Ok health insurance gurus - I need advice

[creekland]

Our family does not have to worry about health insurance since we're with a health share group we love...

 

BUT, my mom (in her 70s) has health insurance from the school she retired from.  Their plan recently changed with the ACA.  I'm thinking she doesn't understand it correctly, but I honestly don't know - therefore - I'm asking the Hive.

 

The situation (over with - last week):

 

On a weekend (naturally) her eye suddenly had lines going through it and was difficult to see out of (very short version).  She and her sister figured out something was bleeding and she was seeing blood.  So... she drove three hours home. (Those of you who know me and medical stuff can use this to figure out where my genetics come from.)

 

When she got home she called me to let me know.  I suggested the ER (yes, I CAN suggest these sorts of things sometimes) to see if it was anything that needed immediate fixing or could wait until the eye doctor on Monday.

 

She refused telling me that her insurance no longer covered ER visits unless they "keep you" and she didn't think they would for this.

 

What, I asked?

 

It's an ACA thing/change (she told me).  They'll cover ER visits if it's truly an emergency and they admit you, but not if they decide it isn't an emergency and send you home.

 

I can totally see this for someone who shows up there with a sore throat and wants Tylenol... but for her eye issue?  How is she supposed to already KNOW if it's an emergency or not?  What about those with chest pains?  What if someone has flu like symptoms, but is also wary of meningitis and isn't sure?

 

Are these folks really on the hook if they guess "wrong?"

 

I don't believe it's true, but I need some sort of "ammo" to answer her with and have none.

 

Does anyone else have something I can use should something like this happen in the future - she's in her 70's, so it could!

 

FWIW, she waited to go to the eye doctor last Monday and it wasn't an emergency - she was correct.  A membrane had torn loose (she was seeing blood), but it would heal itself.  But she didn't KNOW what it was until then or that it could wait.  Would she have been on the hook for the ER visit if she had followed my advice?

 

If that's really true, it's kind of scary, but I still can't believe that's the way it is - is it?

[Jennifer in MI]

I'm certainly not a guru, but my policy will waive my co-pay if I'm admitted through the ER.  If I'm sent home, I owe a $200 co-pay.  Maybe she's confusing the two?  They'll cover it, but she'll owe a little?

[chiguirre]

I think it must be something like Jennifer said. You have to go to the ER if you break a bone, but it's very likely they'll put on a cast and send you on your way. You can't wait to Monday for that. Will your mother let you read through her benefits statement?

[Susan C.]

Get the care you need first, figure out the rest later. Especially since its her eye sight!

[redsquirrel]

My pre-ACA insurer would not cover the cost of a non-emergency ER visit if we had an ambulatory clinic available to us.  My new post-ACA has the same policy. We do have one in town, run by the hosptial, that is open almost all the time so it isn't an issue for us.

 

Before I was married or had kids, I remember a married friend bemoaning the fact that her insurance wouldn't cover a midnight visit to the ER for her toddler's ear infection, and that was during the first Bush administration. They denied the visit on the basis of it not being an emergency.

 

So, she might be correct but it might not have anything to do with the ACA. I know that isn't very helpful to you and I am sorry. Is there a chance you can look at her policy? I know every January I get a mailing from my carrier with a single sheet chart that details what is covered and under what circumstances. But, that might be because of the employer or it might be a NY thing.

 

And my pre-ACA carrier ( Aetna) denied coverage for my son's premature birth and NICU stay. I really can't think of a bigger emergency. They claimed I had gone 'out of region' even though my local hospital didn't have a level one NICU and directed all premature labors to the place I ended up. They refused to cover the birth or his stay in the hospital.

[Caroline]

My pre-ACA insurer would not cover the cost of a non-emergency ER visit if we had an ambulatory clinic available to us. My new post-ACA has the same policy. We do have one in town, run by the hosptial, that is open almost all the time so it isn't an issue for us.

 

Before I was married or had kids, I remember a married friend bemoaning the fact that her insurance wouldn't cover a midnight visit to the ER for her toddler's ear infection, and that was during the first Bush administration. They denied the visit on the basis of it not being an emergency.

