trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
I am trying to see how bad this PPO coverage is. Anyone else have 80/20 IN NETWORK coverage? THat is what I dont get. My old insurance paid 80/20 for out of network and I paid co-pays for in network. This new BCBS of CA PPO pays only 80% of costs for IN NETWORK!!
If you have this type of insurance, My questions are:
How much do you REALLLLLY end up spending with Lyme and associated diseases? I am looking at endo surgery and IV treatment for lyme and labs weekly. (even the labs are only 80% covered!)
Please help me to understand how much in debt I am really going to go if I choose this plan over the horrendous HMO. Thanks, Trails
posted
Hmmm, i think you'd still come out OK. I pay 80/20 for my LLMD, which is most of my medical expense.
The surgery will cost you more, however. Have you checked to see if that is FOR SURE 80/20 also?
Most of the time, I have to pay 80/20 even for surgical procedures....I think it's because my ins is in TX and I'm in MO. I'm covered by the Teacher Retirement System.
As long as I don't have heart surgery, it's not so bad!
Are most of your expenses from your LLMD?
------------------ Do not take anything I say as medical advice. I am not a doctor, but I DID stay at a Holiday Inn Express! oops! Lymetutu
riversinger
Frequent Contributor (1K+ posts)
Member # 4851
posted
Trails, you need to check and see what your total Out Of Pocket is for the year. Once you have spent that much, they usually start to pick up the rest. So, for example, if you have an expensive surgery, your copays may take you over the total Out Of Pocket, and for the rest of the year, the insurance pays 100% on allowable expenses.
Does this policy pay for out of network providers? That is how mine works. On a $130 office visit, they would allow, $80, and pay 50% for an out of network provider, which means I got $40. Once I made it past my total out of pocket, they would pay the entire $80.
Some plans do not pay ANY out of network providers. Very few CA LLMDs are in network insurance providers.
I never had any trouble getting meds paid for, even Mepron and Zithromax, but I haven't done IV, so don't know how that works. Every plan is slightly different.
My sister, who lives twenty minutes from me, has a different BCBS plan than I do. Her benefits are VERY different.
Allowable fees for doctors visits are set depending on the area in which you live. Other things depend totally on the specific agreements of your plan. Be sure to get the plan and read it carefully.
mlkeen
Frequent Contributor (1K+ posts)
Member # 1260
posted
My SO has 80/20, me HMO, same llmd. I pay less than he does for about the same care. The llmd is in network for him, me out and not covered. My cash price is about his 20%. He pays 20% on labs and drugs, ouch! I pay 0 on labs, $20 or less for generic and $40 for name brand. His company covers a good part of the premium, he pays less than $100 for coverage a month including dental and vision, I'm self employed and pay $360 without dental and vision, it comes off my taxable income.
We have never used it for anything but lyme. I understand HMO's are very restrictive in most areas.
Most of the LLMD's in California do not take insurance. I have Blue Shield PPO. For a $300 (LLMD fee) out of network provider they pay about $107.
Most of the Lab work is just a $20 co-pay EXCEPT for Igenex which is again out of network, so I get very little back and usually it takes a few months.
$500 deductible generally, and they will deny deny deny IV except for MAYBE the first 28 days.
Anyway, happy to email with you more. It gets very expensive. I average out of pocket $40-50K a year and I do actually have pretty good coverage
Posts: 152 | From On Horseback | Registered: Mar 2005
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trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
No2- You dont have an expense cap?? 40-50k is what my partner and I will be LIVING on! Looks like this plan PersChoice has a 3,000 cap, but that doesnt include out of network or regular doc visits.
I am unfortunately well aware of the out of network situation which is why I just dont know if an HMO might be the best way to go, since I'll end up paying so much money for all this out of network stuff.
This plan only covers 20% of labs too. That is horrific IMO!
BCBS covered 2 months of IV Rocephin for me in 2001. Any ways to get around them now?
Does Kaiser or Blue shield cover IV for longer than 28 days?
Thanks for everyones replies and homework! I am taking it all into consideration and trying to make a good choice. Trails
I do have a cap, it is pretty high though and the catch is it is only APPROVED in network services. LLMD's, non-formulary drugs, Igenex all that was still not covered.
Some of my expenses, were acupuncture - chiropractor (only 12 visits covered a year) - biofeedback - HBOT - believe me for two years I tried everything.
I can switch through my employer to another insurance, but it is better the devil you know...right?
Although, with serious work on appeals and grievance I did get a majority covered IV wise.
I also was seeing an LLMD every 3 weeks (Dr. S and Dr. G) for about a year. I had Igenex test to the tune of $400 every 6-8 weeks as well.
So, my own agressive stubborn OCD behavoir added to my expenses. But really research their protocol for lyme treatment. Usually you can find those things online.
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trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
You can find their protocol on line? Where? I am 99% sure i will go with BCBS PPO so I'd like to know where to find their protocol for lyme on line.
I know this disease can suck the life and money right out of you. You are living proof of it, huh? Even though we should get PAID to do the things we do. I am thinking of working as an insurance specialist or something so at least I get paid for all the crap I know and deal with, right?
Anyhow, any way to get to this protocol page? Thanks, trails
trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
Well this just sunk it. Now I am 100% going to BCBS PPO. I just finished talking to a nurse at a LLMD office who takes the HMO insurance and she said NO WAY! Dont do it. She said they take the HMO, but the HMO doesnt recognize their treatment plans and poeple with Lyme in CA who are HMO have to pay 100% of their ABX scripts coz they get denied!!
I guess I am waking up to the hostility of the coasts with Lyme. I had NO IDEA that it could be this bad. And believe me, I have had my share of Insurance problems and crappy plans etc.
Thanks for everyone's input. I'll stick to the expensive 80/20 PPO. Trails
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