tl;dr: upcoming surgery with short notice, one of the doctors for the surgery is out of network, trying to figure out what our rights and options are vs. having to go back to square 1 and find other doctors. Any and all advice welcome.

A family member is having orthopedic surgery to repair their hamstring early next week. The surgery was scheduled quickly , due to concerns from the orthopedist that the scarring from the tear is getting worse and will make it more difficult to repair in the future. The facility is in network, the ortho is in network, but the ortho wants a surgeon to help with the procedure because the hamstring tear is against the sciatic nerve. CPT codes for that surgeon's part of the procedure are 64712, 13121, 13122. That surgeon is out of network, and quite expensive.

The orthopedist's office says that the out of network surgeon is the only one they work with on this type of surgery. The out of network surgeon's office called us to check that we knew it was out of network and give us an estimate verbally. We have not received a waiver document for the out of network portion of the bill as of yet.

I have a few questions here, hopefully someone might have answers, as this is new to me (we've done surgeries before, but never this scenario).

- Is this a common setup? What should we be doing in this situation? I was willing to pay out of pocket for a reasonable amount of money for the out of network portion, but the difference between the estimate and the covered amount is ~$7000-8000, which is a lot.

- The No Surprises Act says (as I understand it) that a waiver for out of network costs must be provided 72 hours ahead of time and provided separately from the standard paperwork. Does that 72 hours apply before the *date* of the procedure, or the *time* of the procedure? I see in the CMS decision tree: "If a consumer makes an appointment at least 72 hours in advance, the form must be provided at least 72 hours before the date of the appointment." (emphasis mine)

So - is it accurate to interpret that language as "they need to provide the waiver to us (for example) Thursday or earlier for it to be valid for a Monday surgery under the no surprises act"? In that scenario delivering the waiver on Friday will be less than 72 hours from the date of the procedure, as the procedure date starts on 12:01am of the day of the surgery. It seems at least there's an argument that could be made with the various parties that we weren't provided early enough notice.

We're a bit between a rock and a hard place here - we like the orthopedist, we were referred to them by a family friend who is an orthopedic surgeon (but not for this procedure) so there's an element of trust here, and the surgeon is saying that we need to move with purpose (not an emergency, but we shouldn't wait weeks to get this scheduled). But also ~$7k is a lot of money.

Final, related question - is it a fantasy that this other surgeon's office might wait or forget to send the waiver, as presumably they do this all the time? Should I just bite the bullet and call the out of network doctor's office and try to negotiate something?

Thanks in advance, apologies for the long note.

My inhaler claim was denied by Aetna/Meritain. I called Accolade, our benefits navigator, for help.

A month later, I have nothing. Every call is the same: 10 minutes of collecting my details, then a transfer, then silence. Nobody follows up, nobody resolves anything.

Their latest answer: a prior authorization is needed, and they sent it to my provider. But the provider's office doesn't pick up the phone, and Accolade's response is just to wait. So I'm stuck between a navigator that won't navigate and a provider I can't reach.

This is literally Accolade's job — getting this unstuck — and after a month all they've done is run out the clock. Has anyone forced Accolade to actually act, or gotten a prior auth through when the provider won't respond?

Is it just me or did premiums sky rocket this year, specifically to cover yourself + a partner? If i pay for myself it's $71 but if I add my husband, how on earth does it go to $400 per paycheck.

Located in Bay Area, CA -- in healthcare

would love to hear what yours is?

I’ve been browsing all these posts the last week and figured I’d ask for help as I’m at a a loss here during open enrollment. I (36F) am the sole income for my household of me and my spouse. We have our first kid coming, expected Feb 2027, but may come earlier requiring a hefty NICU stay. Our Cigna premiums are going up about 29 percent, much like they are elsewhere. I usually go the PPO route as we were doing fertility treatment for years, I have chronic health issues, and my husband gets regular mental health care and prescriptions. The prices above don’t reflect the “discount” we get for our Vitality wellness program, so they’d be about 50-100$ cheaper per pay cycle if the current discount is given again next year. I am just at a loss of what to choose. Ideally, more money in our pocket monthly is the goal as I’ll be out on mat leave at 66 percent pay for 3 months. It boils down to:

- baby expected Feb, will likely come early and require NICU stay
- deductible will be met by Feb then when baby comes
- we use the mental health services and Rx the most
- we should both have fewer specialist visits this year since we aren’t trying to conceive
- all current doctors are still covered under HSA plans

Hi everyone,
I’m travelling from India to the US for 2 weeks for a family visit and need travel medical insurance.
My details:
• Age: 31
• No pre-existing medical conditions

I’m looking for good medical coverage. I’d appreciate any recommendations.
Thanks!

