I need insurance help! (kind of long)

Fredifer1115 · August 2014

So I got a new monkey wrench, this one may take the cake (and typically I love cake, but I am not happy about this sh*t at all). Just got notification on Wednesday that my company is changing insurance to, you guessed it, a carrier that my RE doesn't accept. AWESOME. However, the new plan offers the same benefits, BUT I would have to find another doctor, UNLESS new carrier deems me eligible to receive continuity of care for 90 days after the effective date. Oh, and the effective date is OCTOBER 1st. Way to give us fair warning. And the information seminar about the policies and such is not until September 8th. So had I not done all this legwork myself, calling current carrier, new carrier, HR and the RE I wouldn't know anything pertinent for another week and a half, which as we know is the difference between a cycle and being benched for a month.

I currently get $10000 lifetime for IVF, which I will get under the new plan as well, but I want to get the benefit with my current plan, and let the benefits reset under the new plan, but with only 5 weeks, being on CD9 right now, I have no idea how to make that happen. I am going to see the RE on Monday (we are doing natural cycle and timed intercourse this month bc of a stupid cyst). RE said he has no problem putting me on the IVF calendar for next month, but I just have to see how they work billing. If any portion of the bill is submitted after October 1st it goes against my new insurance, AND could even be denied because it is out of network unless approved.

I tried to find something that said a company has to give employees fair notice regarding insurance changes especially in the event of special circumstance, like current treatment, but apparently there is nothing specified. I am also going to appeal to my HR to allow me to stay on the current plan for an additional month. My boss suggested something abut COBRA, but is then unsure if I would be eligible for the enrollment of the new plan after open enrollment.

Does anyone have any suggestions or advice?

jessimi06 · August 2014

I'm sorry you have to deal with this.

I could be wrong, but I don't think cobra would apply in this instance, especially since they're replacing the policy with a similar policy. One thing you can look into is whether your new policy has a gap exception rider. Are there other in network REs within 30 miles of your residence? If not, and you have a gap exception rider, you can try to get your current RE (that would be out of network) approved as an alternative provider (basically the insurance company agrees to cover costs even though it's out of network).

If not, then hopefully you'll be able to get scheduled/ get the billing worked out to be done by October. Otherwise, you'll most likely have to switch Your RE and if that's the case I'd probaby try and schedule an appt for the beginning of oct with an in network provider.

OhMyKittens · August 2014

I'm fairly certain that the date of service should be used to determine which carrier receives the claim/bill. As long as the DOS coincides with your current coverage, your RE should still be in network even if the claim is submitted after your current coverage terminates. It would only be after the new plan effective date that you would hit an out of network issue.

You can also call the new carrier to see if they have a member driven provider nomination process. This typically triggers a conversation with the doc regarding bringing the doc in network.

lebradford · August 2014

murrt said:
@Ohmykittens is right about when the service is done being relevant to which insurance would pay. But, I would double-check with your HR department that you get 10,000 lifetime with EACH insurance company. Typically when an employer makes a decision like that with a lifetime cap, that means for the lifetime that you work for the company - not the lifetime that they carry the insurance and then the same amount is applied to a new insurance policy.

And the "provider gap" is a potential avenue to continue to see your RE too. You have to check with the new insurance carrier though and they may try to guide you to another in-network provider.

This. I said so on your last thread too, but please check on this. Our insurance covers up to 4 IVF cycles, but those cycles count even if you switch insurance companies, jobs, etc. The 4 cycles never reset. I doubt your cap will reset with your new policy like you think it will.

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I need insurance help! (kind of long)

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