PPO, Medi-cal and HMO?????

I currently have open enrollment right now and it ends in a few days.  MY options are BS PPO and a Cigna HMO.  Both of them will cover WLS.  What I don't know is......

How long and what do I have to do to get approved through cigna.  They told me that it would depend on my PCP and the health plan I choose.  I have no idea what health plan to choose or what pcp is wls friendly???

If I choose the PPO I am told I can get the wls faster, but my cost would be anywhere from $5000 to $10000!!  I can't afford that.   My friend then suggested I apply for medi-cal as a secondary insurance to the ppo to cover what the PPO doesn't.  But I don't even know if that is possible.  I know that is how it usually works but with wls I don't know.   (I would be eligible for medi-cal cuz I am a single mom)

I am wanting my surgeon to be LePort or one of his associates and they are providers for the ppo, hmo, and medi-cal so no problem there.

I was on the phone all day today.....I am going to be Insurance expert after this for sure.  Phew!!!

 

Every single insurance is different, I had blue cross PPO when I had my surgery I decided, was approved within 4 monthsm and had surgery too.  I did not pay anything but my out of pocket for the year.  There is usually a maximum that you pay a year.   If you got a book with your options then read and learn.  It should be breaking everything down for you, if you don't have a book, then call the insurance companies themselves, and have them brief you on their benefit package.  It's going to take more work on your part.  Remember knowlwdge is power, so gain some.

Good luck, Diane

The maximum out of pocket expense is $10 grand a year, that is why the office quoted me $5-$10 grand with the ppo.  I read the book that came with the open enrollment packet, but other then saying they do cover wls if you get pre approval.  I justt don't know  what to choose??? 

Hi,
you also have the option of chosing a HMO normally you wouldn't have to
pay anything but some groups have new things like deductibles, and
larger co-pays.  You have to read all the fine print contact the doctors
office and find out who does the authorizations, tell them you are in
open enrollment and you would like to know which one to choose, and
I am sure they have worked with all of them and this would be a general
question.  It won't hurt.
Good Luck

Judy

You might want to call the surgeons office and ask if they know of wls friendly pcp's.  Also, call the hmo and ask them directly what is the requirements for wls?  Do they pretty much approve if you go to an innetwork surgeon and pass all your testing?  Do they have a wls 6 month diet?  Every insurance if different but they should be able to answer those questions.  The surgeon should be able to tell you of wls friendly pcp's and then you call that office and see if they are accepting new patients and find out what medical group they are with.  I picked a pcp, then found out he was not wls friendly.  I went to see him with a list of the things/diets that I have tried, i also was able to inform him how much research I had done on wls.  He didn't want to, but he referred me anyways.  i have Healthnet HMO, I saw my insurance approved surgeon for the first time 8-20-08 and my surgery is next week.  Good luck and feel free to ask me anymore insurance questions.  I used to work in the medical field for a long time and I have been on the consumer side of a hmo and ppo.  If you qualify for medi-cal, couldn't you use that as your secondary insurance to cover any out-of -pocket expenses? 

Yes, I was did ask the girls in the office if they could refer me to a wls friendly doctor and health plan.  (Cigna and the dr's office told me that Cigna covers the surgery but each health plan has different requirements before they refer you too a surgeon.  One office told me Prospect was great, but not Monarch.  The other office said the exact oppisite. Both office said they could not recommend a health plan or a pcp....to call and find out.  When I called the monarch and prospect they said it depends on cigna.  I told them cigna WILL cover the surgery.  I wanted to know what the requirements to be referred to a surgeon.  They said to ask the PCP.  I told I didn't have one yet.  So I called few PCP's and they said to call Cigna.  It was like this all day!!!!  I went around in circles all day. 

So.........then that is when I was venting to my friend that she said get on medi-cal, pick the ppo and just use medi-cal as a secondary.  Sounds perfect, but will medi-cal and the ppo work that way together?  I called caloptima and they said yes whatever the ppo didn't cover....medi-cal would.  I called the doctors office and they said.....they are not sure it will work that easy.

so after a whole day thinking about this and being on the phone.  I still don't have any idea what to do????

 

Thanks Judy...
I did read everything.  I know what the co-pays for the hmo and the deductibles and stuff for the PPO.  I have called 2 different offices and the girls in the office just tell me they can't really tell me anyhting until I have the insurance.  I am going to call a few more offices tomorrow.  I was on the insurance board thingy and it seems that medi-cal is pretty easy to get approval from.  I am going to call them tomorrow to find out how they work as a secondary insurance to a ppo.

It is all confusing.

 

 

 

Ok I have a couple of questions for you.  You are looking for a medical group that would refer you to dr LePort correct.  You found out that it is a covered beenfit for cigna.  So I would contact the surgeons office and ask what medical groups referr to them.  Also, remeber you need to meet the requirements of the medical group.  Many of them have requirements such as wt loss, and other diagnostic testing.  Gastric Bypass is an elective procedure and they will not call it an emergency. 
As for getting a PPO and then getting a supplemental medical policy to cover the remainder.  You have to have a need (financail need)  I am not sure of your financial situation but I honestly do not think that you would be approved especially if your primary insurance is through your employer.  I do not think that it is appropriate either.
Just my @cents
liz

Yes, wls is a covered benefit for cigna that I know for sure.  What I want to find out is :

1. what are the requirement for the different health plans/ITA  before you are referred to a surgeon?
2. who are the friendly pcp's for those health plans?

  I did call LePort's offices (both of them) and asked what medical group refers to them.  Both offices said they cannot recommend anyone. The are not allowed for some reason.  One of the girls did mention Monarch and Prospect though.  And I have been trying to find out what the requirements are for each medical group and no one can give me that informtion either.  Cigna, the surgeon's offices, or the medical groups...they are giving me no information. Hopefully I will get the answer to those 2 questions so that I can make the best choice for me to acheive wls.

As for medi-cal...I do meet their income and property requirements and I have a child under 21 who has an absent parent.  (used to work as a advocate for people applying for M/C and  we had to deal with the medi-cal workers and caloptima.  didn't deal much with billing or stuff like that once they were eligible our job was done ) Never applied for medi-cal because I could afford my copays and such with my current HMO.  Barely, but I could get by. I cannot afford the out of pocket expenses if I choose the PPO.  Having employer insurance doesn't make you ineligible for medi-cal. 

From personal experience, Cigna can be a real pain in the butt. If I remember they reqiure 6 months of Dr supervised diet  but that depends on what program you have with them, and they  can and will sometimes deny for whatever reason they have at that moment.
If you are applying for medi -cal as a secondary you can get it if you are unemployed otherwise you can get CMSP. It just all depends on your income.

JOY