HMO issues

[RightSide]

Now that Blue Cross has raised the insurance premium on my PPO by 38%,
I'm seriously considering switching back to an HMO to save some money on my premium.

But I'm worried about any restrictions an HMO might place on my medical treatment.
Anyone here with an HMO like to comment?  Specifically, will an HMO pay for a kidney transplant?
Has anyone had trouble getting their HMO to pay for their chosen dialysis modality (in-center or home, hemo or peritoneal)?

[tyefly]

I have a HMO   and have had no problems with anything....   I am on the transplant list   and I have a live donor being worked up  and  I am almost done training on Nxstage....So everything is good with my HMO......

[cariad]

I had a Blue Cross HMO in CA before we moved back to the midwest. I still have Blue Cross (Anthem), but since it's through CA, we have no choice but to take PPO.

I imagine HMOs vary considerably, but when I had their HMO they told me that transplant is treated as an entirely different beast. They have the 'center of excellence' requirement for transplant hospitals, which seems to be code for 'a center is excellent if they will cut us a deal.' Blue Cross is a big company, so I think almost every center is on that list, and therefore will be an option for you.

Double listings were a bit of an issue with them. I was in LA, so they wanted me to go to an LA hospital, but my first choice was UCSF. There was a clinical trial there that I was interested in, and they said so long as the hospital is doing something that others are not, I could get approved there, and I was. I had to talk to the HMO administrator first, and then Blue Cross itself - something like that. They told me what to do at each step, and it actually only took a month or two. I was also interested in a clinical trial at Mass General, and they approved me for that, but the paperwork got jumbled. They ended up approving me for the procedure, but at Cedars, who were not doing that particular trial. I gave up on Mass General because I didn't qualify for their trial for medical reasons anyway, but I think they would have let me do it.

The HMO approval was actually easier for me than when I switched to PPO with them and had to start over. The HMO administrator, or whoever that was, was really competent and on top of things and I was able to ask her about every scenario. I mentioned to her that I was already on the list, and was concerned that I might get a call while waiting for approval - could I accept the offer? She said that yes, you can get retroactive approval for procedures like that, but it is clearly infinitely better to avert that hassle and get pre-approval.

I know nothing about how they are with dialysis. Good luck.

[chiefsfan301]

I'm new at all of the things connected to dialysis and the insurance companys roll, I thought that when you started dialysis you were enrolloed in medicare and they pick up the bills. Set me straight.

[cariad]

Medicare pays 80% if you have no other insurance or they are your primary. I believe this is true even for dialysis - you will be responsible for the 20% if you don't have another plan.

Most transplant centers won't accept you as a transplant candidate if you only have Medicare. You will need to either have private insurance, eligibility for extra aid (Medicaid) or be able to show that you can afford to pay the 20% out-of-pocket.