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Made It To Sf - Now Need Some Advice On An Hmo Plan


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Hello everyone,

The last month I've spent moving across country, dealing with some intense family stuff, and trying to unpack, settle, etc. Somehow for the month of the move, I kept up. But I am paying for it this week. I'm so tired/fatigued and everything just feels 'heavy' (arms/legs) but I'm forcing myself to work on unpacking and things when I can.

I have a few 'pressing' questions that are starting to worry me...so any advice you can share will be helpful.

---We are now on an HMO plan The cost of meds + copays + deductibles in the PPO were very, very high. The doctor I've been recommended is on the plan, so that's a plus. Here are my outstanding questions...

A. Will the HMO be likely to question my use of medicine (Mestinon and Midodrine, specifically) as it is not normally prescribed and Midodrine and my BB even somewhat contradict themselves. I have to use all Generic (no real choice)...but my former doctor said generic Midodrine may just vary a bit in strength and not to worry too much about it.

B. How hard is it to see a specialist if needed? I used to self-refer when needed on the PPO (not often, but I need to see a local POTS specialist a couple times a year, at least. Maybe another specialist or two for other things).

C. I have an IUD. The plan doesn't cover IUD unless Oral Contraceptives are not medically viable. In my case, my prior doctor said they are not. What do I have to do to prove this (like when I need a new one, when I need it checked, etc).

Thanks so much for any advice on HMOs. I appreciate it!

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Congratulations on surviving your cross-country journey!

I had an HMO when I was self-employed and it is an entirely different health-plan than a PPO. Yes, they will question EVERYTHING! No, you cannot self-refer. It may take much longer to get to see a specialist and several letters from your doctor. Out of network expenses are high, so be prepared. As for the IUD, your prior doctor should write you a letter for your new doc and the insurance stating that oral BCPs are not an option for you. Get it now, before your records become stored elsewhere or he/she has a memory lapse. Take it easy and don't push yourself too hard! Moving is very stressful, don't underestimate that!

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Hey!

Jade can definitely help you with referrals if you find a specialist that you really want to go to. Dr. Friday has a team of specialists that she refers you to also, so she has a web of people to help with your symptoms =) Also, for your IUD, Planned Parenthood Golden Gate is easy to get to near Van Ness st, and they have another location---and PPGG is very cheap. They do IUD's and it's dirt cheap because of the organization. A lot of people I know just go to them for all their gyno needs. So if you can't find a way for insurance to pay for it, they may be an option. If you explain it to Jade, she may be able to give you some advice on that.

Also, I wanna let you know about SF On-call. If you google it, it's a downtown group of doctors that make house-calls if a patient needs it but doesn't want to make a trip to the hospital or Jade. Hospital is really expensive, moreso than SF On-call. Two things about On-call though, 1. You have to pay out of pocket and then submit a claim to your HMO. This might not work with your HMO though, so you might have to just forget this suggestion lol 2. The doctors might not be -that- helpful with knowing about POTS. But they're very smart guys, and I have had such awesome conversations with them. They spend a LOT of time with you if you see them. They've given me so many tips about the medical system and about practical, cheap remedies if I'm not able to get to a doctor. They're fun and so sweet. I get free ambien and sample packs of all kinds of stuff when I go there because they don't want me to leave without at least trying to get me to feel better. Most of the time I just couldn't though, but still---other medical emergencies unrelated to Dysautonomia were always solved by them. Just wanted to let you know about that service in case you need same-day house calls. Expensive, but maybe you can find out if your HMO lets you submit claims without pre-approval. I'm a bit ignorant on that.

This might not help you at all, but I chose Blue Shield of California PPO and I haven't had -any- trouble approving stuff with them yet. No trouble at all. I pay around $150 a month for the Active Start Plan 35, and copay is 35 for appointments, and $10 for generic prescriptions. If you find out your HMO is going to be a hassle, I'd recommend them if you're able to switch. I think CA law protects people in that if you're on an insurance plan, and you're paid and current with them, you can switch to another insurance and be protected from having pre-existing conditions. At least that's what I've heard from my doc. If they do try to turn you down, you can challenge it legally supposedly. Anyway, so if your HMO turns out a pain in the butt, a PPO might be an option for you, and mine has treated me well so far.

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Hey!