 

So, she might be correct but it might not have anything to do with the ACA. I know that isn't very helpful to you and I am sorry. Is there a chance you can look at her policy? I know every January I get a mailing from my carrier with a single sheet chart that details what is covered and under what circumstances. But, that might be because of the employer or it might be a NY thing.

 

And my pre-ACA carrier ( Aetna) denied coverage for my son's premature birth and NICU stay. I really can't think of a bigger emergency. They claimed I had gone 'out of region' even though my local hospital didn't have a level one NICU and directed all premature labors to the place I ended up. They refused to cover the birth or his stay in the hospital.

What? Did you get that fixed? That is insane!

[creekland]

She might let me look at her policy, but we live 8 hours away from each other, so visiting doesn't happen often and she comes here more than I go there.

 

I know her insurance used to cover everything and anything, so she never was concerned.  She has a deductible and OOP, but always meets that pretty early in the year as she has a bit of prescription meds due to diabetes and other things.

 

Now (she tells me) that ER visits are only covered if they are admitted there.  They are not covered at all otherwise. They had a meeting where they explained the changes, so maybe she's right...  It's just difficult for me to imagine that an average non-medical person is supposed to know the difference when it's something out of the ordinary, so I guess I was hopeful that she had interpreted something incorrectly.

 

We have local clinics around here that have late hours, but to my knowledge, there are none around her as she lives more rural than we do.

 

Whether it's ACA or not isn't my issue at all.  She said they were told that was the reason the policy had to change, but chances are it was just as likely due to cost cutting in general - or cost cutting in that area to cover other areas that had to be added or whatever.

 

I mainly want my mom to feel she has the freedom to go to the ER when something like this comes up without having to sit at home and try to contemplate if it's "bad enough for them to keep me."  I did get her to call and ask when it happened, but all they said was they couldn't determine anything over the phone.

 

Medical stuff is far from my specialty unless it's equine vet related... so calling me is worthless for advice medically.

 

I guess next time I'll just have to tell her to go anyway and we'll cover the bill if needed.

[zoobie]

Have her sign a waiver so you can call the insurance benefits line or call them 3-way. Many true emergencies wouldn't result in admissions, so that seems unlikely. There may be a higher or separate deductible for emergency visits. It's not a provision of the ACA, but if you make an unpopular change, the ACA is where you place the blame right now.

[maize]

Can you find out the name of the policy? There should be a website with plan coverage details. The web address may be listed on her card.

[justasque]

Find out if she has access to a nurse line she can call to help her decide where to go for a particular ailment.  See if her primary care physician has an after hours number too.  And find out whether there's an urgent care type place that would work for times when she doesn't need an ER but does need to be seen.  Having this info ahead of time can help you both to decide how to proceed in a crisis situation.

[mommybee]

My policy last year was $1000 for an ER visit unless we were admitted then it was waved. Screwed us up pretty bad when Urgent care wouldn't take us with 30 left until closing and we didn't realize the new copay or we would have waited until the morning.

[Calm37]

Just wanted to mention that my eye doctor has an emergency number. Perhaps that would have been someone that she could have called for help?

[creekland]

I worked for 2 different insurance companies.  When they tell you they don't cover non emergencies at the ER there is a ton of lee way in terms of what is defined as an emergency.  Pretty much anything other than routine.  I would be surprised if they outright do not cover ER visits unless a person is admitted.  What they might do is waive a copay.  So, yes, ER visits might be expensive. 

 

I only one time came across a claim I denied as ER.  The code said the patient came in for a sports physical.  It could have been coded wrong, but that is surely not an emergency.

 

Does she have the policy details?  Maybe you could look at them?  I do think a lot of people misunderstand their policies.

 

This is what I am hoping for.  I would think something like this has to be the case, because one isn't admitted for broken bones, but they are emergencies.  Is there a middle ground - or is it still that they have to "do" something?  If it's the latter, that still wouldn't have helped her.

 

Can you find out the name of the policy? There should be a website with plan coverage details. The web address may be listed on her card.

 

I'll ask.  That's a good idea.

 

Find out if she has access to a nurse line she can call to help her decide where to go for a particular ailment.  See if her primary care physician has an after hours number too.  And find out whether there's an urgent care type place that would work for times when she doesn't need an ER but does need to be seen.  Having this info ahead of time can help you both to decide how to proceed in a crisis situation.

