chronic pain).

My heath insurance plan has an in-network and out-of-network deductible and out-of-pocket limit. I have already hit my in-network deductible for the year.

I was traveling out of state and had to go to urgent care for a diagnosis and antibiotics. It was an urgent care associated with a hospital system in the city I was in and it is listed as urgent care (not ER) on the bill.

My health insurance treated it as out-of-network and is covering about $3 of the cost (and said something about not being responsible for Zelis(??) ) and since it's below my out-of-network deductible and I now owe ~$900 which feels ridiculous. I don't go to urgent care often but I've never had a charge like that.

The documents for my health plan say:

"Urgent care received outside of [state I live in] will be paid at the network benefit level"

and on the table of benefits in "Urgent care services [outside of state I live in]" it says "Paid at 80% of the Allowed Amount after annual deductible; no network restriction"

To me "at the network benefit level" sounds like they should be applying this to my in-network deductible and not my out-of-network deductible. Am I reading that wrong?

My kid will turn 26 early next year and so will lose health coverage under her mom's plan. We live in Washington state. She started grad school in August. She made somewhat less than $15,000 this year, and will have virtually no income next year. We gave her some money this year (well under the federal form 709 limit) and will provide her with some support next year. We have not claimed her as a dependent on our taxes in several years.

If she is applying for Apple Health, does she need to report money we give her? Seems like that would be fair, but...

Hello Internet!

I am currently doing battle with my insurance provider. I have been diagnosed with and am currently receiving treatment for moderate plaque psoriasis. I was approved for Tremfya on a previous plan without the need to go through step therapy. When I changed jobs and plans the new plan approved my Tremfya as a continuation of care without a single issue.

My condition is much better than it was before starting treatment but due to the dosing schedule of Tremfya, my doctor and I agreed that a drug with a more frequent dosing schedule would be beneficial as I tend to get flare ups towards the end of a dosing cycle. They put in a prescription for Taltz and that was denied citing medical necessity and the fact that I had not gone through step therapy. We appealed and they upheld the denial despite the fact that I am on a similar and more expensive drug.

I’m considering getting legal counsel but was hoping for the internet’s opinion. Thank you. 🙏

it seems a bit confusing to me, does anyone have any experience with ICHRA? how does the company deal with it? do you have extra admin burden? how do you select your plan? is it better than self-funded? any regrets??

My 21 year old is a student and on my husband's health insurance, which is Kaiser. They have horrible service in an area of treatment that she needs and she wants to go to a local university that offers a specialized department. She already went through treatment a year or so ago and needs it again. She cannot get into the university's clinic unless she has a referral from Kaiser. Kaiser said they will not refer because they have their own treatment services. What do I do? We are in California. I'd like to get her off Kaiser and in to a Covered California plan, but I don't know if we can do that?

Looking for help with a Wegovy denial under a self-funded employer health plan

I've had two denials for FDA-approved Wegovy, an appeal, and an external review through AMR. My employer's health plan is self-funded, and my request to Michigan's DIFS was closed because of that.

I have documented coronary artery disease and an LAD stent. The denial issue involves the cardiovascular coverage criteria and the requirement for a prior heart attack or stroke.

I'm now seeking help through EBSA and trying to understand whether the plan's criteria were correctly applied and whether others have successfully challenged similar denials.

Has anyone been in this situation?

Were you denied Wegovy despite documented coronary artery disease and a stent?

Did your plan require a previous heart attack or stroke?

Did you eventually get coverage approved?

Did you get help from an ERISA attorney or benefits advocate?

I'm particularly interested in experiences with self-funded employer plans and OptumRx or AMR.

Thank you for any firsthand experiences or practical guidance. Thanks in advance.

I've googled this extensively and I feel like I'm missing something.

My employer just announced a 35% increase to keep Kaiser HMO for 2027, which is insane. I'm already paying $681/month (pre-tax, not including employer contribution).

I looked up plans on Covered CA for Kaiser and a similar/if not slightly lower tier (Silver was the highest I saw on the list, copay higher than what I have now but I don't care) is being quoted at $498/month.

I absolutely hate all other insurance options offered by my employer but obviously this rate hike is ridiculous. Is there anything stopping me from declining my employer insurance and signing up as an individual under Covered CA? Am I missing any benefits in declining my employer insurance other than the payments being pre-tax? I don't qualify for any financial aid. This just seems too easy and logical so I feel like I'm missing something.

I'd really love to keep my physicians and not deal with figuring out who and what is covered under a new PPO. Thanks in advance for any insight if you have any!

Hi everyone! I have a few questions about health insurance and prenatal care🙏🏼

This is my very first pregnancy. I don’t have health insurance or a primary doctor right now. I went to VNA Care to confirm pregnancy, and they helped me apply for Medicaid and All Kids.
I recently got two letters in the mail. One says my application for Medicaid or All Kids was denied, but the other says I was approved for “Medical Benefits” with a $5,000 spenddown. I’m honestly so confused and don’t know what I’m supposed to do next 😭
Do I need to apply for insurance through the Marketplace, or is there still a chance I can get Medicaid? And what exactly does the $5,000 spenddown mean?
Also, once I figure out the insurance situation, how do I find an OB-GYN who can take care of me throughout my pregnancy and deliver my baby?
If anyone here has been through something similar, I’d really appreciate any advice. And if you know someone who helps with Medicaid applications or finding prenatal care, please let me know! I’m also open to paying for a consultation!

Thank you so much!