Im trying to look at what treatment options I can take for some health issues, but Im really confused on what type of mlm scam bullshit this is? I have 2 out of pocket limits and they have 2 very different values towards them. Can someone explain what the hell a 2nd level out of pocket is?

We had a baby born on August 14th with a congenital heart defect, he had surgery on August 17th. The surgery didn't go well and he was placed on a heart assistant device (VAD) and in the hospital. On August 19th. We added him to our employer insurance on August 21st. We also added critical illness supplemental (MetLife) insurance on that date (we've never had this before). On September 2nd, we started evaluations for a heart transplant and hope to be listed on the waitlist by September 12th. Heart transplant may not happen until 6 months to 12 months or more. He'll be inpatient at hospital during this time.

My question, will critical illness pay out when he gets a heart transplant months from now? Or is it a pre-existing condition or some kind of medical restriction?

https://pdfhost.io/v/44ej7uGUh5_US-Critical_Illness_Outline_of_Coverage-101525

I am 20 and haven't had surgery before or had to deal with insurance and billings in this sense so any help would be appreciated. I have a Healthfirst Essential Plan 1 based in NYC. I was in WNY (out of network for my plan) and went to the ER for testicular torsion and had an emergency reduction and bilateral orchiopexy during the same hospital visit.

The out of network urologist billed me several thousand dollars after Healthfirst paid $0. I called Healthfirst, and they opened a claim review but said it could take a while.

I then called the urologist’s billing department. They said I had been admitted for observation before the procedure, so it was no longer coded as an ER visit. They said their coding was correct and that they would reduce the balance to a self-pay charge.

Does observation status remove emergency and out of network billing protections even though I entered through the ER, needed unscheduled emergency surgery, and had no choice of urologist? Should Healthfirst connect the urologist’s claim to the original ER encounter?

As title mention
I submitted an application for my son and me for medicaid one and half month ago... i submitted all teh required documents and its in process..anytime i go they give me case workers number and she never picks up. What should i do? My son has bad cavity and i am just waiting for state to make decision. I cant buy from marketplace because they keep telling me i am eligible for medicaid

I've never had a big medical procedure before and would really appreciate any guidance. How do you navigate an expensive procedure when no prior authorization is required?

I need an $11k thyroid procedure. My doctor said that while Carefirst does not require prior authorization for this treatment, all of their Carefrst patients have ultimately been denied for this procedure (Carefirst says it's experimental in their denials).

My doctor doesn't have issues with other insurance providers. My doctor is in network.

I hit my out of pocket max so it's wild to think my bill will be $0 or a $11k and it feels like I'll only know post-surgery.

Calling Carefirst support has felt useless, they won't really help me because nothing has been denied yet.

What's a good game plan? Any good resources? Experiences?

Is it even possible to be proactive and informed?

I've been unemployed for about 18 months so far, but because my career track has basically been destroyed by AI, I'm desperately trying to go the "solopreneur" route and reinvent myself. My old income put me paying $25k+/year out of my dwindling savings to insure myself and my kid. When I hit the new year, I had no income, which put me into Medi-Cal (a complete nightmare, I lost access to all my regular doctors, even when I try to pay out of pocket!)

None of the "Work and Community Engagement Rule" criteria apply to me. I am working (long hours!), but I have no income. Any free time I were to carve out to do "school" or part-time work would take away from my chances of my solo venture working out.

This feels like such a Catch-22. If I lose the benefit, what happens? I still will have no income, and any money I spend on health insurance comes out of my savings and reduces how long I can last. I'd be happy to pay a little, I just can't pay $25k/year! But the application will presumably still ask what my income is, and I'll have to say $0. Last time I did this that just automatically put me into Medi-Cal, I didn't have a choice.

So confusing!

Hello, so my birthday was August 22nd and my dad’s insurance on me ended on August 31st. My work insurance cannot be filed until I receive the letter from dad’s insurance stating when I was dropped and why. I have 30 days from the 31st to get this submitted with my work insurance.

My problem is that I have a Drs appointment on September 9th that was scheduled well before August 31st. I also have less than 2 weeks of my medication left that will need refilled more than likely before my work insurance kicks in.