 

She did check with a couple of these and was told if it's an emergency to go to the ER.  If not, wait.  No one would give her their thoughts/leanings either way.

 

My policy last year was $1000 for an ER visit unless we were admitted then it was waved. Screwed us up pretty bad when Urgent care wouldn't take us with 30 left until closing and we didn't realize the new copay or we would have waited until the morning.

 

This is what she tells me will happen - except I think she said $1200 or $1400.  She would have been correct with this eye issue I'm guessing at this point - and it's rather disturbing TBH.  I just don't think the average person can know which side to "guess" when things are out of the ordinary.  Sports physicals, yes.  Sudden eye bloodiness - no.

 

Just wanted to mention that my eye doctor has an emergency number. Perhaps that would have been someone that she could have called for help?

 

Her eye doctor was one of the calls she made (mentioned above).  They essentially wouldn't give any advice via the phone other than to go to the ER if she thought it couldn't wait until Monday.

[Twigs]

Several years ago (pre-ACA) I had a retinal hemorrhage (sudden partial blockage of vision in 1 eye). Since I didn't have a regular primary doc or ophthalmologist, I went to the ER. The doctor there could not.see.anything.at.all wrong in my eye. He did arrange for me to see a local ophthalmologist who referred me to a retinal specialist. I ended up having surgery the next day. My insurance did cover the ER visit, but now that I know that the ER cannot deal with a retinal hemorrhage, I would not go back to an ER for that.

 

Best wishes for you and your mom.

[Danestress]

Isn't your Mom on Medicaire? She should be able to go to an ER and be covered by Medicare even if her supplement requires a larger co-pay.

[creekland]

Several years ago (pre-ACA) I had a retinal hemorrhage (sudden partial blockage of vision in 1 eye). Since I didn't have a regular primary doc or ophthalmologist, I went to the ER. The doctor there could not.see.anything.at.all wrong in my eye. He did arrange for me to see a local ophthalmologist who referred me to a retinal specialist. I ended up having surgery the next day. My insurance did cover the ER visit, but now that I know that the ER cannot deal with a retinal hemorrhage, I would not go back to an ER for that.

 

 

She knows now that the ER can't help with what her issue is, but that's hindsight.

 

My concern is that average non-medical folks need to know ahead of time about all sorts of issues - or take their chances that they might end up paying quite a bit if they guess incorrectly (or paying with delayed medical care and its consequences if they guess incorrectly by staying home to save costs).

 

It just doesn't seem "right" that they need to guess.

 

 

Isn't your Mom on Medicaire? She should be able to go to an ER and be covered by Medicare even if her supplement requires a larger co-pay.

 

Not that she's told me, but maybe?  I haven't asked.  This is literally the first time any issue has come up where payment for medical care is an issue and I was stunned at what she told me.  I've been mulling it over in my mind all of this past week - mainly thinking it just didn't sound right - then thought I'd ask the collective wisdom of the Hive.  Tomorrow I'll talk with her again and I was hoping I might be able to suggest "other" info (sort of hoping I'd be able to tell her she was incorrect to be honest) - just in case something else came up in the future that was "iffy."  Right now she's glad she made the correct decision and we're both glad it ended up not being serious, but what if next time the "something" is serious and she needs to make a determination?

[Twigs]

… It just doesn't seem "right" that they need to guess. … 

:iagree:

[QueenCat]

Ours is the same as it was before the ACA. We can't go for routine care, only emergencies. This is with Aetna but it was the same when we had Blue Cross/Shield. Basically, they wouldn't cover showing up with an ear ache or sore throat. Dehydration, broken bones, heart, lung, etc issues are covered even if not admitted.

[redsquirrel]

My problem with 'nurse lines' is that they will NEVER tell you anything substantive because they (the company that runs the nurse line) are afraid of being sued. If they tell you to go to the hospital and it isn't covered then you will have to sue to get your money. If they tell you not to go to the hospital and something happens then they are negligent.

