Question about marketplace insurance vs. private. My husband and I are partners in our own business so we got on a family marketplace plan this year after much due diligence on my part to ensure our providers were in network. We found out the hard way that just because some hospitals in a health network are covered, doesn't mean all are covered. This was upsetting to us because having both worked for the large health networks around us, we know where you go for procedures matters. I did a search of all marketplace plans for the 2 hospitals we prefer and NONE are in network. I got an email recently from an insurance broker who quoted me a price for Anthem BCBS that is a few hundred dollars cheaper a month than our marketplace plan including subsidies. There is a small deductible that I don't have with the marketplace plan and some limits on how often we can utilize a service but this would be OK with me if we could go to the hospitals we prefer. I'm also worried the healthcare subsidies will go away next year so finding a cheaper plan puts me a bit at ease. Is there anything I need to be super aware of with private plans? I'm curious how a private plan could be cheaper than a marketplace plan which is what is making me wonder if it's too good to be true. Thanks for any insight you can give!

Hi all, Hoping someone here can help me make sense of this or share advice on next steps. I recently had a BRCA genetic test done through Labcorp. Before the test, I received an estimate of $43.17 and got pre-authorization from Anthem. Everything looked good, so I went ahead. Now I’ve received an EOB from Anthem denying the claim. They say I’ve reached my “once per lifetime” limit for BRCA testing—and they’re expecting me to pay $3,000 out-of-pocket. I called Anthem, and they said the correct CPT codes were used and the denial is based solely on the lifetime limit. But I have never had BRCA testing before. It’s my first time. Anthem is now reviewing the case, but I’m trying to understand what might have gone wrong. My theory is that their system may have logged the pre-authorization itself as a completed test, and when the actual test was billed, it triggered the “second” test denial. Has anyone seen something like this happen? Thanks in advance!

What am I missing here? It looks like Anthem BCBS is acknowledging my provider is in-network and then processing it as out-of-network. * Provider has been processed as in-network for visits both before and after the visit in question, always with a $30 copay and no balance. This was another routine, non-emergency visit with the exact same provider. * EOB clearly says in big bold print that "Going to this doctor uses in-network benefits" and elsewhere has the words "(in your plan)" after the provider's name. * EOB shows no copay, a portion applied to my deductible, and a balance in the "Your total cost" column. * EOB gives a reason code: "015: The amount shown here is more than your plan allows for this care. If this was not an emergency, the doctor/facility might bill you for the difference between what your plan allowed and what the doctor/facility charged." How is this possible for an in-network provider? It seems this EOB is just contradictory on its face. I've been trying to get them to fix it, but haven't had any success yet. Any advice?

Hi, I'm trying to reduce the chances that the insurance company not counting the copay card payments toward my deductible or out-of-pocket maximum. Does using their specialty pharmacy make that more likely? In other words, are they more likely to side with the insurance company? I'm with Anthem through the exchange, and their specialty pharmacy is Carelon. I read that accumulator programs have been banned in Nevada starting in 2025, but even the representative I spoke with at Carelon said that's not the case. thanks Matt

Hey everyone, I'm currently living in CA and am on an Anthem Select HMO through my employer - my entire family (wife, daughter, me) are covered under this plan. My wife is currently pregnant with #2 due in September. However, my family will be moving to Pennsylvania in a couple months, and I will likely be staying with my same employer/plan (this is still to be confirmed but seems like it'll be the case). However, the Anthem Select HMO does not have coverage in the area we will be moving to, but the company also offers PPO options that do have coverage in the new area. Will moving across the country, at which point my coverage would essentially be lost, count as a qualifying life event and allow us to switch to the PPO coverage? I tried to reach out to the insurance company, but they said they can't make that determination. Is it a state requirement that determines it? If so, would it be CA state or PA state that would take precedence? I'm waiting to explore further with my company until it's for sure that I'll be staying with this employer as we're kind of keeping it on the hush-hush until it's official. Curious on your guys thoughts.

After a surgery consultation, my doctor submitted a pre authorization request to my insurance, Anthem (North Carolina). I believed it had been sent on March 17th, so I called my insurance to check the status last Friday. However, there was no record of any pre-authorization being sent. This turned into the insurance calling the office, and they confirm it was sent March 24th (so it is confirmed by both the office and the insurance rep who called). Now today, I called to make sure the information had been updated, and that the pre-authorization had officially been received. Once again, they say there is zero record of any pre authorization. This is my first time having to go through this process, and I'm just super confused. I know the expected date to hear back is within 15 days, but I at least thought the request would be on file. I don't want to have to call again, but I'm getting worried that the request won't show up in the Anthem system. Plus I can't schedule surgery until this is approved, and I need it done this summer so the longer this takes the more nerve wracking it is. Basically, is it normal for my insurance to have no record of this pre-authorization request 14 days after it was sent?