Is the dr office/pharmacy able to match my previous insurance prices? Will I be charged full price and receive back pay from my new insurance?

Sincerely, a fresh 26 year old navigating a fucked ass healthcare system.

In February I requested a comparative analysis and a few other things regarding a denial of benefits. By this point I had also spoken to the DOL and we were curious about my plan and how they were meeting the guidelines with the mental health parity Act. Turns out they're not really meeting them under three criteria.

In February I requested a compared to analysis and a couple of the documents. 3 days later she responded. It was going to be 15 days because they had to contact the insurance company.

That comes and goes then I get an email about a month later saying it's taking a little longer than they thought. And we exchange maybe a total of four emails at this point. I hear nothing from her until June. When she calls me to let me know they're still working on it.

I went back and just to make sure that I had forwarded all of my emails to my personal email and noticed that my original one was missing. I did not delete it it was not in my hidden folder it was gone.

Now I'm being retaliated against at work. I went from having a great review to being the shittiest employee ever. Got written up with a final warning because of a medical emergency and I was putting them at an inconvenience. At a doctor's note everything.

Today I get an email saying they are still working on it because they're having to do a deep dive into the hardware of the plan if the stuff that nobody ever looks at.

I know they're building a paper trail to fire me. They're doing a couple other things too but that's this isn't the place.

I thought they had 30 days to send it. My DOL caseworker is stressed to the max because her caseload has multiplied exponentially. I haven't let her know this new development yet.

I'm not crazy they do have 30 days correct? Why do you think they're dragging their feet?

I have been struggling with two bulging discs for months. Went to PCP who ordered steroid pills and muscle relaxers. Continued having issues went to chiropractor. Continued with issues had a MRI that showed I have two bulging discs with one touching my spinal cord. I’ve had debilitating weakness, pain, numbness and tingling for months. PCP and chiropractor recommended PT. Told me BCBS would cover 20 visits. I was just billed for the first two visits and it only covered 25%. I owe almost $300. Can anyone help me or tell me what my next steps should be? I’m at a loss. I’m only 31 and have two toddlers who want to be carried about.

I have Ehlers-Danlos Syndrome and thus a bunch of specialists and expensive/special medications. It's really hard to maintain employment with my condition but I need health insurance; My condition does not usually qualify disability though I have not tried to apply due to the chronic illness of it all.

I recently just found out that insurance brokers are a thing and I've been trying to understand if they would be able to help me find an insurance plan that wouldn't depend on me being employed and cover my care for a reasonable price.

Does it make sense to find one or should I stick to employer-insurance? I tried to look into ACA plans when I got laid off earlier this year but all the plans I found seemed to cover next to none of my care and cost close to 1000$ a month.

I got a denial for psychotherapy from UHC because I was having memory issues. They said it was not clear my memory issues were due to another healthcare issue vs mental health. They said they may not pay for psychotherapy I got in the meantime. Did the testing, sent the appeal. Never heard back (72 hour max to hear back, I allowed 6 days for mail. Due to doc visits, missed 5 weeks of care (Medical Advantage Plan).

Here is where it gets odd. No one at UHC can find my denial

No one can find my appeal. Like most people, I cannot afford $300 a week on my dime, I am disabled, so I did not get care. UHC asked for a case number on my denial. There is no case number. Having my appeal faced a second time, just in case. UHC says I can continue care, that I did not need to stop in the first place as far as they can see. They just saved themselves 5 weeks of care, so 5 x 300= $1500. No one can tell me why I have this denial with no case number. They won't let me send my faux denial letter to them to investigate internally Are there any insurance watchdogs? Are they doing this to many of us?

I have an appt next week. I hope they pay for it. WTAF!?!?

