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Will Insurance Cover My Two New Hips?

Discussion in 'Hip Replacement Pre-Op Area' started by needhelp, Aug 9, 2011.

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  1. needhelp

    needhelp Member

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    I cant figure out how to do a new post....but i have a question hopefully someone can answer..

    Will insurance cover my 2 new hips??? I just got group insurance because my husband has his own business and they had to approve me, but I literally just got the insurance card last week.
    Will I have any problems using my insurance? I have Anthem Blue Cross PPO $2500 deductable, $5000 out of pocket (whatever that means)
    $25 co pay office visit $100 emergency room

    My insurance agent told me to wait for surgery until January if at all possible to be safe (she assured me they would not drop me no matter what, but sometimes they deny surgeries within the first 3-6 months)

    Also she said another reason I should wait is because the biilling is from January to January? So I guess this means I will save out of pocket money??

    If anyone knows what I am talking about I would really appreciate your input!

    THis forum is so great! Thank you all!
     
  2. Juliep

    Juliep Graduate

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    Re: need 2 new hips

    What this means is that your deductible runs from January 1st - December 31st. For any kind of hospital stay (surgery) you have to pay $2,500 of a deductible then you have a percentage you have to pay. Some plans are 80/20 or so on. Meaning you pay another 20% of all bills until you reach a total of $5,000 out of pocket expense. (Your $2,500 deductible and another $2,500 of 20% or whatever your % is) once your $5,000 has been met you pay nothing further for the remainder of the year.

    My second hip was covered 100% because I had a $6,000 total out of pocket and I had used that with MRI's, tests, etc and then my first hip.

    There could be an issue with pre-existing clause in the policy and then it would not be covered. This really needs to be addressed and looked into prior to surgery. Hopes this makes sense and if you have any other questions let me know.
     
  3. needhelp

    needhelp Member

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    Re: need 2 new hips

    Hi Julie, thank you for posting your pictures.

    What do you mean a pre-existing clause? I thought if you are under a group insurance there is no way that they can turn you away??? Thats what I have been told at least.
     
  4. needhelp

    needhelp Member

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    Re: need 2 new hips

    Hey everyone..i really dont mean to sound so superficial or anything , but I am just curious to know if there is plastic surgery that can be done to completely take away the appearance of the hip replacement scars. Honestly the most important thing is to be pain free, I know that...but before all this happened to me I was a beach bunny, I loved being at the beach and wearing cute bikinis on vacation or whatever. I'm 25 and dont want to have to cover up...but of course if there is no way, it is what it is and ill have to live with it
     
  5. Jamie

    Jamie Administrator

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    Needhelp.....I have moved your post and the comments you received to its own thread. If you will check under the OFFICE tab (at the top of every page) there is a link to a section that will give you lots of information on how to use the forum. Click here to get there.

    Some insurance companies have rules about covering problems that were diagnosed prior to you being covered by their company. All insurance companies are different, so your best bet is to contact your company directly and ask them if they will cover your surgery now or is there a waiting period for a pre-existing condition.
     
  6. Juliep

    Juliep Graduate

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    Re: need 2 new hips


    My mom was just over before and she was showing me her scar again from her hip replacement 2 years ago, you can't even see it......it's so thin and faded that I couldn't even tell it was there. It will take time, but I bet you will see the same thing.

    About pre-existing, did you come from one group policy to another group. Basically did you not have a lapse of insurance for more than 90 days of coverage? That's one of the leading factors about pre-existing. If you go from one insurance (say from a job or husbands job) to another within that time period usually you are good to go. You just need to check with the Blue Cross.
     
  7. needhelp

    needhelp Member

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    Thanks Jamie...I just called my insuracne agent and asked if they could deny me for any reason and they said definitely not. They said they have people with existing cancer and they dont get denied insurance if they are under a group, and they get treated.
    julie
    I never had insurance before and no doctors have ever officially diagnosed me through any insurance, so I think I am ok there. Anything I ever did (i.e. MRI, EXrays, dr appt. ) was all paid in cash.

    My husband and his partner have a towing company and all of us got group insurance under their company (Thank God!) None of us ever had any insurance before.
    My inurance agent DID put on the application that I have joint pain.

    So, I dont know if that helps. I am an idiot when it comes to these things!
    Im not exactly sure what you mean by 90 days lapse...i dont think so.
     
