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Switch to HMO in 2017

Had to switch to HMO this year and say bye to my ortho and PM. Scary? Yes. 

First of all, it was hard to find an HMO GP. All said they're not taking new patients. Never seen that before I'm used to PPO insurance. Every doc takes my call. Anyway, finally got a GP and she referred me to a PM. Finally saw him last week and he kept me on the same meds. No questions asked. Yippy!!!! I have to seen him each month. My old PM was every 2-3 months. It's a very long drive but happy to do it if I can keep my meds. 


  • SavageSavage United StatesPosts: 7,248
    Very good to hear it worked out for you!
    I have always had to see my PM doctor monthly. It may depend in your meds or other treatments...or doctor policy...I really don't know..
    But as you said, small price to pay to continue with pain under control!
    Spine-Health Moderator
    Please read my medical history at: Medical History

  • AkiraAAkira Redlands, CAPosts: 75
    edited 04/01/2017 - 3:19 PM
    HMO monthly payment for me is $763.00 monthly for a 62 year old male.  I need to see my PM doctor monthly for my meds and my co-pay is $65.00 each visit, for that matter any doctor I need to see.  RFA, epidurals, etc.  all come with co-pay of hundreds of dollars since I haven't met my $6000.00 deductible.  I had to got to the ER few months ago for my back, of course they ran all kinds of tests.  7 hours ER stay, my co-pay was $1238.56.  I called the hospital for a copy of the bill, she stated it was $16,760.00.  So, I keep making my monthly payments.  I live in Redlands, CA.  I have another MRI next week, co-pay $200.00.
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  • jimandjrjimandjr Dallas TXPosts: 453
    edited 04/02/2017 - 6:48 PM
    Thanks for the comments, Savage and Akira.

    My HMO monthly premium is $14. Copay to see a GP is zero and a PM is $10. I have a max out of pocket for 2017 of $1250. My scripts are anywhere from a dollar to $15 for my Lyrica. Monthly script prices will be just under $25. I feel very lucky to have found this HMO plan. For the low price, I had to work hard to find doctors but I was able to get to a new PM. 

    Akira, sorry for your high bills. That is so sad. I have been there so I know how it feels. Told my ortho, one time, that my cervical MRI was $7k. He said I hope you did not have to pay all that." I paid $700. It hurt bad. It was out of network. He would not let me go in network. I'm sure he got kick-backs for steering patients out of network. Sad. He is no longer my ortho. Let him go in 2012. I'm in Dallas TX so I'm sure my docs don't cost as much as CA docs. 
  • itsautonomicitsautonomic LouisianaPosts: 2,294
    A lot of the problems I see people having on Obamacare seems to be same issues many workers comp cases saw in past.  Doctors won't accept WC case, high out of pocket , long waits , etc.  I am sure it's more but it reminds me a lot of my mothers issues with workers comp.  is this the reason you switched to HMO?
    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • jimandjrjimandjr Dallas TXPosts: 453
    I live in N TX and all the PPOs have left Obamacare since they were losing millions. I went through all of them. BCBS, UHC, and Scott White Baylor. HMO was the best option for me since no more PPO plans. It has been a struggle to get through the system. I have not had a PPO since the 80s. With a PPO, I can go directly to the specialist with no questions asked. I worry about having a PPO procedure. I am used to 8 to 12 spinal procedures a year. I had an SCS installed in November hoping that I would need no procedures this year. I have already discussed ablations with my new PM. We will probably start those soon. I worry that all docs in the op room will not take my HMO plan. We'll see. 
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  • jimandjrjimandjr Dallas TXPosts: 453
    Last year, my PM decided not to take any ACA patients. However, since I was on a Baylor PPO plan and he was a Baylor doctor, he decided to take me. Baylor Scott and White is gone, this year, so I was going to lose my PM this year anyway, so I decided to go with a cheap HMO plan. My GP made me pay for 4 xrays to prove my spine surgeries and SCS install. That was weird since all of that was in the medical records that were trf'd from my ortho and PM. Probably a money grab. Just 40 dollars. Not too bad. 
  • jimandjrjimandjr Dallas TXPosts: 453
    when you are a spiney, the most important number when shopping for insurance if max out of pocket. Of course, the monthly premium also. ACA has many plans, each year, where the max out of pocket is $1500 or less. I usually reach this number in March or April. After that, my PM is very aggressive. We do lots of procedures. We also get compound pharmacies to whip me up some pain patches and pain ointments. These come to me, via, FedEx, many times a month. My PM also orders as many as he can at the end of December. Why not? The insurance pays 100%. Not sure I will ever find a PM as good as my last one. He is also the only PM I have ever had. Started a new one this year. Not sure he can measure up but I'm happy just having a PM at this point. 
  • AkiraAAkira Redlands, CAPosts: 75
    Thanks Jim, you're getting care and not getting wiped out on dollars is good.  I want to try alternative care (acupuncture, chiropractic) and that's not covered under my HMO.  Just went to the pharmacy to pick up my oxycodone and gabapentin.  Some mix up with me showing no coverage, UGH!  I had to pay $260.00 for the oxy and $239.00 for the gaba.  I called United Health Care and was told they will send me the forms for reimbursement, which with the proper information filled out with receipts from the pharmacy I should be notified on the reimbursement in approximately 4-6 weeks.  It was a clerical error on their part, but the chronic pain sufferer me the customer has to deal with their clerk inputing a wrong code.  It's never easy!
  • jimandjrjimandjr Dallas TXPosts: 453
    Yikes. Sorry that happened. If only you had some spare pills to get you through a few days so they could get their records straight before you picked up those scripts. I switched back to Lyrica from gaba this month. Lyrica was $15 vs $2 for gaba. I feel Lyrica does a better job. It can mess with my head a bit but it's worth it. In the past, I have paid hundreds a month, for Lyrica, because it works. 

    Having no med coverage is THE scariest thing for us. Trumpcare worries me a lot. I have depended on Obamacare since it was introduced. I hope to get at least one more year (2018) out of Obamacare. 
  • AkiraAAkira Redlands, CAPosts: 75
    Jim, you wrote you switched back to Lyrica from gaba.  How long where you on gaba and the dosage?  Also, did you slowly wean off the gaba?  My PM did give me some samples of Lyrica last visit, but I have not tried it.  I am currently on 800mg 3x daily of gabapentin.
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