advice on medical visit
 

Hi,
I need to go to see a doctor to do some scans (nothing major or urgent). I understand that insurances start all over again in January, so is it best for me to wait January to do it, or it does not matter?
As I understand (perhaps wrongly) I have to pay a certain amount per year before reimbursement kicks in, so if its best to wait but im not sure if I understand properly? have I misunderstood the system ?
also, is it like in the UK where I have to get a letter by the GP to do those scans or can I just go to the relevant doctor straight away?
thank you!

Re: advice on medical visit
 

It all depends. What you are talking about is called the deductible (the amount you have to pay out of pocket before the insurance takes up the slack). That said it sometimes depends on how it is billed out to the insurance company. Office visits generally just attract a co-pay ($20-40) and won't count against the deductible, a scan done in a hospital setting probably will use up your deductible. Some insurance plans have a rollover period where if you only start using your deductible after a certain date (often in October) that amount rolls over into next years deductible.

Bottom line, call up the insurance company and ask what the specific coverage you have is and what it will cover.

I recall my physical therapist once telling me how odd it is that all her patients miraculously get better in the last week of December.

Re: advice on medical visit
 

It all depends on your plan - and whether the precise coverage that you will have next year is the same as what you have now.

In general I don't see any advantage in waiting unless (and this is extremely unlikely) you are going to have a higher level of coverage next year.

Other reasons for not waiting would be if you had either already reached your maximum out of pocket limit for this year, or if you had money remaining in a health care spending account that you need to spend before the end of the year.

Re: advice on medical visit
 

You may or may not require a prescription from your GP/MD for the scans...check with your insurance company. Depending on your insurance cover you may need a referral to see a specialist. Unlike the UK where when you have seen a specialist his/her report is sent to your GP...so all your medical history is in one place. It is not the case in the US. Your MD will often not have a clue about other medical procedures you have had...or meds prescribed by another doctor.

Re: advice on medical visit
 

well thats the thing, I dont really want to talk to the insurance company because im scared they will take it as a "pre existing condition" (which is mentionned in my exclusions and limitation clauses) and as a result refuse to pay any possible future outcome.. not sure how to approach this with them..
Surely I cant just call them and say "i'd like a scan please?" they will have to ask why I want one, and id have to tell them about my pre existing condition...

the roll over time might have been possible because we arrived in the US in October, but it looks like our company is changing suppliers next year so thats why I was wondering if I should just wait... at least Id start with the new supplier and if I have to pay myself, then it would count in the new deductible? ohhhh sooooo confusing! :)

Re: advice on medical visit
 

Have you been to see a doctor about the scan? If not I doubt that you can just go and get a scan just because you think you need one.

I don't need a doctor's referral to see a specialist but I always need a script/referral to get a mammogram/bone density scan/MRI/CAT scan/x-ray etc.

Re: advice on medical visit
 

yes I litterally just hung up with the hospital and indeed they will want a doctor subscription. I have a letter from a uk doctor telling me to do a scan in 3 months time but thats not enough for them
cost of the scan is $791 so not sure whats the best option now!

Re: advice on medical visit
 

Without knowing what the scan is for and whether you need a referral to see a specialist it's hard to give advice.

Your MD may be able to provide you with a script but he will probably pass you onto a specialist who will then give you a script if he thinks it is necessary.

Re: advice on medical visit
 

Sounds like a pre-existing condition. However you have a Group plan by the sounds of it so it may not be as exacting as if you had a Private insurance plan. You cannot just turn up at the hospital for a scan - you need a referral from a primary physician and usually your insurance company will need to give the OK for it to be done (per-authorisation).

After you pay your deductible your plan probably pays 80% or 90% of the remaining bill. Once you have paid your full out of pocket expenses for the year your plan probably pays 100%.

If you have not paid any of your deductible for this year then it makes no difference if you have the scan now or in the New Year. You still will have to pay the full deductible (either now or in the New Year) before the insurance company pays for the rest of the cost.

However, as said, you need a primary physician to refer you - not a letter from a UK doctor.

Get a primary and have a check up - maybe you don't need the scan.

Re: advice on medical visit
 

As far as the concern about pre-existing conditions goes, if you are covered by a group health plan (through your employer or your spouse's employer) and you enrolled in that plan within 63 days of leaving the UK you should be OK because the NHS counts as "creditable coverage" for pre-existing conditions and a gap of less than 63 days does not count as a break in coverage for these purposes.

Re: advice on medical visit
 

Our Insurance covers pre-existing conditions I am pleased to say so I wasn't faced with this. It is a big worry for a lot of people.
If your company is changing providers next year and you haven't been treated for whatever you are getting the scan for then maybe you should wait. You should really go over your policy or perhaps ask a friend who understands all this stuff to go through it with you. I have heard that in some cases (and I don't know for sure if it is true) if your were under care with the NHS and you got medical coverage here without a gap then that is the same as if you were just changing insurance companies. In that case they cover anything you were being treated for previously but I think it varies state by state. Check within your state and see what their rules are. I have enclosed a link below. It is for MN but try and find out if something similar applies in your state.

http://www.health.state.mn.us/hmo/hipaa.htm

Re: advice on medical visit
 

If you're met your deductible already, do it now. If you haven't, you might as well wait till next year.

Sometimes, if it is a continuous set of scans, over the Dec/Jan threshold, they might let you do the scans without restarting on the deductible, but this depends on the plan and the state.

If you need a referral or not depends on your insurance, if it is a HMO or PPO.

Re: advice on medical visit
 

Cost of the scan alone or is that the cost of someone interpreting the scan and writing up a report of the scan too?

You might as well ring the insurance. If they agree to pay, get it in writing and you're sorted, other wise, you'll be paying anyway and better to not be surprised.

Re: advice on medical visit
 

HIPAA is a federal thing. The NHS is considered creditable coverage, if within 62 days of getting new cover.

Re: advice on medical visit
 

if the NHS is counted as credible coverage but I got the treatment done privately (through our private UK health insurance which was with work too) because the NHS waiting list was few months, does it still count?
I guess you are all right, Ill just need to call the insurance and see what they say
thank you all!