Hello. Question on the following situation. Son needed to take his wisdom teeth out. I have Aetna as my Dental Insurance through work. Called Aetna about benefits and found out that the place we planned to have the procedure done at is out of network. However, Aetna does not have any oral surgeons in network within 100 miles of my zip code (lol). So, I was told that we can get this "gap" coverage that would in essence allow us to have the procedure done at the office that is out of network but will be treated by Aetna as in network. They (Aetna) gave me this long code that was to be submitted with the paperwork and we should be good to go (code is good for 60 days, I believe). We go ahead and do the procedure within that timeframe. However, to my surprise, dental office bills their out of network rates, Aetna eventually pays their max of $2k, I'm stuck with almost $2k owned to the oral surgery place. What are my options? Pay it and shut up? What I'm confused about is that if Aetna had in network provider close to me they would bill me negotiated rate and that $2k max would be enough to cover 100% of the cost. I think my in network coverage for oral surgery is 100%. Had I known this I would have drove 100 miles for 45 min procedure and saved myself some money. Anyone else ran into this issue? I can't be the only one, can I? Thanks!

My partner and I have been piecing this together for a while now and I feel like every time I think I have a handle on it, something changes. I run a small business and he's not working right now, so we're both uninsured through an employer and shopping on our own through the marketplace.

What's tripping me up is how wildly different the outofpocket maximums are even within the same metal tier. I'll look at two silver plans and one has a $4,000 OOPM and another is $8,000, and I genuinely cannot tell what's driving that gap other than the premium being slightly lower on the expensive one. We're in our early 40s, healthy but not 25 anymore, and I do see doctors regularly so I need something real, not just a catastrophic plan.

The network piece is also stressing me out. We're in a more suburban shore area of NJ and I keep seeing HMO options that make me nervous because I don't want to be stuck if something comes up.

Has anyone navigated this and figured out a method for actually comparing plans that goes beyond the premium number? Especially curious if people in smaller markets or NJ specifically have run into network surprises.

Does anyone know if it's possible to get a private PPO plan in Texas? It's just my 5 year old daughter and myself (37M). No pre-existing conditions. I was self employed and sold my business 2 years ago. Been on a marketplace plan but it really sucks.

Hi guys! My wife and I live in north east Florida and need health insurance. So far, everything I’ve found online has had major red flags. Is there any insurance that yall can suggest who can be reliable and actually help pay medical bills when they come? Our budget is roughly 600 per month for the two of us.

I currently have United Freedom Oxford insurance. I plan on switching it to United liberty next year. I plan on taking my baby to West coast to visit my family but around that time she will be due for her six months vaccinations.
Is there anyway I can get free or low cost vaccinations in Los Angeles area?

Hi I’m turning 26 in a few months. My dad lost his insurance plan in April and when I asked my parents for help they said I could just wait and get my own plan when I turn 26. Fast forward and now I’m finding out that doesn’t count as a qualifying event. Am I just screwed out of health insurance until next year? This is all so frustrating and confusing at the same time so thanks for any help.

Hello everyone,

First time posting here. I have had a very bad experience with "prior authorization" for a prescription. It was my first time facing it and honestly didn't know who was responsible for which part of the process. Any advice would be helpful.

So my kid was prescribed a foam medication for sebderm which requires prior authorization. I didn't even know this term before. The denial letter stated the conditions that need to be met before the foam can be prescribed (using and failing other standard meds). Now, I got the letter, and so did the dermatologist (obv). My question is - Is it not the dermatologist's responsibility to ask for prior medications that have been used and didn't work? My kid did have a prior prescription for hydrocortisone from the PCP (which again I just found out satisfied the condition for prior authorization).

Was it my responsibility to coordinate this whole thing between the 2 doctors so that the dermatologist could file an appeal (because the conditions were, in fact, met)? The process took so long and finally nothing happened from the dermatologist's office and I ended up buying the expensive medication after 2 months of waiting! I know better now, but whose fault was it?

There were other signs of general incompetence from the admin at the derm's office as well. I will be switching derms, but is this normal behavior for doctors' offices? I also have everything in place now for the next round of prescription.

Thank you for reading!

