Conference moira::parenting_v3

re: .32

>    The MODS may feel that this conversation is best to take place in the
>    DIGITAL conference, as it is... but my questions and concerns, as you
>    can see, are specific to issues surrounding obstetrics and gynecology.

This topic is very appropriate for this notesfile.  Feel free to respond with 
FACTUAL information about what is covered and what is not by the various 
health care service providers.  But if you have any recommendations, or 
responses to questions like the two quoted below, please respond by VAXmail 
directly to the author of 119.32.  And .32, you might get better response if 
you specify what service providers you are interested in, or what geography 
you care about.  You mention Harvard, but that covers a very large geographic
area.

>      - Could you please comment on the care that you received?  Anything
>        really good or really lacking in the care afforded you by the HMO?

>        Was
>        there anything about the services provided by the HMO that were
>        outstanding or lacking?

Clay Satow
co-mod

    Thank you, Clay.
    
    I live in Central Massachusetts - Worcester area and belong to Harvard
    Community Health Care.  In one sense I would love to get specific
    answers about Harvard.  In another sense, I'd like to get peoples'
    overall feeling about the various types of health insurance for OB/GYN
    matters.
    
    Thank you!

I think this discussion should either be moved to the general infertility
note or should be a new topic ("Infertility and health insurance").

We're on our third infertility specialist.  I don't think any HMO would have
let us switch for the reasons we did (basically, we didn't think we were
getting the best care for our situation).

If you need psychological counseling, HMOs are very limited in what they'll
cover.

Let's compare the two Digital Medical Plans (DMP 1 and DMP 2).  The
payroll deduction for DMP 1 is $637 less per year (52 * (34.00 - 21.75)).
The downside is that DMP 1 has a 20% copayment for hospital and surgical bills.
At first glance, DMP 1 will cost you more than DMP 2 if your hospital and
surgical expenses come to more than $3185.  Almost any infertility surgery
(laparoscopy, varicocelectomy, etc.) will cost more than this.  However,
if you're going through infertility treatments, there's a good chance
you'll hit the out-of-pocket maximum just from office visits, so DMP 1
seems to be the winner.

    Base noter--please feel free to give me a call to discuss some things
    off-line. I belong to the Fallon HMO (also in the Worcester area) and 
    could share some experiences I have had with my pre-natal care (I am 
    7months preganat now) including hospitalization for some problems. 
    
    I am also our "site expert" for the Managed Care training each major
    site will be offering in late November so I should be able to answer
    questions about POS as well as the Medical plans (altho' you already
    seem very well informed!)
    
    Sandy, 237-3035 

    We belonged to an HMO when our infertilty was discovered.  The HMO
    ob/gyn ordered the test that revealed Pat's blocked tubes.  Once it was
    determined that the tubes were blocked, he started recommending things
    that were obvious stalls.  Thank goodness Pat had done her homework
    through reading and talking to RESOLVE, and pretty well knew what our
    options were.  The HMO doctor never mentioned any realistic options,
    but suggested some cheaper, long-term options that were totally
    irrelevant to our problem.  Example:  the first thing he wanted to do
    was put Pat on Clomid for six months.  With two blocked Fallopian
    tubes, what on earth for?????  The only reason we could think of was to
    avoid spending the money to do what was necessary to resolve the
    infertility:  namely, either surgery or in-vitro fertilization.
    
    Incidentally, the policy of the HMO did *not* rule out surgery to open
    blocked tubes, though they do not cover in-vitro fertilization.  The
    doctor merely wanted to fool around with cheap but useless treatments
    for a long period before offering such an expensive option.
    
    To make a long story short, we found ourselves a positively wonderful
    infertilty specialist, and paid for her services out of our own pockets
    until January when Digital would let us switch back to John Hancock. 
    BTW, our infertility specialist verified our opinion that the HMO
    doctor's suggested treatments would have been totally useless but
    cheap.
    
    That has been our first and last experience with an HMO.
    