  8. Jamie

    Jamie Administrator

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    Lapse would mean you had insurance at one point and for some reason stopped it....that's the lapse. If it goes over 3 months, that would be a 90-day lapse. Since you have never had insurance, that doesn't apply to you.

    Just be sure that you always make it clear that, while you may have had joint pain, you have never been diagnosed with arthritis.....just in case.
     
  9. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    Re: need 2 new hips

    I know of no plastic surgery that will remove all evidence of such a scar.
    But why would you want to cover up your beautiful badges of honour? They will fade with time, anyway, until you might even have a job seeing them.
     
  10. HippyGal

    HippyGal Member

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    The scars will fade. It does depend upon your skin, too, regarding how long it takes. You'll actually know how long by other scars and healing that you've been through. This will fade.

    It is not shallow or superficial to want your beautiful body to remain that way. On the other hand, you are likely the only one who really gives a damn. I hope that your body heals quickly and that you are quickly pleased with the results of the surgery.
     
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  11. needhelp

    needhelp Member

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    I felt the need to make an update on this thread because I just found out today that my insurance is no longer covering me for anything until February 2012.
    I am so sad that I cant even breathe right now.
    The way I found out was I went to a rheumatologist (my first appointment as a new patient)and they said my insurance isnt paying for the cisit so, I need to pay $250 for the office visit, or they will bill me a cancellation fee of $350. So I paid them with my head down. They were the rudest most horrible doctors I even been to. When I told the doctor about what his girls told me upfront about cancelling, he said he would prefer not to discuss this and it is not up to him what the girls ar doing up in the front of the office. I held back my tears the best I could.
    I dont understand why my insurance isnt even covering an office visit.
    Anyway, I do have Ankylosing Spondilitis, and need serious treatment that I cant afford called Embrel. I need a plan asap to get myself this medication.

    The silver lining in all of this is the rheumatologist (however much I hate and despise him and I will be writting a terrible review online) said that he is confident that I will feel soooo much better once I get this medication. He said this can potentially delay the need for hip replacments for years (i dont know about that!)
     
  12. cotton1958

    cotton1958 Supremo

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    Insurance companies are tricky. They can figure out all the prescriptions you have had filled and even Doc-in-the-box visits out of pocket. Don't know how they do it, but they do.

    Also as far as a deductible goes, it depends on if insurance covers a specific thing and also how much is reasonable to them...and they can deny part of a claim.

    As far as the drug you want, if you have a Costco near you, they have lower prices for underinsured and uninsured. Haven't tried them lately. I think there is a form to fill out online or in store. I don't think you even have to be a member....that I'm not sure about.

    I recently saw someone's 2 month old hip scar and I was shocked at how small and well healed the scar was and it was easily covered up.
     
  13. Jamie

    Jamie Administrator

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    Tara, call your insurance company and ask why you are not covered until February. Are you not paying premiums NOW? It doesn't make sense that you would be paying and not have at least some coverage. The only thing I can think of is that they may have a 6-month wait before covering pre-existing conditions. In that case, you need to fight to establish that this is not a condition that was previously diagnosed.

    Don't give up, hon! Be sweet, but firm and ask for information,. If you find that there is some sort of waiting period, ask how you go about disputing their assertion that this is pre-existing. I've known people (myself included) who were successful in fighting insurance denials. It can be done. You must be persistent and follow all the little rules. And you'll need the help of your doctor, so I think I'd hold off on writing that awful review. In spite of the fact that the doctor was a ninny to say that he had no control over the actions of his office staff....you need him right now, so don't make an enemy. You can always write the review later once you get what you need.
     
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  14. needhelp

    needhelp Member

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    Hi Jamie, I am afraid I was too hasty and I already went ahead and posted the reviews. I couldn't help myself, I was treated so badly at the office it was unbelievable. I probably should've waited, but I felt so unhappy with their service. It wasn't the fact that insurance company has totally put me in a major bind, it was how rude the office staff was. And the doctor was equally cold and uncaring which I found disgusting. I would usually never write anything, or have the time, but in this case I thought it necessary.
    The funny thing is there was already several reviews from patients that had a bad experience as I did. I shouldn't have even gone there but I was so excited at the possibility to get some pain relief.