 

Does your mom have a primary care provider? Because were I in her situation I would call her or him after hours and tell them what was happening (or their on call back up etc). A doctor is able to tell you to go to the hospital or not. And if your doctor tells you to go to the emergency room you can make a good argument to your insurance carrier.

 

Doctors are very used to being called after hours or on weekends. My dad was a doctor and his beeper was going off constantly. It is a totally normal thing for them and they don't get annoyed. If they do get annoyed then they leave the profession pretty darn quickly, lol.  Or they become a dermatologist (that is a very old doctor joke, btw).

 

 

 

[Catherine]

I think that asking people to "guess" is not exactly accurate...but I do think insurers are trying to discourage overuse of EDs in a lot of ways.  Since I spend a lot of time in the emergency room at work, I see the other side, which is that emergency rooms are overwhelmed with patients a lot of the time.  And at any given time, at least some of those patients do not have an emergency.  I think Americans may need to begin to change their thinking about how they approach medical care.  The idea that if you don't KNOW if something is urgent, you need to go in to check it out, is one factor in the overuse of emergency services.  And certainly during daytime hours one's first call should be to one's primary care office.  Chances are very good that if they cannot treat your problem, they can send you somewhere that can without using the emergency room. The reality is that people die ALL THE TIME because of delays in care that result from emergency room overcrowding.  There is good data to support this.  Truly, it is NOT just insurers that are trying to address this problem.

 

Here is an example. I've just in the past 2 days seen people who had dire, life-threatening problems like extensive burns, heart attacks, overwhelming infections.  But I've also seen a healthy person in their 20's with pneumonia.  Yes, I think that person was feeling lousy, upset stomach, bad cough, and a fever.  But IMO that is something that can wait for the urgent care clinic to open tomorrow morning.  Just for comparison, I talked to my friend who is a doctor in Germany.  She trained here with me.  Emergency rooms are quiet, seldom-visited places in Germany.  They are far smaller and employ a smaller number of people than emergency rooms here.  This is because people very rarely use them. They go to their doctor instead, for almost everything.   

 

I think that rather than people being expected to guess, they should be expected to use every resource at their disposal to avoid a trip to the emergency room.  Call the primary care office on call number for starters  Most primary care people have sufficient knowledge of emergencies of different kinds, including surgical or eye emergencies, that they can reasonably advise someone on the phone.  Contact the emergency line for the specialist in question.  Here in my city, there is an eye emergency room.  Not everyone has that available to them, but the equivalent in the form of a phone triage system almost always exists.  It's worth a call there is you have a question about whether something requires emergency care. 

 

I too was burned when my insurance did not fully cover an hospitalization.  We went to the closest hospital, instead of the in-network hospital (it was probably a 20 minutes drive further for us) when my son had appendicitis.  Is appendicitis an emergency?  In their view, not so much that we couldn't have driven 20 minutes longer.  I honestly think thery were right.  But it definitely behooves on to know exacly what is covered, and under what circumstances, before it comes up in real life. 

[creekland]

I don't actually know if she called her regular doctor.  I know she called her eye doctor and the ER and essentially was told to "make her own judgment" on the phone.  If she thought it couldn't wait, then she should go to the ER.  Otherwise, go see the eye doctor on Monday morning.  It was a Friday when this happened.  She had been visiting her mom (my grandma), it happened (afternoon-ish), she conferred with her sister, then drove three hours home.  She called me about 8 or 9pm that night, told me about her shaky drive and what had happened...  I suggested she call the eye dr and/or head to the ER to see if it was an emergency or not as neither of us had any clue.  I guess we could have used google.

 

She told me about the new coverage policy... then called the eye dr and ER... then called me back with their report and told me she was just going to wait until Monday.  Saturday and Sunday were no worse and perhaps slightly better. Monday she got in and found out what it was and that it would have to get better on its own.

 

So... she guessed correctly.  I'm seriously glad.

 

But what if next time she has chest pains and "isn't sure?"

 

Or something similar.   She's on insulin for her diabetes.  I can think of a multitude of things that could happen - on a Friday - in an area where there is no urgent care clinic.

