My friend does not know what to do
 

Okay, so far here is her story.

She's a woman in her 60's on SS Disability. She has an HMO. She has a lot of health issues, various conditions and is in the middle of going for tests, biopsies, etc. etc.

She was just told that ALL of her doctors are no longer in her network. They did not give her any notice. They just said "As of March 1, we are not in your network and if you come to us you have to pay"

Like I said, she is in the middle of all testing and such, needs more biopsies, and even her health care provider is not in her network anymore. Her prescriptions will soon run out.

I told her "you need to get a new health care provider immediately". Then you can deal with the rest of the stuff. You need to be able to get your prescriptions written". I then said "I don't think what they are telling you is legal, but I will post your problem on the forum and see what answers people come up with'.

So I think she needs to call a lawyer or advocate to advise her what her rights are.

She lives in Brooklyn, NY. Does she call the ACLU? She did call customer service for her HMO but she said they are useless and told her "you need the numbers of your providers?" ?????????????

What the heck (if anything) can this woman do? Does she have any recourse? Can these doctors who went off network, well can they bump her off like that? She has no rights here?

Any info will be helpful

Melody
P.S. I told her to write me a detailed explanation of what she was telling me so I could post here but until I get ALL the stuff, I figured I would run (what I do know) by all of you.

Who can she call?

Thanks very much

Melody

Hi Melody
 

I feel so sorry for your friend. Unfortunately it is happening alot in this country;. Including in the medicare/medicaid area. Doctors aren't getting paid enough so they drop their patients.
If your friends Docs. are not in the HMO, they can do this. It may not be moral but they can. To find a new doctor quick, have her call her local hospital advocasy gourp. Almost all big hospitals have such an organization. They may be able to provide a new physician referral. Also the doctors she had, if they care at all should provide a referal to someone they know.
Womens resource centers also may have ideas to help. They too are in most big cities, even in local communities. Lastly there are the clinics, that are based on your finances, some are free clinics.
The important thing is for her to find a new PCP right away. As that is the doctor who makes suggestions on what specialists she may need.
I sincerely hope your friend is able to find a quality, compassionate doctor quickly. She must be very upset. You are a good person for trying to help her like this. I will keep both of you in my thoughts. ginnie:grouphug:

I hope she finds another doctor soon. That's just awful that they can drop patients like that.

One question......are they under any obligation to forward copies of her medical records to the new doctors? Seems like if they elect to stop treating her they'd have to send the records to the new doctor.

Hi Kitty
 

It is my understanding in a situation where the doctor denies a patients HMO, that they do return the records to the patient. Also they can forward the records to the new doctor. A patient has the right to all their records. I sure hope it works our for our friend here. ginnie:grouphug:

When is her birthday? I'm assuming you're talking about her supplement for Medicare? Do her current docs still accept Medicare? (She's not receiving Medicaid, correct?) Would she just have to go out of pocket the 20% difference? Testing and the like shouldn't be a problem, although she may have to go to a different lab.

She is on Social Security Disability and has a Medicare Advantage plan, hence she is using an HMO.

Melody

http://www.medicare.gov/sign-up-chan...#collapse-3192

She can disenroll now if she wants, but will have to wait until next year to change plans.

If she has limited income, she may qualify for Medicaid. Most states have a website that will allow her to check to see if she qualifies.

If she doesn't qualify for Medicaid, and can afford to spend a bit on a Supplement, I'd highly recommend switching during open enrollment if she has serious health issues.

So let me see if I got this right. She can disenroll from the HMO she is now on. But she CAN'T get into a different HMO until next year? Then what will she do for coverage. She is a special case under SS because she was screwed in her benefits under a former mayor's term in office. She explained it to me but it was so complicated I never understood. She does not get a lot in SS, she has a roomate and she is going through lots of stuff. So I think her best bet would be to get an advocate, get a new primary care doc in her plan and let him refer her to all new specialists. Did I get this right?

Thanks so much

Melody

She'd still have Medicare, part A & B, she just wouldn't be enrolled in the HMO. (I'm making an assumption here about her plan.) So she'd have to go out of pocket 20%. Does her current plan include prescriptions? That might complicate things further if she doesn't have a separate plan.

If she has very little income, then she very likely qualifies for Medicaid. In CA she would. Many people that qualify don't bother applying. That's where I would start.

And, they probably sent her a huge booklet a few months back letting her know which docs would be eligible and which wouldn't. The kind of thing most of us ignore, so I doubt her rights have been violated. She needs to figure out how important it is to her to stick with her current treating docs. Will this docs accept Medicaid if she qualifies, etc.

it sounds like she went to the same group for her gp and specialists and the group as a whole dropped that insurance.

insurance companies put lists of participating doctors on their websites now.
if she cant get to see a doctor before her prescriptions run out, i would insist that the doctors who are dropping her give her a refill to hold her over until she can get a new gp. they arent suppossed to just leave you in the lerch. i would make noise about filing complaints with ny state if they dont comply.

Look up the benefits of the HMO plan she is in online. Many HMO's provide nursing case management for complicated medical cases. That could be one person on the inside, trying to help her find new coverage for all of her needs.

Best of luck. What a difficult situation.