    Steve

    
    We belong to CMHC (Worcester area) and chose our own doctor. We chose a
    family practitioner for a number of reasons. My wife had a difficult
    preganancy last time, becoming gestationally diabetic. For the last two
    months, she saw a specialist once every 2 weeks, her own doctor once
    per week, had a non-stress test twice a week and an ultrasound once a
    week. We were nothing but 100% satisfied with all the care we got. No,
    we did not get to pick the hospital, but that wasn't a problem for us
    (for what it's worth, we won't be able to this time either, as the one
    we delivered at before no longer does maternity.). Her own doctor
    delivered our son, with an ob/gyn, whom we had previously met, standing
    by in case a c-section was needed (family practitioner cannot do
    surgery). We were guarranteed our doctor since he scheduled her to be
    induced one week before her due date (but had a real good chance of
    getting him in any case, as he was only "off" one weekend per
    month...he had a light ob'gyn load at the time).
    
    I should mention that CMHC is not a "traditional" HMO, one where you go
    to a specific center which is just for that HMO. With CMHC you pick
    your doctor form a long list of privately practicing doctors who belong
    to CMHC, so you seem to be a bit more flexible about getting "your"
    doctor when you need to.
    
    Good luck with whatever you decide.
    
    --dave-- 

    I belong to Fallon (HMO) also since last February.  Prior to joining
    Fallon, I had John Hancock.  I had been treated for infertility for
    the past 3 years.  I met with the Fallon infertility specialist in
    February and he just referred us back to where we had always gone.
    Instead of paying 20% of the visit (with John Hancock) we would have
    paid $2 per visit with Fallon.  Luckily for us I didn't need further
    treatment because I was pregnant (due in 3 weeks!).  I have been
    very satisfied with Fallon during my pregnancy.
    

    
    Is BayState an option for you?
    
    I have been on BayState for at least 10 years and have been *very*
    happy.  BayState is a PPO--which means I choose my physician(s) from a
    very large book of member physicians.  A lot of physicians belong to
    BayState--including those affiliated with Mass. General, University
    Hospital, Dana Farber--the biggies in Boston--as well as plenty of MDs
    at small, community hospitals (such as Emerson, Newton-Wellsley, etc.).
    
    If BayState isn't an option for you, is there a PPO that is an option? 
    I really recommend PPOs over HMOs.  I don't know how PPOs make money,
    but there is never a question when it comes to referring to a
    specialist, going the extra mile, etc.  Since you pick your physicican
    from a large book of member physicicans, you are in essence, a private
    patient--and are treated as such.  I pay $3 per office visit.
    
    Bonnie
    
    

    What does PPO stand for?  Is that an option we're being offered?
    
    BayState is not convenient for me in Central Mass.  Can't recall
    whether or not it was part of the HealthNet option, either.
    
    Rgds,
    marcia

>    What does PPO stand for?  Is that an option we're being offered?
    
Preferred Provider Organization.

It works like a very loose HMO.  You can use any doctor you choose, but if
you go to one of the docs with a PPO then you get a discount (when I
belonged to one 5 years ago all I had was a $5 co-pay with any doc visit).

I don't live in Mass., but from what I know DEC now has no PPO
options/plans.  (But I'm not in personnel so don't take me 100% here.)

    
    Baystate and Tufts are both PPOs--and DEC offers both.  I highly
    recommend PPOs.
    
    Bonnie
    
    

I have a question concerning insurance.

I have been covered under my husband's insurance since 1988 (the waiting
period has been fulfilled).   I am planning on dropping my primary insurance
this open enrollment period and will rely strictly on his policy.  I called 
my husband's insurance and explained the situation to them (I am expecting 
in May; will be dropping my primary insurance; husband's policy will then be 
my only coverage).  I was assured that, as I have already fulfilled the required
waiting period, that I will be treated just like any other member.  

The problem is: they will not put this in writing until they receive a notice 
from my primary insurance that I have dropped coverage.  I have been told (by 
the three customer service reps that I spoke with) that I am already a member 
of the plan; they are sending me information regarding maternity coverage; and 
that I have nothing to worry about.

