Topic: Any experiences with HealthNet before I decide on going with them?
TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
I hope it's OK to post this is medical.
I have to decide if I am going to go with my husband's coverage rather than my current coverage. At present, I get some coverage for prescriptions but nothing for the doctor etc..
I would really appreciate information from anyone who has had any experience, good or bad in getting coverage for lyme disease before I go with them.
After spending the last 1.5 hours on the phone with the insurance company it sounds like they have turned a few people down for coverage by saying that any treatment that is over 1 month is experiemental.
How they can get away with that is beyond me but apparently they do allow one to get what they call continuity of care where you can get coverage for whatever you are currently being treated for, for up to a year.
It all sounds very confusing to me but I have to decide soon so any experience from anyone would be very much appreciated.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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CaliforniaLyme
Frequent Contributor (5K+ posts)
Member # 7136
posted
HealthNet was great for me, they worked with my Lyme doc and paid for my Mepron for 2 years with no protests- $10 a bottle co-pay- and I was blood negative!! I have nothing but good to say about them.
-------------------- There is no wealth but life. -John Ruskin
All truth goes through 3 stages: first it is ridiculed: then it is violently opposed: finally it is accepted as self evident. - Schopenhauer Posts: 5639 | From Aptos CA USA | Registered: Apr 2005
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
Thanks Sarah!! That's good news.
Hopefully they haven't changed their policy since the IDSA has put out all their propoganda BS about chronic lyme.
I think I've read you say that you finished treatment 7 years ago? Is that when you were covered under them? Do they currently cover your abx? Sorry to be asking such personal questions here but please PM me if you'd prefer.
Thanks again. Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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Greatcod
Unregistered
posted
I had Healthnet Orange. The IV ABX one month limit is based on the IDSA saying that Lyme is cured after one month of IV ABX. I suspect that all insurance companies will use that standard, saves them big bucks. I had no problem getting four months of Tetra-its generic and cheap and costs them little. They place severe limits Zithro and Biaxin, and it might be hard to get several months worth because they don't want to pay. I was under Medicare D, so I don't know if that information is true for all Healthnet plans..
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
Thanks for the info GC. Sorry you couldn't get more than a month of coverage for IV. My medicare Plan D has paid for zith for a year without a complaint. In fact, they've never balked at paying for anything and they've never even asked for any info on my diagnosis.
From what I can tell, medicare plans can be very different from each other. I was on HealthNet Orange the first year of coverage under Part D. I wasn't getting lyme treatment then and they were still a nightmare to deal with. I kept calling them to get them to change some things, they said they would but never did even after numerous letters. ugh!!
If I go with my husbands insurance, medicare pays a premium to HealthNet and they take over. I'm not allowed to change back until open enrollment, next January.
According to medicare, the primary carrier depends on how many employees are under the company. Totally insane and bereft of logic. Makes a huge difference for me as to what is covered and what isn't, all based on if the employer has > 100 employees. Sheeessh!!
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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CaliforniaLyme
Frequent Contributor (5K+ posts)
Member # 7136
posted
I had Blue Shield when I got sick and they were horrible, horrible, for two years and then right after IV we switched to HealthNet for the next 2 years!!! Then switched to something else, Pacific care or something?, and actually came back to HealthNet 4 years ago. I am lucky though, all our local Lyme docs take insurance. Insurances have always covered my Lyme docs AND all orals, Blue Shield flat refused to cover IV Rocephin. So I have HealthNet now, and it is good coverage.
Except- I had forgotten- sorry, I have ONE bad thing to say about them but it is minor-
The only problem I have ever had with them is a few years back I was trying to make a hole in a belt and had the bright idea of trying to use a sharp knife, and I nearly cut the top of my left index finger off, sliced it very deeply.
Well, I went to the ER and got it stitched back on and they sent papers and refused to cover it!! I asked why and they said that it was "out of area". I called them and explained it was at my very own home and in county and they made me repeat myself for half an hour until they said, "Oh, of course we'll cover it- it happened IN YOUR HOME!" I think they may have a policy of denying all ER claims because it was so weird and made so littel sense, but they DID cover it. Still, if I had NOT called they were going to deny it which is amazing frankly-
Anyway, overall, a good company, espeically compared to the Blues- Blue Shield & Blue Cross are both bad with Lyme- Take care, Sincerely, Sarah
-------------------- There is no wealth but life. -John Ruskin
All truth goes through 3 stages: first it is ridiculed: then it is violently opposed: finally it is accepted as self evident. - Schopenhauer Posts: 5639 | From Aptos CA USA | Registered: Apr 2005
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Aniek
Frequent Contributor (1K+ posts)
Member # 5374
posted
Terry,
You want to find out if the plan is self-funded or fully insured.
Self-funded means your husbands employer pays all the claims and has the final say on all appeals. Fully insured means that the employer pays the insurance company a premium for each person on the plan and the insurance company makes all the decisions.
This is important to know because there is sometimes more flexibility on appeals if it is self-funded and the employer is sympathetic.
Insurance companies usually have very insurance friendly language in the plan describing experimental.
-------------------- "When there is pain, there are no words." - Toni Morrison Posts: 4711 | From Washington, DC | Registered: Mar 2004
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
CALyme - thanks so much for your input. I did talk to the company and they said they had denied several chronic lyme claims. I feel very nervous about going with them. My plan is an Oregon plan though and I suppose that could make a difference. It seems like CA is much more consumer friendly.
Aniek - thanks for the guidance. That's a good question. I've had both types and actually, it didn't seem to make much difference but that may have been because the employer was pretty cheap when it came to insurance. They were trying very hard to hold down costs and they were cheap with everyone.
Edited to add: I found some interesting underwriting info about lyme and HealthNet. They won't take lyme patients if they have out of treatment for less than a year. After that they apply a surcharge, 50%, then a few years symptom free 20%, then after 5 years symptom free they give preferred status.
Of course this does not apply to those who will be included in an employer group plan.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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My medicare Plan D has paid for zith for a year without a complaint. In fact, they've never balked at paying for anything and they've never even asked for any info on my diagnosis. 
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