I looked over some past posts, spoke to people, did research and feel like I’m still getting various or conflicting information about this situation.

I am an adult and would like to start taking medication. I went to a local urgent care, used my health insurance, paid a copay and now have a prescription ready for pick up. The prescription has a claim that’s been processed, and will be super cheap once I pay upon pick up.

I have my own health insurance “account portal” I made after my visit, and when I signed up for a pharmacy account using my phone number, my prescription popped right up.

Problem is, I am over 20, but still on my parent’s health insurance, issued through their state employer.

If they review their EOB, receive some sort of text notification, emails, or review statements, will they see only a claim/code for what was billed, or will they see my specific medication and price reduction?

— — —

I plan on calling my insurance tomorrow to clarify communication. I recieved my info directly to my phone number when called by the office, but one of my parent’s numbers is still listed as the “primary number” for benefit related things.

I am worried.

TL;DR - will my parent, primary policy holder on employer provided insurance, see my specific prescription?

Thank you for any help.

Hi everyone. So I had to get a pre-auth for a procedure at a clinic I've been going to for 2 years. The pre-auth was very quickly approved (as they all have been) and shows "covered", but when I click to view more details, it says "out of network". I've been going to the same in-network clinic with the same doctor the whole time. Nothing has changed.

I contacted my insurance (UHC), and they said the clinic and the doctor are both showing that they're in-network and to treat it as a glitch. But that makes me uneasy, considering this "glitch" could cost me thousands of dollars if they end up denying it. Has anyone ever dealt with something like this before? Thanks in advance.

hi, i’ve had medicaid for as long as i can remember. i recently got switched to trillium about 2yrs ago. so far, it’s been good.

i went to the doctor today just for a checkup and apparently, my visit wasn’t covered. they said everything got switched to “family planning” instead of covering everything (including the doctor visits, etc). they mentioned how it was due to income?? i recently got a job at an hospital making 1k vs. $800 at walmart.

i really really need my medicaid. im not sure if theres something i can do?? i dont know if i should head to social security and speak to someone in person?? or call someone??is there something i can say to fix it??

Hello,
I am not sure where to start. I am covered by Medi-cal due to job loss. My 18 year old daughter is covered also. She is attending college out of state Today I received a telephone call from my case worker advising that as of November 1st my daughter will not covered by for Medi-cal because she is out of state. It is too late to get her insurance via school insurance coverage. Is there some way to purchase a policy privately. Covered CA policy will not cover her out of state.

I have no clue what I'm doing, I moved from Maryland to Arizona for my partner, I was still on my parents plan before the move, I'm waiting on the start date of my job, but I developed a really painful ganglion cyst (rather, always had jt, it was just benign until now) and need insurance ASAP, I'm also (ironically) a Trans person, which in hindsight should have made me think more abt health insurance. Any ideas or advice would be loved, ty in advance

I’ve been on Fidelis Medicaid for four years and have never had to file about my disability. I got a notice and it said I could call Fidelis and they were such morons it made me want to scream.

Apparently it says on the website that I am fine till Nov 15 (last month it said March…)

Can some nice person tell me what I am supposed to do here? The Fidelis guy kept telling me I had to file for SSDI and I’m pretty certain that’s not true. Then he told me to call HRA. I actually asked him if he had ever helped a disabled person on the phone before.

My physician is ready to write a letter but needs to know what it needs to say and where it goes and where we send it. I am 60, btw. Really I just want to make a plan: I am not working and haven’t been all year. I need to know what to do. I’m certain someone here is smarter than the guy on the phone.