    In regards to the insurance. I have no idea how to fight or what to ask them. I called my insurance agent crying my eyes out right after the doctor appointment and she will be calling blue cross to find out what's exactly going on in The morning.
    All I know so far is there is a six month pre-existing clause or something like that, which means no coverage until February, since my plan began as of Aug. 1st.
    Do you know if this goes for everything? i mean, even if there is this pre existing clause thing, shouldn't doctors visits still be covered???????

    I am just so incredibly disappointed now. Feeling pretty hopeless.
     
  15. Jamie

    Jamie Administrator

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    The pre-existing clause should only effect something that was diagnosed prior to you starting this insurance. So regular doctor's visits and all that will be covered.

    As far as this appointment goes, wasn't this the first diagnosis you had for Ankylosing Spondilitis? And, as far as your hips go, I thought you had never had a diagnosis of arthritis in your hips...or did you? These are the things I believe you can try and fight. I keep forgetting that you actually have an insurance agent. That's good and you should let her help you.

    If you don't have a copy of your policy, get one. You need to become very familiar with what is covered and when.

    When you talk with your agent, find out what to do to contest the decision that these problems were pre-existing. I feel like you have a good argument if they were never diagnosed, but your agent can probably tell you more about that.

    Try not to let this upset you....I know it's difficult. Be calm. Be determined. Be assertive in your disagreement. And get all the people you can to help you fight. Then FIGHT IT!!!
     
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  16. needhelp

    needhelp Member

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    Thank you Jamie.
    I have never been diagnosed with ankylosing spondilitis ( but I had a gut feeling this is the root of my arthritic pan) and my very first appointment, with my new insurance was on Wednesday when I got my hips injected ( this was the first time ive ever used insurance for my condition) That dr. Sent me to the rheumatologist i saw today.
    Prior to that there was no official diagnosis that I know of.
    Just a bunch of OS saying those hips are bad u need THR, but we need to get to the bottom of why this is happening. So, I guess today's doctor visit was my official diagnosis of ankylosing spondylitis.

    My insurance agent is definitely going to get to the bottom of everything.

    Now I have a bunch of new fears in regards to the ankylosing spondilitis.
    I don't want to end up hunched over or in a wheelchair with my back all fused together. These are some of the things that can happen and I'm terrified. Now I wish that the hip replacements were all I needed.

    I'm so sorry to keep on and on about this. Thank you for all of your advice.
     
  17. Jaycey

    Jaycey Moderator

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    Tara, I so hope you get this all sorted. Please don't give up. You need care and you already pay to get that care.

    Please update us when you can!
     
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  18. Josephine

    Josephine Forum Admin and Mother Hen Administrator

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    It's not inevitable that you will end up like that. Mostly, with planned medication and physical therapy, people can continue a reasonably normal existence. Don't expect the worst yet.
     
  19. Jamie

    Jamie Administrator

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    I agree, Tara.....your best bet right now is to stay off the internet sites until you can learn more from your doctors about your specific case. Nothing is going to happen to you overnight or even over weeks. But, there are plenty of scare stories out there that may or may not be true, may or may not apply to you, and may or may not happen for decades. So please don't do this to yourself. Change your focus from the "what ifs" to deal with each step of getting this insurance thing worked out and dealing with what is on your plate for that day.
     
  20. needhelp

    needhelp Member

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    Hey Gals, well I had my "oh poor me day" and now I am feeling a little better. I kinda feel bad too because the Doctor that I saw yesterday called me this morning and scolded me. He said he couldnt believe I left his office without doing the TB test, and how I dont have to like him or his staff, but I need to change my attitude towards them because they are going to help me so much.
    He also went on to say that he "never calls patients like this" but when he saw me yesterday he felt so bad because he knows he can help me and he sees alot of people that he cant help but he feels confident he can help me with the shots and he wants me to come in take the test then come back on Thursday and get my first shot of embrel.

    He is still extremely arrogant, I still think he is rude, but should I still go in and do the shot ?

    I dont want to deal with him in the future, but for now what should I do?
    See another Rheumatologist, get a new appt, pay another $300 plus whatever the doc wants to charge for....or should I go in and do the test today so Thursday I can get the free shot?

    What should I do????? I need to make a decision before this afternoon as they want me to come in today
     
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