Hey y'all This is my first time posting here. I am going to be starting a job here soon where I need to get my pre exposure rabies vaccine prior to starting. The issue I am having is my health insurance (Anthem blue cross blue shield) doesn't cover it and it is gonna put me down like $800 with finical compensation from my employer. I live in Kentucky. I was wondering if anyone has any advice or ideas of ways I could try to get that price down. I'm not sure of theirs any good answers but figured I would ask. Thank you all.

Hey so I buy my own medical, dental, and vision insurance from Anthem rather than going through my employer. For the 2nd time, Anthem has decided to drop my medical coverage without telling me. The last time this happened, I had to get on the phone for 1 1/2 hours with them and they still couldn't identify why they dropped it. Instead they gave me some bullshit reason - "our records say you already had an active plan so we dropped this one". I don't have any other active plans. I'm 100% sure of this. I had to go through the re-application process again in December and purchase new medical coverage. Fortunately, I'm young and healthy so this isn't hard to do but it's deeply frustrating and I had to push my yearly physical forward because of it. Fast forward to now (April), I log into the Anthem portal and I see medical coverage is dropped again as of March 1st. Vision and Dental are still active but Medical is inactive. I tried calling them today (Sunday) but of course they only work M-F 8am - 5pm. The frontline phone operators are useless. ChatGPT does a better job than them. Has anyone else had this experience? What was the resolution? What can I do to prevent this moving forward?

I have medi-cal through anthem blue cross in association with LA care health plan. I have never had Medicare part B. I had a ultrasound in october 2024 which was approved by my primary care provider. I just got a letter today from the centers for medicare and Medicaid services, fargo ND. It is saying that the ultrasound was not approved and i may be billed 220$ It also says i have not met my part B deductible of 240$ Again, i don't have medicare part B. Im not experienced with these insurance issues. I dont know if medi-cal already paid this or not, it's been almost 6 months. Is this medicare preparing to bill me for services already paid by medi-cal ? Thank you, input appreciated.

My daughter is going through a lot of PT/OT that is being billed via a local hospital outpatient center. I talked to the insurance company administrator for this portion of my insurance and I ensured that the provider (hospital) we were going to would be treated as in-network (see \*\*\*\* paragraph below, as they guaranteed it and I couldn't find a provider that would do this within 30 miles of my home). To do this, they had to negotiate and worked out an agreement. On top of this, the provider has to get pre-authorization in blocks of visits so no visit has occurred without someone at the insurance company pre-authorising these. My certificate of coverage does say that I do have PT/OT benefits but there's two kinds of it, one that is based on a hospital stay and one that is based medical necessity . They both have the same copays and costs, so it shouldn't matter but regardless, there are two ways one can get PT/OT via my insurance plan. The provider has submitted these PT/OT requests to the hospital administrator Anthem. Anthem has rejected these with the code: "\*00NYP Your policy will cover this service only if it follows surgery or a prior hospital stay for the same condition. Please refer to the section of your contract or benefit booklet that describes the coverage for this type of service." \*\*\*This is what my certificate of coverage at a glance says about CT/PT/OT: "Chiropractic Treatment, Physical Therapy and Occupational Therapy Network Coverage Each office visit to a network provider, including related radiology and diagnostic laboratory services, is subject to a single $25 copayment. No more than one copayment per visit will be assessed. MPN guarantees access to network benefits. If there are no network providers in your area, you must contact MPN prior to receiving services to arrange for network benefits. Therapy must be prescribed by a qualified provider." AND "Physical therapy following a related hospitalization or related inpatient or outpatient surgery is subject to a $25 copayment per visit. Physical therapy must start within six months of your discharge from the hospital or the date of your outpatient surgery and be completed within 365 days from the date of hospital discharge or outpatient surgery. Medically necessary physical therapy is covered under the Managed Physical Medicine Program when not covered under the Hospital Program (see page 12)." From looking at how they are capitalising things, I believe Managed Physical Network/MPN is yet another administrator for PT/OT like United Healthcare, Anthem, and Carelon for medical, hospital, and behavioral. Am I right? So they are not sending it to the right place? Or it is coded incorrectly? I'm wondering why this provider is having so much trouble getting reimbursed the right away since there's been a lot of communication already with SOMEONE and it should all be set.