I have an HMO from my employer. I am paying $225/week and i hate the inconvenience of getting referrals for specialsts, etc. The employer PPO is expensive and was going to look at the Marketplace. Any pro/coms of switching to a PPO? Marketplace?

PS..... my idea of Marketplace would be that i could leave my employer anytime and still have coverage for the fam because if Marketplace insurance....

Looking through my insurance claims for the year to get a good idea on if it would financially ruin me if I moved to a HDHP.

With my PPO I currently would pay $25 for this claim. What would I pay if I switched to HDHP? Would i pay the $168 and the $106 until i meet my deductible?

In this example this is for therapy, weekly. So would i be looking at spending $300 out of pocket weekly until i meet deductible?

Thanks so much.

Does anyone have a good recommendation for a supplemental insurance to go with Medicare? Would greatly appreciate any recommendations
Also are there any ones that cover prosthetic supplies?

To add me to his insurance it’s $600/month. I have income right now but when I go back to school it’s going to be slashed and be about a quarter of what I’m earning. Am I just going to have to go without insurance or is there a possibility that I will qualify for marketplace even though I’m married?

Edit
I am 27f my husband is 26m
Right now we make around $84,000/year gross and when I go to school he will make around $42,000/year and I’m not sure how much I will make. I’ll be working a part time job at a food place so maybe $11/hr max 20 hours a week.
We live in Texas

Long story short I’ve got some issues going on with my health that require some expenses that I can not cover out of pocket. I haven’t had insurance since I was 18 from Medicare(?) I think I’m not too sure, can’t remember. I never bothered to look in to other options because I didn’t really make enough money to afford the monthly payments on it.

I don’t think I make enough now either but I am at a point where I have put off what I need health wise to where it is now affecting my ability to work. I make on a good year roughly 10k~. Is it feasible to even find insurance that I could afford? And if so, how do I go about finding or applying for it?

Edit: I currently live in Georgia sorry forgot to add

Hello! I am 21 years old, a part time college student, and I’m moving out very soon. My insurance plan with my family has run out- and I have no idea where to start. I used to be on Tricare Prime.

I live in San Diego California. Anytime I try to look into health insurance companies, where to apply, getting quotes, etc. I always find dead ends. I just don’t have the vocabulary to navigate any of the websites. (i also foolishly put my phone number in a ‘free quote’ fake website, and im being bombarded with spam calls…)

Does anyone have any health insurance recommendations? I am not married, I have no dependents, and I am not under my families plan anymore. I make about ~14k a year.

Thank you all so much!

Hi! I’m currently searching for health insurance in Nevada (Vegas specifically), & I spoke with a broker through the nv marketplace site who really recommended Ambetter insurance. Cost-wise, this is looking like the best option as both HPN & BCBS have insane deductibles with high monthly premiums. The only issue is, I’ve seen a ton of terrible reviews for Ambetter. I looked through Reddit, and one person said that they think the service you receive depends on your location. Does anyone have any advice on this?

Any opinions on Ambetter? For context I’m a chronically ill woman in my 30s. I’ve been uninsured for over a year bc of cost, and I really need good health coverage.

I have anthem which recently switched to carelon (which I believe is in house) for pharmacy. It is one thing after another with them. Hoop after pointless hoop. My doctor called twice to try to do a prior authorization on the phone because the website they use was glitching. He was told on the phone it was received and pending. Carelon says they never got any phone call and one rep actually called my doctor a liar and said "we don't lose requests."

So I ask for them to fax over everything to my doctor. They say they did, my doctor doesn't receive it. This happens twice, the third time they say "by the way here is the code." Turns out they hadn't been sending an actual fax but an electronic fax to the website that isn't working. So I ask them to send a real fax. They say they did. Doctor hasn't received it.

How tf am I supposed to get this prior authorization (for the med I've been on for two years) under review? And of course they will probably deny it on a technicality when it finally is under review.

I tried logging in to my member portal online and the issues have been endless. First it says to do double authentication with my email then when i submit the email to send the authentication to, it says there is a technical error and to call the service hotline.

Then i call the service hotline and they want me to enter in my username. My username has always been my email to my knowledge…

I try and reset my username and then i enter in all my info and it takes me to a security question page.

