changing from Blue Shield HMO to Blue Shield PPO

[Guest guest]

HI Everyone -

I am in the middle of " Insurance Hell " . I have

Blue Shield HMO switch to the Medical Group that the

Bariatric Surgeon that I want belongs to. I had a

physical with my new PCP, who I absolutely love. She

refer me to the surgeon and is completely support of

this surgery. I saw the surgeon, have a my psych eval

and have gone to several support group meeting...Only

to be denied by my Medical Group & the Insurance

Company as " living and work out of the contracted

service area for this medical group. " The Blue Shield

then, without my knowledge, assigned me back to my old

PCP and Medical Group.

There is a 50/50 chance that my Human Resources

Dept will let me switch this month from the HMO to the

PPO plan. Then I can self-refer to my surgeon (and

also continue seeing my new PCP).

I guess my question is -- has anyone else done

this? Will I have any problem with my Morbid Obesity

being considered Pre-Exisiting? Will my Blue Shield

PPO question me asking for surgery the same month that

I join them.

Before I make this change, any input would be

greatly appreciated.

gail

__________________________________________________

[Guest guest]

HI Everyone -

I am in the middle of " Insurance Hell " . I have

Blue Shield HMO switch to the Medical Group that the

Bariatric Surgeon that I want belongs to. I had a

physical with my new PCP, who I absolutely love. She

refer me to the surgeon and is completely support of

this surgery. I saw the surgeon, have a my psych eval

and have gone to several support group meeting...Only

to be denied by my Medical Group & the Insurance

Company as " living and work out of the contracted

service area for this medical group. " The Blue Shield

then, without my knowledge, assigned me back to my old

PCP and Medical Group.

There is a 50/50 chance that my Human Resources

Dept will let me switch this month from the HMO to the

PPO plan. Then I can self-refer to my surgeon (and

also continue seeing my new PCP).

I guess my question is -- has anyone else done

this? Will I have any problem with my Morbid Obesity

being considered Pre-Exisiting? Will my Blue Shield

PPO question me asking for surgery the same month that

I join them.

Before I make this change, any input would be

greatly appreciated.

gail

__________________________________________________

[Guest guest]

Gail,

Pre-existing condition clauses do not apply as long as you have been

continously insured from any medical insurance company for the last

18 months - so don't worry about that one.

Do check though for WLS exclusions in the PPO policy. Also, even

when you get approved you might have to do this famous battle of the

DS being " investigational " . Still, the probabilities are higher with

the PPO.

Is your company fully insured through Blue Shield, or are they using

them as a third party adminstrator?

In my previous job I had Blue Shield POS and then Blue Shield PPO for

a couple of months. They had the worst coverage I have ever had.

The POS really was bad, and the PPO was not quite as bad. I was

working for a small compnay that was trying to save a few bucks.

Now I work for a large corporation with an excelent plan (Aetna PPO),

but I still might have a fight regarding the DS being

investigational. It is a fight that I am confident I will eventually

will win, but they may stall and make things inconvient for me.

Do you live in California? In California BC and BS are actually

separate entities, while they are merged in most other states. Blue

Shield of California is much worse than Blue Cross of California.

Can you pick another insurance company with a PPO. United Healthcare

seems to be fairly good, though a few have had problems. If your

company is small then you won't have much flexibility.

Hull

>

> HI Everyone -

> I am in the middle of " Insurance Hell " . I have

> Blue Shield HMO switch to the Medical Group that the

> Bariatric Surgeon that I want belongs to. I had a

> physical with my new PCP, who I absolutely love. She

> refer me to the surgeon and is completely support of

> this surgery. I saw the surgeon, have a my psych eval

> and have gone to several support group meeting...Only

> to be denied by my Medical Group & the Insurance

> Company as " living and work out of the contracted

> service area for this medical group. " The Blue Shield

> then, without my knowledge, assigned me back to my old

> PCP and Medical Group.

> There is a 50/50 chance that my Human Resources

> Dept will let me switch this month from the HMO to the

> PPO plan. Then I can self-refer to my surgeon (and

> also continue seeing my new PCP).

> I guess my question is -- has anyone else done

> this? Will I have any problem with my Morbid Obesity

> being considered Pre-Exisiting? Will my Blue Shield

> PPO question me asking for surgery the same month that

> I join them.

> Before I make this change, any input would be

> greatly appreciated.

> gail

>

> __________________________________________________

>

[Guest guest]

here as well. Something you wrote to Gail here caught my

eye. You said Blue Shield of CA is worse than Blue Cross of CA.

From evertyhing I've heard, Blue Shield is much better about approving

than Blue Cross. To what were you referring?

> >

> > HI Everyone -

> > I am in the middle of " Insurance Hell " . I have

> > Blue Shield HMO switch to the Medical Group that the

> > Bariatric Surgeon that I want belongs to. I had a

> > physical with my new PCP, who I absolutely love. She

> > refer me to the surgeon and is completely support of

> > this surgery. I saw the surgeon, have a my psych eval

> > and have gone to several support group meeting...Only

> > to be denied by my Medical Group & the Insurance

> > Company as " living and work out of the contracted

> > service area for this medical group. " The Blue Shield

> > then, without my knowledge, assigned me back to my old

> > PCP and Medical Group.

> > There is a 50/50 chance that my Human Resources

> > Dept will let me switch this month from the HMO to the

> > PPO plan. Then I can self-refer to my surgeon (and

> > also continue seeing my new PCP).

> > I guess my question is -- has anyone else done

> > this? Will I have any problem with my Morbid Obesity

> > being considered Pre-Exisiting? Will my Blue Shield

> > PPO question me asking for surgery the same month that

> > I join them.

> > Before I make this change, any input would be

> > greatly appreciated.

> > gail

> >

> > __________________________________________________

> >

[Guest guest]

>

>

> here as well. Something you wrote to Gail here caught my

> eye. You said Blue Shield of CA is worse than Blue Cross of CA.

>

> From evertyhing I've heard, Blue Shield is much better about

approving

> than Blue Cross. To what were you referring?

This was my experience in general, but not regarding WLS. I didn't

even dare try to get WLS with the shitty Blue Shield insurance I had

with my previous employer. Just getting routine stuff covered was a

nightmare. And psycotherapy - forget it unless you go through their

network psycos. The POS reimbursed me all of $30 up to 20

appointments and the PPO wouldn't reimburse me at all. Medications

were limited to what was on their " formulary " and I had to have my

Dr. write a nasty note explaining that I had been stable on this " non-

fromulary " medication for years before they would cover it. My wife

went to see her personal OBGYN when she was diagnosed with cancer

and - you guessed it - they wouldn't pay for that either. They tried

to claim that it was " routine care " for which you must go to your

primary care physician. What a bunch of crap. I wouldn't touch

those guys with a 10ft pole, and I will NOT work for another company

that chooses them as their insurer! You can't pay me enough to go

through the hassles I went through. Oh I forgot, they made my wife

change birth control pills from Orthotricyclene (what her OBGYN

reccomeded) to some other crap that was cheaper for them. Ay carumba!!

Hull