I was just informed yesterday that my insurance company has adopted a significant new change for next calendar year.
They have decided that they will now will NOT cover the first $7,500 for surgeries conducted by non-preferred providers. This is independent of the "catostrophic limit" included in the plan. My surgeon is not a pref. provider, and in fact there are no such preferred providers in my State (Alaska) for spinal surgery. There are some orthopedic surgeons on the list, but none for spinal issues.
They would cover a share of the room charges, assistant surgeons, anesthesiologist, etc. But the surgeon fee would have to exceed the $7,500 for them to pay anything.
I am at the tail end of an "open season" at my work (ends in less than a week), and I could change to another company, but there aren't very good alternative choices. The other company I'm seriously considering has abysmal ratings (50ish percent satisfaction) vs. my current company (80ish percent satisfaction). And the alternative company only will cover 20 PT sessions per year, vs. 70-75 sessions for my current plan.
I'm currently in PT regularly (about once a week)for my cervical issues and so I'd burn through PT sessions in the new plan fairly quickly. So those expenses would be reasonably certain, whereas the surgery is more "iffy."
The current treatment plan is for me to continue PT and home therapy using a portable cervical traction device. The surgeon and physical therapist hope this will help me and I can postpone a 3-level cervical fusion. I may need that eventually, but right now I'm living day by day and watching for signs of myelopathy, or an increase in radicular pain.
So I might not need surgery this year, but if I did, that is a huge financial bite. On top of the $7,500, I'd have the other relevant deductibles, catostrophic limits, etc. So the total bill would exceed that amount.
This is really maddening. Does anyone have advice on a situation like this? If there are no preferred providers within 100 miles (in my case, there probably are none for more than 2,000 miles), would I have any basis for appeal should I require surgery?
Or if I had to travel out of State to access a preferred provider, should surgery be necessary, is it likely they would pick up some of those travel expenses for me and my family?
Assuming those are not options, it seems my choices are:
1. Switch plans, but almost certainly pay for PT expenses once 20 visits are exceeded.
2. Stay with my current plan and roll the dice that I won't need fusion surgery this year.
Gotta love our free market, deregulated health care system. Seems they can change the rules with impunity.
Any insights or advice would be appreciated !