 

I fully suspect my plan is going to be to tell her never to worry and we'll cover it if her insurance does not because she guesses incorrectly.  I'm not exactly worried that she'll head to the ER for her next sports physical - or the flu/cold/etc.  On the contrary, she's a bit more like me and would likely die of Meningitis or anything else that is fast acting due to "waiting to see" if it's necessary to do anything.  But at her age?  Things like chest pains?  If those were to happen, I don't want her having to guess.  I'd rather she didn't with her eye stuff too. 

 

Oh well.  Such is life I guess.

 

It makes me more glad than ever that we (ourselves - our family) don't have to deal with insurance and wistful that our country could change its ways.

[eternalsummer]

In a perfect world, I think it would make a lot of sense to have much more widespread urgent care centers, including many that are open 24 hours.

 

The thing is, there are a lot lot of things that might or might not need to be seen right away, but that (like your mom) most people can't assess themselves.  An urgent care center, ideally near a hospital, could work really well for those sorts of things, as well as taking care of all of the flus, strep throat, back pain, cut that needs stitches tonight but is not really worth $1000 and being seen by a doctor who is trained (and paid) to be able to save your life surgically, etc.

 

It is stupid for us to use ER care for these things; it is a waste of money, regardless of who pays.  A lot of the time, though, the ER seems like the only option, because the doctor can't see you for 24+ hours, and even though it's not a dying-emergency, it's still something that needs to be seen.

[creekland]

In a perfect world, I think it would make a lot of sense to have much more widespread urgent care centers, including many that are open 24 hours.

 

The thing is, there are a lot lot of things that might or might not need to be seen right away, but that (like your mom) most people can't assess themselves.  An urgent care center, ideally near a hospital, could work really well for those sorts of things, as well as taking care of all of the flus, strep throat, back pain, cut that needs stitches tonight but is not really worth $1000 and being seen by a doctor who is trained (and paid) to be able to save your life surgically, etc.

 

It is stupid for us to use ER care for these things; it is a waste of money, regardless of who pays.  A lot of the time, though, the ER seems like the only option, because the doctor can't see you for 24+ hours, and even though it's not a dying-emergency, it's still something that needs to be seen.

 

:iagree:  But in her rural area where the ER is literally never crowded, I seriously doubt an urgent care center will ever be built.  I'm glad we have ours around us though.  They are super useful when little things happen.

 

Our urgent care center has a sign telling people not to go there for chest pains though - they are supposed to head to the ER.

 

[QueenCat]

 

But what if next time she has chest pains and "isn't sure?"

 

Or something similar.   She's on insulin for her diabetes.  I can think of a multitude of things that could happen - on a Friday - in an area where there is no urgent care clinic.

 

Chest pains are an emergency. Always. No one at the er or insurance company would tell her differently.

[redsquirrel]

Part of this ER mentality stems from people not having access to health care. I was told approx 15 years ago (when I was working and I had professional interactions with my local hospital admin) that 85% of the people visiting the local ER were using it as their primary care provider. They didn't have insurance and they didn't have a doctor. Lots of doctors here won't see you if you don't have insurance. I can't think of anyone who will, but there might be one or two. But the ER can't turn you away, even if you owe the hospital money. So, we had a large population of people in our largely rural community who went to the ER for everything and just didn't pay or paid a small amount. Of course it ended up in collections etc. But, for a substantial percentage of the population, having large medical bills in collections is just a part of life.

 

The hospital did open up a walk in clinic and I am not kidding that it can deal with almost anything, even chest pains. It does x-rays and scans and bloodwork.  It charges 50$ for a walk in visit and then you have to pay for everything else on top of that, but it does try to keep cost somewhat affordable. I am sure there is still a percentage who cannot pay and keeps a running balance/debt.

 

There is  a significant number of people in town who claim it as their primary care provider. When I have had to fill out forms for my kids I see 'Convenient Care' listed as a primary care provider choice. It is staffed with ER docs who sign up to work for these companies that supply doctors and they move around from town to town. The docs stay in town for a 6 months or maybe a year and then are sent to a different city. Made it a right pain when we needed one to testify. We had medical records only to find that the doctor was now in Texas or Indiana and couldn't come back to testify.

