HMO Plan - OON Doctor - what is Covered?

[kgmom219]

Here's a copy/paste from the BCBS HMO SOB. Formatting stinks, but you can see that OON is Not Covered.

Urgent Care: 50% coinsurance Not Covered

Must be affiliated with member's chosen medical group or referral required.

Thats OON. Sorry, I was confused,

The ER is only covered for emergencies. Urgent care is for colds.

The new Blue benefit designs are pathetic

 

[Ann H]

Is the "not covered" in the Out-of-Network column on that SBC, Allen?

At a Humana webinar today, they reiterated that their $500 copay for ER is IN ADDITION TO the Deductible & Co-Insurance. So, I would say it's not really a copay, but a penalty for using the ER. And, also, it's NOT waived if admitted to the hospital from the ER.

If that is the way those BCBSIL benefits work, then ER is actually lower benefits than Urgent Care.

 

[AllenChicago]

Is the "not covered" in the Out-of-Network column on that SBC, Allen?

At a Humana webinar today, they reiterated that their $500 copay for ER is IN ADDITION TO the Deductible & Co-Insurance. So, I would say it's not really a copay, but a penalty for using the ER. And, also, it's NOT waived if admitted to the hospital from the ER.

If that is the way those BCBSIL benefits work, then ER is actually lower benefits than Urgent Care.

1. Yes. "Not Covered" for Out of Network Urgent Care. Was covered for 2014 and 2015. For 2016 Out-of-Network Urgent Care facilities are not covered.

2. BCBS SOB still says the Co-Pay is waived if admitted to the hospital.

When travelling, E.R. is preferable to an Urgent Care, since Out of Network Urgent Care is "Not Covered"..unless you get a referral. A referral?

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Thats OON. Sorry, I was confused,

The ER is only covered for emergencies. Urgent care is for colds.

The new Blue benefit designs are pathetic

The whole point (and only point) I have been trying to make since my first post at 7:17pm (CDT) is that through modifications in plan design, BCBS incentivizes members to use the E.R. in 2016. In 2014 and 2015, BCBS plan design incentivized members to use Urgent Care.

Just thought it was interesting, that's all. The real pain will come when all the newly minted HMO people need to see referrals...or have an emergency away from an In-Network hospital.

 

[kgmom219]

1. Yes. "Not Covered" for Out of Network Urgent Care. Was covered for 2014 and 2015. For 2016 Out-of-Network Urgent Care facilities are not covered.

2. BCBS SOB still says the Co-Pay is waived if admitted to the hospital.

When travelling, E.R. is preferable to an Urgent Care, since Out of Network Urgent Care is "Not Covered"..unless you get a referral. A referral?

----------

The whole point (and only point) I have been trying to make since my first post at 7:17pm (CDT) is that through modifications in plan design, BCBS incentivizes members to use the E.R. in 2016. In 2014 and 2015, BCBS plan design incentivized members to use Urgent Care.

Just thought it was interesting, that's all. The real pain will come when all the newly minted HMO people need to see referrals...or have an emergency away from an In-Network hospital.

The whole damn transition is going to be a PITA. I'm working on talking points now. "Things that are different on an HMO"

 

[somarco]

Humana webinar today, they reiterated that their $500 copay for ER is IN ADDITION TO the Deductible & Co-Insurance.

That has been a Humana staple for sometime. Too many agents and consumers just ASSUMED the plan worked like the BX and Coventry plans from a few years ago where an ER visit only cost $500. And, the $500 was waived if admitted to the hospital.

Out of Network Urgent Care is "Not Covered"..unless you get a referral.

What *** came up with that idea?

We have used urgent care as our PCP for other than annual exams. When it was in network, we used one that was about 4 miles away. Walk in. No appt needed. Usually got in to see the doc/PA/NP within 30 minutes.

When we had a copay it was $50. Finally convinced Rachel to go with HDHP and HRA but even then the withdrawal was only $60.

They had onsite mini-lab, X-ray.

One stop shopping like the KP clinics except without the HMO restrictions.

Who the hell stops to get a referral for an emergency?

Carriers have been cracking down on ER use for sometime, even denying payment if you didn't have what they considered a medical emergency.

Sprained ankle, possible broken bone? ER not needed. Say what?

Proliferation of doc-in-a-box has changed most of that. Not the ones in CVS so much as the free-standing clinics. Often hospital affiliated but lower cost than ER.

One Atlanta hospital even built an urgent care facility on the hospital campus. Show up in the ER with non-life-threatening condition? You are triaged and sent to UC.

Win win