Question for those with Affordable Healthcare Act Health Exchange insurance

tvguy

Question anything the facts don't support.
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Dec 15, 2003
Do you have trouble finding specialists that take your insurance?

A friend has coverage through Covered California, California's version of the ACA health exchange. She needs surgery for Stage 1 cancer. There are only three OBGYNs in her community that accept her insurance but at least she had three options. Now she is trying to find a surgeon that takes her insurance. Her OBGYN warned her she would have to travel to a city 150 miles away to an area with a population of 1.5 million to find a surgeon that accepted her insurance. Guess what? So far, nobody takes her insurance. The odd part, EVERY hospital will accept her insurance.

She lives in a city with 91,000 people and a county with 171,000 residents. Not a huge community, but not small either.
 
Do you have trouble finding specialists that take your insurance?

A friend has coverage through Covered California, California's version of the ACA health exchange. She needs surgery for Stage 1 cancer. There are only three OBGYNs in her community that accept her insurance but at least she had three options. Now she is trying to find a surgeon that takes her insurance. Her OBGYN warned her she would have to travel to a city 150 miles away to an area with a population of 1.5 million to find a surgeon that accepted her insurance. Guess what? So far, nobody takes her insurance. The odd part, EVERY hospital will accept her insurance.

She lives in a city with 91,000 people and a county with 171,000 residents. Not a huge community, but not small either.


Our 17 year old daughter has been very sick since Easter. And has lost 15 pounds.

We need a specialist. Our area is about the size of what you described.

I tried 3 specialists. Each were an hour and a half to 3 hours either direction of our home. The earliest they could see her would be July or August.

I got back to her pediatrician and we have waited 2 weeks for a work in appointment with a 4th doctor an hour and a half away tomorrow.

Has nothing to do with our insurance. We have Aetna insurance through dh's employer.

I am finding that there is a shortage of this type of doctor.

One of our sons wants to be a doctor. I've suggested this specialty as a field for him to look into.
 
I don’t have it anymore, but when I did I picked the insurance company that I knew was most prevalently accepted in the area. I know some areas don’t have a lot of companies to choose between. I did not have issues getting the insurance accepted when I had it.

I’m sorry she having such issues getting it accepted. She should also look into things like if the anesthesiologist is within network. I’ve heard horror stories of patients ending up with massive bills because the surgeon and hospital were in network, but they never checked on the anesthesiologist.
 
Has she called the insurance company? There are requirements set by the government as to the minimum numbers of providers by specialty that they have to have contracted to be able to sell in a specific market. If they don’t have anyone contracted, they will need to issue a waiver which will allow her to see an out of network provider but pay as though s/he is in network.
 


Our 17 year old daughter has been very sick since Easter. And has lost 15 pounds.

We need a specialist. Our area is about the size of what you described.

I tried 3 specialists. Each were an hour and a half to 3 hours either direction of our home. The earliest they could see her would be July or August.

I got back to her pediatrician and we have waited 2 weeks for a work in appointment with a 4th doctor an hour and a half away tomorrow.

Has nothing to do with our insurance. We have Aetna insurance through dh's employer.

I am finding that there is a shortage of this type of doctor.

One of our sons wants to be a doctor. I've suggested this specialty as a field for him to look into.
My DS needed surgery a few days after birth. Luckily we live here & had access to Children’s Hospital NOLA. But while there, we met all kinds of families from hundreds of miles away who had to travel to see the specialists at Children’s.
 
Has she called the insurance company? There are requirements set by the government as to the minimum numbers of providers by specialty that they have to have contracted to be able to sell in a specific market. If they don’t have anyone contracted, they will need to issue a waiver which will allow her to see an out of network provider but pay as though s/he is in network.
Since this is being sold through covered California, I wonder if they consider that to be the market. That is a lot of area to expect there to be Doctors who are on the plan to be in. And this is a major insurance carrier with contracts with lots of Doctors who take all their other polices, just not their Covered California ACA plan
 
How far is she to a major city?

My mom was on an ACA plan, but we are about 30 miles from a major city (Atlanta), so that is as far as she would have to travel.

We have Kaiser through my DH's job with the federal government. I had to give birth in an Atlanta hospital instead of our local one because Kaiser did not have an agreement with the hospital here (even though they are both Piedmont Hospital). In other words, I don't necessarily think it is a blame it on the ACA versus how the insurance company operates or the availability of the specialists.

