Will Humana Have a Heart?

[Bob_The_Insurance_Guy]

Little girl, 11 years old, develops Wegener's Disease, and will be placed on Dialysis for an indefinite period of time.

Father just found out that the ACA Plan they got last year from Humana - not a subsidy plan - does not have this facility in network. This is the only facility in the northern half of Georgia that does this.

The facility is contacting Humana to get an "exception" for this treatment. It's not like she can wait. The treatment starts on Labor Day.

The father called me last night, the Friday before Labor Day, to tell me this, and to ask what can be done if Humana does not accept the exception.

I did not have an answer for him.

She was at Children's Healthcare of Atlanta, then transferred to Egleston Children's Hospital, and will be going to this facility (I neglected to get the name from him).

Georgia Agents: any ideas? I am calling Rusty Lamb on Tuesday, to have him fight for us, but other than that...

 

[KennyWest]

Have seen similar situations where Humana & Cigna both have worked out to "do the right thing". Fingers crossed and prayers on the way.

 

[Josh]

Most carriers (maybe by law?) have to provide coverage at an out of network facility if there aren't any providers within a reasonable distance that provide the same service. Now that doesn't mean they don't like the provider, but if they literally don't offer it (I think it's usually something like 100 miles?) then they get an approval and can go to the out of network provider.

 

[FLM2]

Little girl, 11 years old, develops Wegener's Disease, and will be placed on Dialysis for an indefinite period of time.

Father just found out that the ACA Plan they got last year from Humana - not a subsidy plan - does not have this facility in network. This is the only facility in the northern half of Georgia that does this.

The facility is contacting Humana to get an "exception" for this treatment. It's not like she can wait. The treatment starts on Labor Day.

The father called me last night, the Friday before Labor Day, to tell me this, and to ask what can be done if Humana does not accept the exception.

I did not have an answer for him.

She was at Children's Healthcare of Atlanta, then transferred to Egleston Children's Hospital, and will be going to this facility (I neglected to get the name from him).

Georgia Agents: any ideas? I am calling Rusty Lamb on Tuesday, to have him fight for us, but other than that...

It would be awful if she didn't get the needed treatment so hopefully they will do something but this should teach you something as well-don't offer plans, regardless of cost, with poor networks, it just isn't worth it for a small savings in premium.

I review hospitals with every client before doing an enrollment and the easiest thing I do is show them why a network like Humana, which lacks so many national hospitals, is a poor choice. I live in Florida and my summary is that there are three hospitals I would absolutely want in network for my plan-Mayo Clinic, Johns Hopkins, and Sloan-Kettering; Humana has none of these plus many other local hospitals throughout Florida.

 

[ameneses54]

It would be awful if she didn't get the needed treatment so hopefully they will do something but this should teach you something as well-don't offer plans, regardless of cost, with poor networks, it just isn't worth it for a small savings in premium.

I review hospitals with every client before doing an enrollment and the easiest thing I do is show them why a network like Humana, which lacks so many national hospitals, is a poor choice. I live in Florida and my summary is that there are three hospitals I would absolutely want in network for my plan-Mayo Clinic, Johns Hopkins, and Sloan-Kettering; Humana has none of these plus many other local hospitals throughout Florida.

I find your reasoning very thorough and considering you've already done your homework and if you're willing, I (we) would like to know which network within a carrier and at a reasonable premium, provides service with these 3 top rated hospital you mention. I live and write in Florida.

 

[taterpeeler]

hahahahahah small savings in premium... You drunk? in some states the "small savings" you yap about is about 150- 200 bucks a month, that aint small.... what a strange comment

 

[FLM2]

hahahahahah small savings in premium... You drunk? in some states the "small savings" you yap about is about 150- 200 bucks a month, that aint small.... what a strange comment

What a piece of work you are.

I've done my homework in the states where I am active, the rates for Humana in Florida, for their PPO plans, are about the same as the competition with a much better network.

As an example, in Tampa, for a 50 year old non-smoker (PPO plans):
Bronze Silver
Humana $319 $375
Assurant $321 $383

So I'm far from drunk and have every right to make a comment based on the facts. Unless your name is Sam you don't own this forum, maybe you should consider that sometime, maybe then someone will actually pay attention to you.

 

[somarco]

Even if Humana allows treatment in the non-par facility that provider is not obligated to accept Humana's payment as "paid in full, no balance billing".

Is this an HMO plan or POS?

 

[Bob_The_Insurance_Guy]

This is the POS network.

As for the gentleman that told me that this is what I deserve when I try to find the cheapest plan around. I made sure that doctors and hospitals were in network.

I know that you are well versed in Florida. Do you happen to have a license in Georgia?

The pediatrician and primary doctor for the father were both in Humana. Here, in the Metro Atlanta area, most insurance providers - Humana, BCBSGa, Coventry - have a pretty robust network. If you were to go to Healthgrades > Find a Doctor | Doctor Reviews | Hospital Ratings you would see what I mean.

The same holds true for hospitals. In this case CHOA, Egleston, Northside and Emory St. Joes.

That is why I, specifically, asked for feedback from Georgia agents, who are familiar with the Atlanta area, and may have come across this situation.

While it appears that you know the Florida market, and I think that's just peachy, do you also hold a Georgia license, and work the Metro Atlanta area? If so, is Wegener's one of the diseases you routinely ask about?

Thank you, though, for your response. Due diligence is definitely needed, even in this ACA environment.

 

[somarco]

Bob #2, I understand and agree with your thought process on most of this, but we will differ on the expanse (or lack thereof) of the BX network circa 2014. Unless they added something after the fact, they are using an HMO network statewide, in or out of the network and that network is quite limited, even here in Atlanta.

In this case since it is a POS you have a little more flexibility but the family will still most likely run into a balance billing situation even if H agree's to treat it as a par provider.