Jade can definitely help you with referrals if you find a specialist that you really want to go to. Dr. Friday has a team of specialists that she refers you to also, so she has a web of people to help with your symptoms =) Also, for your IUD, Planned Parenthood Golden Gate is easy to get to near Van Ness st, and they have another location---and PPGG is very cheap. They do IUD's and it's dirt cheap because of the organization. A lot of people I know just go to them for all their gyno needs. So if you can't find a way for insurance to pay for it, they may be an option. If you explain it to Jade, she may be able to give you some advice on that.

Also, I wanna let you know about SF On-call. If you google it, it's a downtown group of doctors that make house-calls if a patient needs it but doesn't want to make a trip to the hospital or Jade. Hospital is really expensive, moreso than SF On-call. Two things about On-call though, 1. You have to pay out of pocket and then submit a claim to your HMO. This might not work with your HMO though, so you might have to just forget this suggestion lol 2. The doctors might not be -that- helpful with knowing about POTS. But they're very smart guys, and I have had such awesome conversations with them. They spend a LOT of time with you if you see them. They've given me so many tips about the medical system and about practical, cheap remedies if I'm not able to get to a doctor. They're fun and so sweet. I get free ambien and sample packs of all kinds of stuff when I go there because they don't want me to leave without at least trying to get me to feel better. Most of the time I just couldn't though, but still---other medical emergencies unrelated to Dysautonomia were always solved by them. Just wanted to let you know about that service in case you need same-day house calls. Expensive, but maybe you can find out if your HMO lets you submit claims without pre-approval. I'm a bit ignorant on that.

This might not help you at all, but I chose Blue Shield of California PPO and I haven't had -any- trouble approving stuff with them yet. No trouble at all. I pay around $150 a month for the Active Start Plan 35, and copay is 35 for appointments, and $10 for generic prescriptions. If you find out your HMO is going to be a hassle, I'd recommend them if you're able to switch. I think CA law protects people in that if you're on an insurance plan, and you're paid and current with them, you can switch to another insurance and be protected from having pre-existing conditions. At least that's what I've heard from my doc. If they do try to turn you down, you can challenge it legally supposedly. Anyway, so if your HMO turns out a pain in the butt, a PPO might be an option for you, and mine has treated me well so far.

I find all insurance moderately confusing and am hoping it can be made more reasonable for everyone in the future!

In the meantime, the HMO is through my spouse's employer and reading through all the plans, it seemed to provide the best 'overall' coverage even though it requires specialist referrals. I know I want to start with Dr. Friday (and I've already seen so many specialists before I moved) and see where that goes. At least I have a bunch of stuff I've tried behind me and I know it can take months to see a specialist so at least I won't be seeing some big-time specialist every few weeks so hopefully can stay under the radar!

I looked up the PPO plan you mentioned - did you get it before you had POTS? How do they handle pre-existing conditions? It looks like a decent PPO plan (no deductible - the ones I was looking at in comparison to the HMO had 3500-5000k deductible.)

The SF On-call sounds great. I hate going to the ER for anything (avoid it at all costs, always have). In the big cities they are overfull from minor ailments, it seems, unfortunately.

Didn't even think of Planned Parenthood. I'm not working now - but even if I'm working it sounds like I can still go? For some reason I just assumed it was for non-working/low-income only but if not that's a good idea.

Thanks for everyone's advice. I'm trying to get a couple letters from my doctor and gathering all my medication list to take to my new doctor. I think this changing doctors/medical stuff is worse than moving. Almost.

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I know a lot of working people who use Planned Parenthood when they have jobs. I don't think they require any info from you really, I think it's for everyone, and there's an option of complete privacy. You can use your insurance with them too, if you want, they accepted mine and my appointment was 10 dollars, or was that my birth control? I can't really remember but you can definitely go to them =) Hopefully some people won't be protesting outside of it though...that's always weird, but whatever.

Well I definitely know there are some laws protecting Californians with pre-existing conditions, but I'm very bad at looking up laws. Maybe you can find someone to consult you on that subject who is knowledgeable about the CA laws protecting the already insured people. I know that if you miss paying your insurance for 30 days, you can be stuck without insurance because they're allowed to not accept you back because of your condition, but I'm a little confused about how they find out you're insured with someone else. You're supposed to tell them you're with someone else when you're signing up, but I don't really know if they actually go check to see if you're current and whatnot. I really don't know much about that. Maybe there's a hotline somewhere you can call to ask questions about that, hum... Not sure.

lol Yes, seeing a new doc is a lot of work. My medical info file is my most organized and detailed possession I own because I've had to get it together for so many specialists.

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