HMO Plan - OON Doctor - what is Covered?

[Yagents]

I see a lot of NON GF and ACA OFF PPO clients not being able to afford the higher PPO non subsidized premiums this year. Here is my question:

If I put this client in an HMO, and tell them to pay cash for their current doctor that is is not in the HMO network, what will be covered if that OON doctor prescribes medical items? Will it be covered under the benefits of the plan if they they get those services IN network?

If OON doctor prescribes RX, will it be covered under the plan?
If OON doctor refers to specialist in network, will it be covered under plan?
If OON dr, prescribes xrays or MRI's, etc, will it be covered?
If OON dr prescribes preventative services, will it be covered?

 

[houcoogster]

I see a lot of NON GF and ACA OFF PPO clients not being able to afford the higher PPO non subsidized premiums this year. Here is my question:

If I put this client in an HMO, and tell them to pay cash for their current doctor that is is not in the HMO network, what will be covered if that OON doctor prescribes medical items? Will it be covered under the benefits of the plan if they they get those services IN network?

If OON doctor prescribes RX, will it be covered under the plan?
If OON doctor refers to specialist in network, will it be covered under plan?
If OON dr, prescribes xrays or MRI's, etc, will it be covered?
If OON dr prescribes preventative services, will it be covered?

I'm not sure about the first one (doubtful though).....but 2 (he can't refer),3,4 the answer is unfortunately no.

But what he could do is take the OON Dr's recommendation back to his PCP and hold his feet to the fire!

 

[somarco]

My experience with HMO's is this.

Outside of an emergency, any services rendered or prescribed by the non-par doc are not covered.

Also, no "discounts" for the doc or any prescribed services even if those providers are in network.

In the past you could beg forgiveness and sometimes the carrier would approve the ancillary claims but this is a different world.

It's ............... Obamaworld.

 

[kgmom219]

I see a lot of NON GF and ACA OFF PPO clients not being able to afford the higher PPO non subsidized premiums this year. Here is my question:

If I put this client in an HMO, and tell them to pay cash for their current doctor that is is not in the HMO network, what will be covered if that OON doctor prescribes medical items? Will it be covered under the benefits of the plan if they they get those services IN network?

If OON doctor prescribes RX, will it be covered under the plan?
If OON doctor refers to specialist in network, will it be covered under plan?
If OON dr, prescribes xrays or MRI's, etc, will it be covered?
If OON dr prescribes preventative services, will it be covered?

I'm going to answer assuming it is an HMO without a OON benefit. (such as a POS plan, that requires a PCP, but includes OON benefits)

Disclaimer: this gets into specific policy language and I am giving you "general" answers that I would give a client. (And that's how I am answering the question)

Its important to remember that a true HMO uses capitation for PCP reimbursements. The doctor who you choose as your PCP receives a monthly payment from the insurance company, irregardless if you see them or not. Part of the capitation agreement is that the doctor agrees to what they can and can not send you to for a specialist.

For example: you see your current internist and he discovers you have high blood pressure. The internist is naturally cautious and wants you to see a cardiologist and have an EKG. The cardiologist is in the network. However, since the referral did not come from your PCP, the visit is not covered, nor is the EKG. Your PCP most likely would not have referred you to a cardiologist for high blood pressure nor requested an EKG.

Preventive services are absolutely NOT covered OON.

Prescriptions are iffy. It depends on if the HMO uses an in house PBM that can match based on the network or contracts the PBM out. Generally, the answer is yes, they will cover it. (I would use the word MAYBE when dealing with clients)

 

[Yagents]

I am speaking about those clients who will be forced to buy an HMO ACA plan (because PPO plans will be $100/mo+ or more in cost).

So, if my clients doctor is not in the new HMO, but they want to keep their doctor, can I tell them just to pay cash to that doctor, but make sure all services are done IN the HMO network and have them covered (labs, Rx, MRI, etc)???

It sounds like it's a "NO", everything ordered must be done through HMO PCP.

In this case, the sales pitch will be.......buy this cheap HMO, and if you want to keep your non network doctor, it will just be a hospital/surgical/Emergency insurance plan.

Just like those old "insufficient" plans we've been selling for the past decade.

 

[Ann H]

Yeah, we're back to the 1980's, aren't we? Here goes the HMO nightmare all over again.

I agree with all of the answers above. My understanding is that nothing is covered OON unless your PCP gave you a referral, except Emergencies. KGMom is an expert in prescriptions, so I will defer to her there, and say that perhaps RX would be covered.

 

[kgmom219]

I am speaking about those clients who will be forced to buy an HMO ACA plan (because PPO plans will be $100/mo+ or more in cost).

So, if my clients doctor is not in the new HMO, but they want to keep their doctor, can I tell them just to pay cash to that doctor, but make sure all services are done IN the HMO network and have them covered (labs, Rx, MRI, etc)???

It sounds like it's a "NO", everything ordered must be done through HMO PCP.

In this case, the sales pitch will be.......buy this cheap HMO, and if you want to keep your non network doctor, it will just be a hospital/surgical/Emergency insurance plan.

Just like those old "insufficient" plans we've been selling for the past decade.

Exactly. But even then, it really won't work.

You get the HMO. You find a lump. You go see your OON doctor. He wants a CT scan. You pay cash or you get in to see the HMO doc. The PCP has to order the CT scan to get it covered. Even if you are willing to pay for the CT scan, if you want surgery, you will have to start all over again at the PCP. (And when you have a lump, do you really want to do that?)

Its an Emergency plan, sure.

You screw up your knee and pay for everything at the ortho office? Great. But you are STILL going to have to go through the PCP to get anything covered when you need surgery.

Please don't get me wrong...HMO's can work. If the network is decent.

I plan on offering this as an option. And anyone who takes it will be told "Call now and get a physical scheduled for January. I don't want you to be considered a new patient if you get sick and need a quick appt."

If these are all HSA folks, its not going to be pretty. Ugh. I'm sorry!

 

[FLM2]

I only speak for myself but wouldn't put a client into an HMO plan without his PCP being in network, it's just too messy and could easily become a nightmare for both the client and the agent if there is a claim denied or screwed up (which will undoubtedly happen).

All HMO's of course, aren't the same-I have one client on a Humana HMO in the Tampa area and it's been terrible for him getting referrals (took 3 months) and I will not repeat that in 2015 (his premium was $1.67 and the lowest cost PPO plan would have been $200).

 

[AllenChicago]

I've learned a lot from this thread! Thanks to all contributors.

There are some companies that don't have Out-of-Network coverage. For example United HealthCare says that with their 2015 Exchange plans, you are either in the HMO network, or you are "not covered".

It sounds like in many regions, it's best for the client to bite the bullet and pay an additional $100+ dollars to stay in a PPO, because the extra headaches and costs of going out-of-network will negate those premium savings anyway.. if they need to use the plan within the first year or two.
ac

 

[somarco]

HMO's usually have a preferred pharmacy. In the case of KP they prefer you to use their own but some HMO's have contracted providers for Rx, lab, etc.

When Aetna came to town a few years ago with their IFP product (PPO, not HMO) I was told clients had to get a new Rx written by their (network) doc if they wanted it covered. Even if Doc Jones was your doc before you had Aetna, and he is still your doc and in the Aetna network, he had to write a new script and enter it into the Aetna system before it would be covered.

Really?

What a pain in the arse.

If you are going to write HMO plans you better know the rules. Each one is different. My only real exposure is to KP which is a closed panel system. I almost never used an HMO for small group but the rules were similar.