Question:
Out of State coverage for HMO's

BCBS has already told me that the procedure is covered BUT there is one issue. Although I live in Maryland-- I live right next to the MD/PA border. (like 5 miles) I spend more time in PA than MD. Anyway,I had my PCP write me a referral to have my surgery done in PA. (since its closer) MY PCP is in MD. I called careFirst to find out if they would cover out of state. One person said that they would ,as long as my PCP sent a request in asking for permission that it would be ok to do so. Second person I talked to said it would not be covered because HMO can't be out of state. I don't know who to believe. Have any of you in MD had your surgery out of state using a BCBS HMO? Thanks Melanie    — Melanie O. (posted on February 22, 2005)


February 22, 2005
Mealaine, I live in Pa and I had my surgery in New Jersey, my reg Doctor also is in Pa, as long as the surgeon is in your Network it should all go well, just make sure, so your not stuck with any Bills. Well GOOD LUCK!!!! Christine 155lbs on the losing side! :)
   — blainejrjeni

February 22, 2005
I live in Delaware and had my procedure done in PA. I have a BCBS PPO. In the network I belong to, I know the only difference in these plans are you need a referral. If your PCP gave you a referral for that Dr. then they must be in the network for you to use. I thought each Dr had a unique number assigned to them? Go online with BCBS and check out Dr. to see if he comes up in the network for you to use.
   — dcox94

February 22, 2005
Melanie, The previous posters coverages are PPO coverages. There will ALWAYS be coverage no matter what provider you choose. As you know, with HMO coverage there is ONLY in network coverage. If you go to an out of network doctor, it would not be covered, unless there is a referral from an in network doctor. I would have your PCP call the insurance company and have them send you something in WRITING to indicate that the out of network provider will be covered. Once it's in writing, they have to honor that.
   — Patty H.

February 22, 2005
Melanie, you need to look at this on a provider by provider stand point. Having an HMO does not limit you to only doctors within your state, it limits you to only doctors on thier network for your plan. When you live in an area that close to a state line, the docs that are in either state will be considered for your network of doctors. I lived in Kansas City for many many years and the city itself is on the border of MO and KS. There is no way an HMO can limit these people to one state. The insurance compainies will look at the metro area and set up a network. Again, it has nothing to do with state boundaries, just the limitations of your network. Your best bet is to choose a few surgeons, but them in order of preference and then check with your ins company to see if any are in network. Best of luck. REbecca
   — RebeccaP

February 23, 2005
Hello Melanie Yes, I live in New Mexico and Have Blue Cross NM HMO and had my surgery in Colorado last month. BCBS told me that as long as the surgeon is an approved BCBS provider you can have your surgery anywhere. So I can't answer the question for your BCBS in Maryland but I believe that as long as your PCP gives you a referral they should honnor your choice of surgeons no matter what state they live in.
   — Jeffrey T.

February 23, 2005
Thanks everyone! The Pa Surgeon is within the BCBS network. But Carefirst tried to tell me that only docs in VA,MD, and DC were considered "in network" They said that outside those states were "Out of network." Barix Clinic in PA even has a contract with BCBS! So I find it odd that they would not approve Dr Marymor as my surgeon Well my PCP is calling BCBS to find out what the problem is. Hopefully, they will be able to convince them to cover it. Mel...
   — Melanie O.

February 23, 2005
I live in New Jersey and had my surgery in PA. I have Amerihealth which is a subsiderary of BCBS. If the the doctor is apart your health insurance network then the insurance should cover it.
   — JerseyGirl

February 23, 2005
Melanie, there is a seperate network of doctors for each type of policy. While a provider may be a participating provider in New York, he may not be on YOUR network for your plan. I can see what they are saying to you with only providers in certain areas, but it doesn't make sense limiting it by state line when you are so close. BX can allow the use of another participating provider outside of your area, it's just more work for them. I would venture to say that is what the deal was with the surgery in Colorado mentioned earlier. It's just paperwork and red tape. Best of luck to you!
   — RebeccaP

February 23, 2005
Thanks everyone! I haven't given up yet! Melanie
   — Melanie O.

February 24, 2005
Carefirst denied me. Even though I have a referral from my PCP they said that they will not cover Barix in PA. I hate carefirst!
   — Melanie O.




Click Here to Return
×