My FIL, more than 30 years ago-nothing to do with ACA, had heart surgery in NC even though he lived closed to Atlanta.
 


Also, my insurance company has a directory. It’s not perfect, but you can search by specialty and you can also call for assistance. I’ve seen a printed copy, internet search engine (specialty and distance can be searched), and used the customer number to find in network providers. I couldn’t tell by your post how she was trying to find a surgeon.
 
How far is she to a major city?

My mom was on an ACA plan, but we are about 30 miles from a major city (Atlanta), so that is as far as she would have to travel.

We have Kaiser through my DH's job with the federal government. I had to give birth in an Atlanta hospital instead of our local one because Kaiser did not have an agreement with the hospital here (even though they are both Piedmont Hospital). In other words, I don't necessarily think it is a blame it on the ACA versus how the insurance company operates or the availability of the specialists.

My FIL, more than 30 years ago-nothing to do with ACA, had heart surgery in NC even though he lived closed to Atlanta.
150 miles from a major city, and she is not finding a surgeon that takes her insurance there either.
 
Also, my insurance company has a directory. It’s not perfect, but you can search by specialty and you can also call for assistance. I’ve seen a printed copy, internet search engine (specialty and distance can be searched), and used the customer number to find in network providers. I couldn’t tell by your post how she was trying to find a surgeon.

She used the online directory. But it still lists Doctors that no longer take her insurance. The problem seems to be complicated by the fact that this is a major health insurer that has contracts with lots of lots and Doctors for all their policies....except the Covered California/Affordable Healthcare policies they sell. That policy is not singled out in the directory.
Her next step is to contact Covered California and have a patient advocate step in and look for options
 
The current problem as I see it with the Affordable Healthcare Act is coverage is a crap shoot dependent on how your state chooses to implement it and how many insurers remain in the marketplace.

Here's sending good wishes your friend is her best soonest.
 
She used the online directory. But it still lists Doctors that no longer take her insurance. The problem seems to be complicated by the fact that this is a major health insurer that has contracts with lots of lots and Doctors for all their policies....except the Covered California/Affordable Healthcare policies they sell. That policy is not singled out in the directory.
Her next step is to contact Covered California and have a patient advocate step in and look for options

That’s terrible, my insurance company only shows the doctors offered within your specific plan.

I hope and pray the advocate is able to help her.
 
That’s terrible, my insurance company only shows the doctors offered within your specific plan.

I hope and pray the advocate is able to help her.
I all fairness, I know over the years with my work health coverage that those directories can include Doctors that opt to stop taking certain insurance after open enrollment closes. So that is something that is not unique to Affordable Health Care Act policies.
 
I believe there is a shortage of ObGyn specialists due to sky high liability insurance costs. Doctors that assist in births get sued a lot more often.

I had to wait two months to see a nurse practitioner at a gastroenterology office, not even a doctor. As a new patient, you just don't get any leverage.
 
I had no problem with finding a specialist to evaluate my thyroid issues, and an ENT saw me quickly for sinus issues. I am no longer on ACA insurance, but I actually loved my insurance back then. I think it depends on what state you live in, PA had some really good, affordable, low-deductible plans on the exchange and in my area UPMC rules all so if you have UPMC insurance you can pretty much get any services you want as long as you are willing to drive into the city to one of their hospitals.
 
Do you have trouble finding specialists that take your insurance?

A friend has coverage through Covered California, California's version of the ACA health exchange. She needs surgery for Stage 1 cancer. There are only three OBGYNs in her community that accept her insurance but at least she had three options. Now she is trying to find a surgeon that takes her insurance. Her OBGYN warned her she would have to travel to a city 150 miles away to an area with a population of 1.5 million to find a surgeon that accepted her insurance. Guess what? So far, nobody takes her insurance. The odd part, EVERY hospital will accept her insurance.

She lives in a city with 91,000 people and a county with 171,000 residents. Not a huge community, but not small either.

Pretty small community. She may have to look to Southern California for coverage.

What about City of Hope in L.A.?

I live in a city in So Cal with 150k people, but our county has over 2 million people. Her city accounts for more than half the county population? Wow!!!
 
For most diseases and treatments, St. Jude accepts children, adolescents and young adults who are 21 years old or younger at the time of acceptance. Exceptions to this age limit include:

https://www.stjude.org/patient-referrals/seek-treatment.html

UPDATE: She called yesterday. She found a Doctor at a University of California hospital. I guess it would be odd of a university run by the state not to take insurance issued by the state.
 

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