Dr. Coates

[Melanie0574]

Thank you all for the replies. @DianaCox I believe I just have straight Medi-cal,as it is not through a insurance company,I received it when I applied for food stamps when I lost my last job. I received an email back from Dr. Rabkin's office,and they sent me a preliminary insurance form I need to fill out,and fax back to them. There is a section on here requesting all the previous surgeries I have had. How important is it that I have to provide exact dates for these surgeries?

 

[southernlady]

There is a section on here requesting all the previous surgeries I have had. How important is it that I have to provide exact dates for these surgeries?

If you know exact dates, give that but I have had surgeries where I gave month and year and even one where it was listed as just Spring 1994. I honestly can't remember the date of one. I wasn't hassled over the season/year on that one.

 

[DianaCox]

Thank you all for the replies. @DianaCox I believe I just have straight Medi-cal,as it is not through a insurance company,I received it when I applied for food stamps when I lost my last job. I received an email back from Dr. Rabkin's office,and they sent me a preliminary insurance form I need to fill out,and fax back to them. There is a section on here requesting all the previous surgeries I have had. How important is it that I have to provide exact dates for these surgeries?

What county do you live in? The counties are, I believe, responsible for managing their Medi-Cal patients, as the choice of coverage is at the county level. I help my indigent brothers manage their health care, and they had to choose between Health Net and a more local plan as their HMO providers of Medi-Cal:
https://dhs.lacounty.gov/wps/portal/dhs/coverageoptions/medical/: "To receive medical care in LA County DHS hospital or clinic, you must choose L.A. Care Health Plan or Health Net on your Medi-Cal Choice form from the state." However, if you have special needs, you can get an exemption to be on straight Medi-Cal, which allows you to see medical providers who are NOT in either of these plans - so long as those providers accept Medi-Cal. But if you live in a county that doesn't provide health care coverage through an HMO, which I believe is required to cover bariatric surgery, you may be SOL - the problem you are going to find with straight Medi-Cal is that neither Rabkin nor Keshishian accept it.

This may sound counter-intuitive, but are you SURE you don't qualify for an ACA plan, at the very lowest level of co-payment? Because I'm almost certain you would be better off with one, at least for long enough to get surgery.

 

[Melanie0574]

If you know exact dates, give that but I have had surgeries where I gave month and year and even one where it was listed as just Spring 1994. I honestly can't remember the date of one. I wasn't hassled over the season/year on that one.

That is good to know,because my first two surgeries (tonsils,and appendix) were when I was very young,so I am really unsure of even the years.

 

[Melanie0574]

@DianaCox I live in Mendocino County. I have never heard of these AMA plans that you mentioned. Where could I look into these more? I really appreciate all the help,and information.

 

[DianaCox]

Looks like for Medi-Cal, you have only one choice in Mendocino county**: http://www.dhcs.ca.gov/individuals/Pages/MMCDHealthPlanDir.aspx#mendocino
Mendocino County
Plan Name Phone
Partnership Health Plan of California
(800) 863-4155
TTY/TDD (800) 226-2140

I couldn't see ANYTHING on their Member service booklet about bariatric surgery - you need to call and find out what your benefits are for that. DEMAND to receive a copy of your Evidence of Coverage document (should be about 100 pages long).

You are put into Medi-Cal plan if your income is below a certain point. But you can go to the Covered CA website (https://www.coveredca.com/shopandcompare/2016/ - DO NOT create an account to do this - do it without being logged in!) and play around with the numbers to figure out the least amount of income in your county, for your family situation (dependents, etc.) that qualifies you to be in an CoveredCA (ACA/ObamaCare) plan instead of Medi-Cal - in Santa Clara County, for a single person with no kids, it is around $16,400/year. And then I think you can claim to make that much money (or $400/year more, just to make it look LESS suspicious, I suppose). And then see if you can get on an ACA plan that covers Keshishian (Rabkin is not, to my knowledge, in-network with any insurance plan, or wasn't the last time I checked - OTHER than NorCal Kaiser - he has a contract with them to provide DS for NorCal Kaiser patients who demand the DS). Since the open enrollment period changed, I don't know if you can get on it this year, or whether you can claim a change of circumstances (you're making more money??) justifies it. Be careful, and don't put yourself into a situation where you can be caught lying, of course.


** From the Medi-Cal site:
"Medi-Cal Managed Care Health Plan Directory
When you first qualify for Medi-Cal, you are covered under Medi-Cal Fee-for-Service. However, you must choose a health plan within 30 days. If you do not choose a plan within 30 days, the State will choose a plan for you.

If you find only one health plan, the county has chosen this plan for you. Please wait for your health plan information mailer in the mail.

If you find multiple health plans listed, please explore each plan and choose the one that suits you and your family’s needs. Remember, if you do not pick a plan within 30 days of receiving your health plan information mailer, Medi-Cal will pick a plan for you.

If you live in San Benito County, there is only one health plan available and you may enroll in this health plan. However, you may also choose to stay in Fee-For-Service Medi-Cal."

You can still do a Fee-For-Service Medi-Cal, your county, by applying for an exemption. But since neither Rabkin nor Keshishian are Medi-Cal providers, it doesn't do you any good.

 

[southernlady]

Since the open enrollment period changed, I don't know if you can get on it this year, or whether you can claim a change of circumstances (you're making more money??) justifies it. Be careful, and don't put yourself into a situation where you can be caught lying, of course.

Change of circumstances include change of job (not income or title within a company), marriage, divorce, death of spouse, loss of employer based insurance, moving from one county or state (zip code MIGHT) to another, birth or death of a child, turning 65. And the last one triggers Medicare not ACA.

Just change of income within present employer does not trigger a change that allows ACA enrollment outside of the Open Enrollment time frame.

(I verified this with my hubby who is licensed to sell insurance here in NC but is not with a broker. The broker he worked with handled ACA and still does.)

 

[DianaCox]

Change of circumstances include change of job (not income or title within a company), marriage, divorce, death of spouse, loss of employer based insurance, moving from one county or state (zip code MIGHT) to another, birth or death of a child, turning 65. And the last one triggers Medicare not ACA.

Just change of income within present employer does not trigger a change that allows ACA enrollment outside of the Open Enrollment time frame.

(I verified this with my hubby who is licensed to sell insurance here in NC but is not with a broker. The broker he worked with handled ACA and still does.)

Thanks - I know there are SOME ways you can get on an ACA plan outside of open enrollment, but I don't know what they are. It would seem to me that a change in income that disqualified the person for Medi-Cal should be one of them.

 

[Melanie0574]

So I called Partnership,and requested an Evidence Of Coverage, and the woman that I spoke to told me,that I should be able to see it on there website. I explained that I had looked at the list,but did'nt see anything about bariatric surgery. She then basically told me that I would need to get a refferal from my doctor to Rabkin or Keshishian,and then give them my insurance info. Then they would be the ones to see if my insurance will cover the DS. So I think I might just fill out the form that Dr Rabkins office sent me,fax it to them,and see what they say. Did you get a referral before dealing with insurance? I currently do not qualify for a ACA plan.

 

[DianaCox]

You can try - but I would also ask Keshishian. As I said above, Rabkin is not in-network with anyone, as far as I know, other than NorCal Kaiser, and even then, it's ONLY by referral and special approval. I think the person you were talking to is yanking your chain and wasting your time.