Out-Of-Network for a Pre-existing Condition, What do I Do?
My daughter has Obama care. She is 27. At the age of 18 she had an operation by specialists in Massachusetts (her Rhode Island doctor referred us as he couldn’t do the operation and the doctors at Hasbro were not helpful in assisting him). She was referred to Dr K the surgeon and Dr P the Infectious disease doctor). They removed part of her jaw (she has Osteomyalitis) and replaced it with metal. She was supposed to have it removed within the year, but since she turned 19 she was no longer eligible for the state aid which we had. A few weeks ago she suffered pain from the jaw. She went to her RI doctor who said it was still in place but needs to be removed as soon as possible. He cannot perform this operation and suggested she return to Dr K so he can finish the job. Dr K is setting up an appointment for her to see him. So my question is how does my daughter go about applying her Obamacare in Massachusetts, since she is from Rhode Island. Thank you for your prompt response.
If someone needs treatment out-of-network for a pre-existing condition they either need to pay out-of-pocket, pay their out-of-network cost sharing amount, get approval from the insurer, or switch to a multi-state plan.
Generally if a person needs treatment outside of the plans network they will either need to pay the amount under the plans cost sharing, or need a specific referral that the plan accepts to pay the claim for. This is one large benefit of multi-state PPO's or plans with out-of-network cost sharing.
When you talk to a doctor, it's important that they understand what plan you have an what your plans network is like. This way they can refer you to a doctor in-network. During open enrollment switching plans is easy, outside open enrollment it can be a little tricker. You should contact the RI Marketplace healthsourceri.com and look into her Medicaid and cost assistance options. Once you know that, you can contact the Doctor again, let them know what you network looks like and then find a specialist in the network. You could also call your current insurer directly to find out more options.