 

The one good thing about the clinic is that now our ER seems to be pretty quiet. I had to visit a few times with my younger son. Turns out when your toddler faints for no known reason you get seen by an ER doctor Very, Very Quickly, lol. But all the times we had to go the ER was empty. I asked and was told it was quieter now that the hospital was providing a primary care clinic. The staff there was better able to deal with actual emergency cases. If someone walks in during hours when the clinic is open with a primary care need they will be told to go to the clinic.

 

There is stuff the ER does do when the clinic is closed. They have a walk in nighttime croup area, for example. But I don't even think they charge you for that. All the primary care doctors in town will tell you about it and I was told you just walk in and talk with a nurse and your child gets maybe a nebulizer treatment? But they will admit etc if needed obviously.

 

IMO if my primary care doctor tell me that it is up to me if I go to the ER, and I will be seen by an ER doc, then I prob don't have to go. If he tells me he is meeting me there then I am going. But, I know him and know how he operates. He even makes house calls.

 

 

 

[creekland]

It is sort of interesting to learn about all of this in a way.  I still think the bottom line I plan to tell mom is that if she feels something is worth going for to go, and if necessary, we'll pick up the bills.  She definitely is not in the category to abuse it.  I mainly don't want her at home debating about something she feels could be serious over the thought of the bills.  She can debate based upon symptoms and hassle (or whatever), but I don't want finances to come into play with it.

[maize]

Chest pains are an emergency. Always. No one at the er or insurance company would tell her differently.

And yet if it turns out the chest pains were just heartburn, you could be out thousands of dollars for an emergency room visit.

[emzhengjiu]

"But the ER can't turn you away, even if you owe the hospital money. "

 

This is not true in our area.  An ER must stabilize a patient, treat or transfer in life threatening or very serious issues, but the hospital is under no obligation to treat anyone else.  Several people I know IRL have been turned away from the ER because of outstanding bills at that hospital, but only after the ER doctor checked and determined the conditions were not life-threatening.

[umsami]

As the wife of an ophthalmologist, I will tell you that ERs in general are hit or miss for eye issues.  She's better off going to the Wal-Mart optometrist or somebody similar (open on the weekends).  They can usually tell enough to refer her to the right guy.

 

As for ER visits, if she's in her 70s, she should have Medicare…and then a supplemental insurance on top of that (hopefully).  I'm betting that a good portion of the ER visit will be covered, but she may have a $100 copay.  IMHO, based on what you described, better to pay that $ to an optometrist open on the weekends.

 

Medicare does cover eye visits usually, though… so for most things, she could wait until Monday to see an ophthalmologist.  Even if it's a retina tear, they wouldn't do anything different until Monday likely.  If it's a blood thing, it may involve lasering or cryo, which is an in-office procedure.

 

DH is out right now, but when he gets back, I'll tell him what you said…and see what he thinks.  (OK…reread and she saw somebody. NM.)

[creekland]

And yet if it turns out the chest pains were just heartburn, you could be out thousands of dollars for an emergency room visit.

 

And this is her fear...  If "whatever" is truly something, it's covered and she owes nothing since she's met her deductible and OOP.  If "whatever" is nothing, then she owes the cost - or so she said.  This is what I was hoping was NOT true, but it appears it could be unless she's on Medicare.  I'm about to call soon - just thought I'd check in one more time first.

 

As the wife of an ophthalmologist, I will tell you that ERs in general are hit or miss for eye issues.  She's better off going to the Wal-Mart optometrist or somebody similar (open on the weekends).  They can usually tell enough to refer her to the right guy.

 

(OK…reread and she saw somebody. NM.)

 

I love this suggestion should she have another eye issue on a weekend.  It's one neither of us had thought of at all.  She has quite a few eye issues all related to her diabetes, but hadn't encountered this one before.  If anything new pops up... this option sure seems better than just waiting until Monday!  Thanks.

 

And yes... this particular issue is all played out.  I'm not generally one to share in real time when stuff is going on (just not my style most of the time).  However, this one has played on in my mind since then and I was thinking she wasn't right with what she heard - so I was hopeful the Hive would be able to give me leads on how to counteract...  I don't know that my hopes were realized, but I do at least have a plan that can work to share with her if there's a "next time" whether an eye issue or something else.  Her health is not the best and health issues can pop up on Friday afternoons...