I have been using my husband's insurance as a secondary policy, and they have
paid claims in the past (after my primary insurance).

I just want to make sure that my maternity bills will be covered by my husband's
insurance.

Am I needlessly worrying?  Has anyone been in a similar situation?

Thanks,
Cathy

	You have nothing to worry about.

	My husband was covered under my insurance as secondary to his.  He then
changed jobs and we elected to not take insurance with his new employer.

	The next time I filed a claim, I included a note saying that he was no 
longer covered under the other insurance.  Absolutely no problem.  (And he was
in the middle of being tested and for underlying reasons for his high blood-
pressure at the time of the switch so even a pre-existing condition doesn't 
affect this as long as you are already covered as a dependent (which they have 
confirmed for you).

Tracey

    re .13
    
    Did you get pregnant before or after you went onto your husband's
    insurance???  I'm in the same situation now but I got pregnant before
    my husband starting his new job.  I've kept the DEC insurance but we're
    also paying for a family plan under his insurance.  (Theory being I
    would rather spend the $$ for extra insurance than end up having to pay
    the medical bills for ob, delivery and hospital stay.) I've heard about
    insurance companies not covering 'pre-existing' conditions so and I am in 
    the process of trying to find out the ramifications of dropping the DEC
    insurance once the baby is born.
    
    I would be curious to hear about anything that you learn.
    
    Carol

    re .14, we had a similar situation on "pre existing" condition. We were
    under an HMO, I was in the hospital having surgery when our changover date
    came (we were going into JH).  The HMO agreed to pay the hospital
    bills, John Hancock refused to pay more than 80% for post-op and
    therapy bills.  Their reasoning was that they had no record of ANY
    SURGERY.
    
    Re. 15, If I'm understanding your question correctly, and also that of
    John Hancock's policy, you can change your policy at anytime if "family
    size or circumstances change".  
    

    
                          {  PRE-EXISTING CONDITIONS  }
    
    
    Does anyone out there know if John Hancock insures "pre-existing
    conditions"?
    
    Any input would be appreciated.
    
    Mel

    
    
    	RE: .17
    
    	If you're referring to the Open Enrollment period, I'd check
    	with your PSA and if you're STILL not satisfied, call John
    	Hancock themselves and ask.
    
    	I recently switched from John Hancock to an HMO and needed
    	to be sure they would take a "pre-existing condition" since
    	I'm due in March '91.  Basically the girl I spoke with at
    	the HMO told me that Digital is too large of a company for
    	them to NOT take pre-existing companies.
    
    	I would *think* that JH would be the same way...
    
    	/Kim

    Please remember - with the Digital Medical Plan, DIGITAL is your
    insurer.  John Hancock simply administers the plan.
    
    Your PSA will have all the details on coverage.
    
    			Steve

    re pre-existing conditions...has any one had any problems with
    getting coverage when moving from one insurer to another with
    
    (1) infertility as a pre-existing condition
    (2) pregnancy as a pre-existing condition
    
    further twist :
    
    a. when you go from DEC insurer (i.e. hancock) to an DEC HMO ?
    b. when you go from DEC insurer (i.e. hancock) to a spouse's non-DEC
       HMO policy?
    
    (sorry for the terminology above, i.e. DEC HMO...i know it is a
    misnomer but i just mean an 'HMO' available via DEC benefits pkg.)
    
    thanks.

    I tried to get insured under my husband's non-DEC insurance and
    was denied because of pregnancy as a pre-existing condition.
    
    Good luck!

    further to .20 re pre-existing conditions...
    
    what if you were w/ a DEC HMO and then went to the same HMO
    but not under DEC ? i.e. DEC HCHP to non DEC HCHP ?
    
       
    i hate all this stuff !

I changed from John Hancock to Tufts (thru DEC) during the last enrollment 
period and I was 7 months along by then.  I changed to Tufts because it meant 
that I could keep my doctor.  It was jsut a pain going through all the 
pre-admission approval again!

    so tufts took you in with a 'pre-existing condition'....i wonder if
    it wasn't DEC to DEC if would they have done so....? you were lucky to get
    to stay with the same doctor.