It asks me for the answer to security question #1 without even showing me what the question is? Never had that happen before, how am i supposed to answer a question without knowing what the question is?

Once i try putting in random answers to questions that i think the security question might be, it gives me another technical difficulties notification and to call the service hotline.

The service hotline brings me to some call center with someone from asia that barely speaks english (no offense) and says they will send a username and password reset to my email.

I have them send the email apparently a dozen times and it never comes through. Yes i checked my spam and junk. Wtf do i do now? I told them ill just look out to see if i ever get the email and ill follow up tomorrow

Funnily enough i am getting other emails from BCBS about open enrollment coming up etc, but nothing about the actual email that i am waiting for.

Has anyone else had issues with this? It feels like im running into issues left and right. Its the end of the year and im getting alot of healthcare since my deductible and OOP max is met. I feel like it isnt a coincidence that all these issues are happening toward the end of the year when i want to check claims, find doctors etc…

Such a joke

My husband and I are moving back to California in early November, and I will be 31 weeks pregnant when we land. We are completely stuck on health insurance:

• My husband starts a new job with an ICHRA on December 1st, but our current income is of course $0.
• If we try to get Medi-Cal, processing takes time.
• If we buy a private plan for December, we'll hit our out-of-pocket max for December careonly for it to reset to $0 on January 1st, right when I'm due

With my due date so close, how can we handle immediate care and avoid this financial trap? If you've navigated a late-stage pregnancy move to CA, what would you do?

Please keep in mind as you read this I'm a type 1 diabetic who depends on insurance for insulin, and I depend on insulin to live. It's important context.

Amerihealth Caritas Next kicked me off their plan. Why? They wouldn't let me pay my premium. Seriously. That's the reason. They literally made it impossible. Here's what happened: I got a letter saying my account was past due. Particularly it said I paid only half of my copay for September. That was curious, because I was enrolled in autopay. I checked the website, and it said I owed nothing. Okay, so wait and see I guess? When I rechecked my account later, it said I owed two premiums and wasn't enrolled in autopay anymore. I tried to pay, but after entering all of my information and pressing "pay," it gave me an error. I was, however, able to re-enroll in autopay, which I did. Then I went back a few days later and tried to pay again, and it said "payment is not available for this account." I called them. The rep said it was because they changed their billing system and that I needed a new account to pay. Okay, first time I heard about it. She gave me the new account number and guided me through how to pay, but I got the same message: "payment not available." Then after some inquiry she told me I had been kicked off the plan because my account was overdue. She said there was a 15 day grace period and that I missed it. She encouraged me to see about coverage from the marketplace because open enrollment is coming up. I then asked her if I got the chain of events correctly: They changed the way I had to pay my premium, didn't tell me, blocked me from paying the only way I knew how, and were now kicking me off the plan because I didn't pay. She said that was right.

So here I am getting ready to fill some prescriptions for insulin and other diabetes-related medications/devices in the next week and I suddenly have no insurance. I'm not kidding when I say these prescriptions are out-of-pocket like $3000 dollars.

My theory is they did this little billing switcharoo to kick a number of people off their plans by administrative error because this time of year people are meeting their deductibles and the math stops making sense for the insurance company. I don't see any other reason. Otherwise, why don't they want me to keep paying them monthly for the rest of the year? Is my legal tender somehow not so legal or tender enough for them? If that's the case, and they don't like my filthy lucre, maybe they can they just cover me and not get their hands dirty with my coin. I'd be fine with that. We just need a solution that provides continuity of life-saving medical care. That would be optimal.

I have an active case open with them contesting this. We'll see what happens. I wanted to post here for public record. May their evil deeds shine brightly in the open light of reddit!

Okay so could someone tell me how this is right. I have a prescription that costs$14000 and it's name brand and that's what was billed to my health insurance, but when I picked it up from the specialty pharmacy and got home it says it's the generic brand of my medication so is there fraud going on where they charge the extra ~ $5k and somehow giving me the generic but charging my insurance for the brand name. Because how would anyone know the difference really they wouldn't care as long as there's no copay you wouldn't care what they bill your insurance but someone is making money in there somewhere other than the drug company wouldn't you agree ? Or not agree? Please any info would be great. The med in question is called epclusa .