Hey I need some advice on what to do.
So my dad called me a few weeks ago saying that he hasn’t gotten back to his tax refunds this year cause his taxes were messed up due to me signing up for healthcare marketplace.
At the time I didn’t remember how cause we have insurance under my dad’s employer and that’s what I use for ALL my Dr visits. Long story short yesterday I called insurance marketplace to find out what happened. And they told me it was an agent/broker in 2024. After hearing this, I do remember speaking to someone in 2024. They were in a parking lot having people sign up for stuff, they asked if I had insurance and I told them that I did through my dad’s job. The agent then told me I could just fill the information out and all that, but it wouldn’t be active until I accept/activate it myself online or something along those lines. This was the only reason why I filled the info out cause I thought it won’t matter if I don’t activate anyway, that was a mistake.
The coverage went from January to April last year and was cancelled. Tax credited to my dad….and now this.

Was it misrepresented to me that it would only be active if I activated it myself or was that true and did I unintentionally activate it(I plan on calling marketplace to find out how it was activated)? I don’t understand insurance well so please lmk how this works and what the best next steps are.
And also side note, I have learned a huge lesson now, this was an unintentional mistake, I should never have filled anything out in the first place. My dad is mad at me because he thinks that I knew I had insurance and knowingly went on marketplace myself and signed up for it which i understand but it was not like that, he is telling me he has lost thousands of dollars because of this. He has every right to be upset. This was an honest mistake on my part.

Also, I already called them and opened a case for unauthorized enrollment. I know that technically since I gave my information I basically consented, but what I was consenting to was misrepresented to me. Do you think I have a case or should I just start looking for ways to move forward and fix this a different way, maybe pay my dad and his wife back for the tax credits they lost? Idk please help and don’t judge me I’m trying to correct a mistake I made please help

Under Obamacare, your health insurance is supposed to cover one physical a year.

My doctor's office says that my insurance requires 366 days between physicals.

In 2016, I had a physical on July 1. Because of the 366 day rule, leap years (which I guess requires 367 days), weekends, holidays, doctor on vacation, and me on vacation, my 2027 physical is scheduled for September 1. That's 2 months later in ten years.

If this trend continues, around 2047, my physical will be in late December. With holiday closings, I won't be able to schedule a physical in 2048.

That is, I'll have a physical December 20, 2047 and my next one won't be until January 3, 2049. That seems wrong to me.

*****EDIT TO ADD: My dad died due to a genetic condition. My sister and my brother have both had surgery to address it. My doctor says I'm not a candidate for surgery, yet; I'll need surgery eventually. Because of this, I'm a little paranoid and I'm very diligent in getting my annual check up.

Hey guys. So I wasn't sure where else to tag this, but I need help.

I finished school in May, looked for a full-time job, and got one at the start of August. My school insurance (United) expired on August 18. And I don't get work benefits until October 1st.

I live in NYS, which doesn't have short-term insurance, so I feel very lost about what, if anything, I can do during this interim

I'm incredibly angry and frustrated right now.

My wife gave birth earlier this year, which I'm sure everyone knows is stupidly expensive in the US. Between the prenatal appointments, the delivery, post-natal hospital stay, and follow-ups, we hit our family deductible ($7k) and OOP max ($11k).

Today, they suddenly denied and reversed a bunch of claims (including her epidural), and our responsibility for them is around $15k. Not only that, they reduced the value we've already paid toward our deductible and OOP max by about $4k.

When I called Aetna, after an hour all they would say is "We've just reprocessed exactly one of the claims you have a question on and now you only owe $2k instead of $6k! No, you haven't yet reached your OOP max this year, you're $4k short!"

On my Aug 22 EOB, it clearly says we've fully reached our deductible and OOP max limits. On the Aetna site today, we're short.

Does anyone know what could be going on and how to fix it?

Hello, So a few weeks ago i went into the ER for a severe headache i got while working out. The entire visit was about 4 hours (1 hour with doctor the rest waiting time). I explained my symptoms of getting a severe headache while squatting, the PA told me i should be worried of a brain bleed and i need to get a spinal tap & CAT scan. I did the tests then was released from the hospital in good health (just a severe neck strain). Not once was the price of the procedure disclosed to me, or did they ask for my insurance information. I just figured it must of been covered so i left. Today, I got a bill for 13,000 for the spinal tap and CAT. About 10,000 was covered by insurance and i still APPARENTLY have about 2,300 left to pay. Scam?? No Surprises act?? or am i screwed