[creekland]

For closure... talked with mom before the game, but then had to watch the game - what a bummer of an ending!

 

Anyway... mom does have Medicare and Part B.  Her secondary insurance is from the school at this point.  Her secondary is what has changed and what she was going off of as her school insurance is what she's been used to using for many years.  However, she also admitted that she never has to think about bills since everything is covered (no co-pays) between all three things she has and what she pays for prescriptions.  When I mentioned that Medicare would likely have covered most of the ER visit had she chosen that route (or chooses it in the future), she said she hadn't thought about that, but I might be right.  She's going to check.

 

When I mentioned the Walmart Optometry deal should something happen eye-wise on a weekend, she like-wise thought it was a great idea - esp since she personally knows the guy who runs the place - and mentioned she'd never thought of that before either (neither did I).  She will definitely "phone a friend" if a similar need/question were to arise when her doctor is not available.

 

So... I feel a bit better about "plans" or "thoughts" for the future should she be concerned health-wise, and I could tell over the phone that she does too.

 

Thanks Hive... I really appreciate gleaning from your collective knowledge!  I'm glad I posted with my question - even if the answer(s) turned out to be somewhat different than what I was looking for.

[Twigs]

… Thanks Hive... I really appreciate gleaning from your collective knowledge!  I'm glad I posted with my question - even if the answer(s) turned out to be somewhat different than what I was looking for.

 

Creekland,

 

Thanks for starting this post. I learned a lot.

 

"Learn from others mistakes. Life is WAY too short to make them all yourself!"

 

:iagree:

[Reefgazer]

I ran into this issue years ago (like 30 years ago), long before the ACA.  I was out of town and went to the emergency room for a really stuff neck.  That sounds ridiculous, but it was extremely painful and didn't feel like a run-of-the-mill issue and had been going on for days.  Insurance denied it because it wasn't an emergency and "any reasonable person would not have called that as an emergency".  So I filed a complaint with the state insurance board and listed all of the serious life-threatening maladies it *could* have been and insurance did eventually pay.  So, I would tell your mom that even if insurance doesn't pay a dime, would she trade her sight for that bill?  Worry about fighting the insurance company/negotiating with the hospital later; I wouldn't risk blindness for an insurance bill. 

Our family does not have to worry about health insurance since we're with a health share group we love...

 

BUT, my mom (in her 70s) has health insurance from the school she retired from.  Their plan recently changed with the ACA.  I'm thinking she doesn't understand it correctly, but I honestly don't know - therefore - I'm asking the Hive.

 

The situation (over with - last week):

 

On a weekend (naturally) her eye suddenly had lines going through it and was difficult to see out of (very short version).  She and her sister figured out something was bleeding and she was seeing blood.  So... she drove three hours home. (Those of you who know me and medical stuff can use this to figure out where my genetics come from.)

 

When she got home she called me to let me know.  I suggested the ER (yes, I CAN suggest these sorts of things sometimes) to see if it was anything that needed immediate fixing or could wait until the eye doctor on Monday.

 

She refused telling me that her insurance no longer covered ER visits unless they "keep you" and she didn't think they would for this.

 

What, I asked?

 

It's an ACA thing/change (she told me).  They'll cover ER visits if it's truly an emergency and they admit you, but not if they decide it isn't an emergency and send you home.

 

I can totally see this for someone who shows up there with a sore throat and wants Tylenol... but for her eye issue?  How is she supposed to already KNOW if it's an emergency or not?  What about those with chest pains?  What if someone has flu like symptoms, but is also wary of meningitis and isn't sure?

 

Are these folks really on the hook if they guess "wrong?"

 

I don't believe it's true, but I need some sort of "ammo" to answer her with and have none.

 

Does anyone else have something I can use should something like this happen in the future - she's in her 70's, so it could!

 

FWIW, she waited to go to the eye doctor last Monday and it wasn't an emergency - she was correct.  A membrane had torn loose (she was seeing blood), but it would heal itself.  But she didn't KNOW what it was until then or that it could wait.  Would she have been on the hook for the ER visit if she had followed my advice?

 

If that's really true, it's kind of scary, but I still can't believe that's the way it is - is it?