Keeping the same doctor was one of the reasons I chose TUfts.  But I had to play
their rules against them!  

Most HMO's won't refer you out of the local clique of doctors that your primary 
Care is in unless they have to.  Which translates to they don't have that kind 
of specialist in the area.  So I chose a PCP from Needham as Needham doesn't 
have any OBs in their area.  They therefore had to refer me outside of the area
to my doctor in Natick.  This way I got to choose my own doctor while still in
an HMO in a sense.

I would start by finding out which plans your OB and Pedi are a part of.  Most
of these plans you can call and ask questions like this without any problem.

 

    re. .20
    
    I changed from John Hancock to Montachusett this past January when I
    was 8 months pregnant.  I kept my own obstetrician who happened to
    belong to Montachusett (which is why we chose that HMO).  I'm covered
    under my husband's policy now and receive the Opt-Out payment.
    
    The only problem we had was with the doctor's billing company.  We
    pre-paid for what we were assumed to owe if I stayed with J.H.  This
    prepayment was made in early Fall.  Montachusett covered 100% of
    my maternity expenses from 1/1/91 thru and including the delivery.
    It took 6 months and a lot of letters to get our refund of the
    remainder of our "prepayment" (anything past 12/31/90) back from the
    billing company.  A letter sent to the billing company, the doctor, and
    Montachusett finally cleared things up.
    
    If you're already pregnant--congratulations and if you're still
    trying--I wish you much success!!!
    
    Robin

    
     I changed from John Hancock to my husband's (DEC) CMHC HMO during the
    last open enrollment.  I'm now covered under my husband's policy and
    receive the OPT-OUT payment.  (I was also able to keep the same OB)
    
    I was due Jan 11 so I had a "pre-existing" condition.  When I checked
    to see if this was going to problem, they said no since it was DEC
    and it was an open enrollment period.  I did have to work on Jan 2
    because you had to be an "active" employee to change policies.
    
    I was told that since DEC was the second or third largest employer
    in the state, that even people with other pre-existing conditions
    could change health insurances with no problem during the open
    enrollment period.
    
    

    While not pregnancy related I wanted to tell the gliche I ran into a
    few years ago, we were under Fallon Plan, and due to change to John
    Hancock on July 1, no problem right?  Wrong, on June 26 I had to have
    emergency disk surgery on my back.  While the hospital and surgeon were
    covered 100% because I was admitted under FCHP, John Hancock refused to
    pay anything but 80% of follow up visits, which included suture removal
    etc, and the many months of physical therapy.  Hancock's reasoning was
    strange, they had no record of the surgery so they couldn't pay the
    post-surgical visits and therapy.  Kind of strange, you'd think they'd
    understand when they got a bill for "suture removal".  
    
    We finally quit fighting Hancock and paid the balance ourselves.  IMO,
    you'd think Hancock would be willing to pay the extra 20%, since they
    got off by not having to pay the hospital stay and doctor for the 3 or
    4 days of July I was hospitalized following the change in plan.
    
    Insurance companies, can anyone keep up with their rules!!
    
    

    In general, when applying for health insurance not as part of a
    group policy, is pregnancy treated as a pre-existing condition?
    If so does that mean that the insurance company will refuse to cover
    it?  Does anyone know of specific insurance companies that will
    not disallow coverage.
    	Linda

    
    My experience is that pregnancy is considered a pre-existing condition
    by insurance companies.  I have tried to switch insurance since I
    became pregnant (not as part of a group policy), and after an
    exhaustive search, NO insurance company will cover my pregnancy - except
    for my current insurance.  My current insurance is so expensive that I
    actually considered switching insurance anyway, paying for the
    pregnancy costs, and carrying the risk that no problems will arise.  
    
    Patty

Some policies have a maximum amount (i.e. $1000) on pre-existing conditions.