Last month in BI 003: HMO vs PPO, I thought I made the clear-cut choice for my family health insurance plan by going with HMO. After a month of struggles, I may not be so sure. I know with a HMO, I need a primary care physician (PCP) first who would recommend me to a specialist if the need arises. Since my wife is pregnant, Cigna allows us to select an OB/GYN without a PCP’s referral, or that’s what I thought.
Since we were starting from scratch, we started our search with the hospital we wanted to deliver in. We found the perfect one, one city over. We then scrolled through their roster of doctors and found one that we liked. Simple right? Wrong.
I called up the doctor to schedule an appointment for my wife. The office manager asked, “What medical group are you with?” I smugly answered, “Cigna HMO”. She fired back, “That’s your insurance, but I need your medical group!” After some back and forth, apparently I still needed to track down a PCP, who belongs to a medical group. The PCP and the OB/GYN need to belong to the same medical group to be considered in network. I thought I was a smart guy when I suggested she give me a PCP that they use. Viola!
Although the OB/GYN can deliver at the hospital we selected, it will not work for HMO patients, only PPO. Wow. You get what you pay for.
After a few days, my wife and I decided to switch OB/GYN’s because we only chose the first OB because of her connection to our favorite hospital. In talking to my Cigna rep, the PCP that was referred to me for the first OB would have been out of network so it was very fortunate I called. They belonged to the same medical group, but in different cities. Wow.
After selecting our second OB who was more experienced and had better ratings, I had Cigna match the OB with a PCP in the same medical group. Cigna would make the change to my wife’s PCP. Finished? Not so fast.
Transition of Care
On a Monday, Cigna’s transition care specialist called me up and wanted to discuss two items. She noticed the last PCP we chose was in a city very far from our home. Before she made the change she wanted me to understand that the hospital we would be able to deliver at would also be very far away. Insanity! Secondly, the specialist offered me the transition of care option. In special cases, when a customer switches insurance or if a doctor leaves the network, a customer can file for transition of care, within 30 days, so they can continue to use their current doctor or specialist and have then temporarily be in network. Please check with your insurance company to see if this applies to you.
There was additional stress because my wife needed to get her monthly exam soon. Jumping through all these insurance hoops, I felt we wouldn’t be able to find a doctor for her in time. The transition specialist followed up and found a PCP in the same medical group and the same city as our new OB/GYN. If you are going through similar struggles, your best bet is your insurance company. Doctor office staff are usually the last to know. Our first visit is the first of the month so this saga will be continued. Holy HMO Batman!