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The Individual Health Insurance Market in Georgia has limited plans available. They are HMO’s only; Ambetter, Kaiser and BlueCross in the most rural areas of Georgia.

The plans available are based on the member’s home location.

The Harsh Reality

2018 will be a difficult year for clients with pre-existing conditions who want to keep their doctors and current healthcare delivery system. Unfortunately, in most cases it will not be possible.

The available HMO plans require the member to select a new primary care doctor. It will be unlikely to find current doctors in the HMO network. The PCP (Primary Care Physician) is then responsible to get the HMO’s approval for the member to see an in-network Specialist.

There is no coverage or benefits when seeing an out of network provider or for care received outside of Georgia unless it is an emergency.

What’s the Strategy for 2018?

Many clients will have to adjust to an HMO Health Plan.  It’s not the end of the world, it’s for 12 months. We understand this will be very difficult for clients managing serious ongoing conditions.
How do we make the best of a difficult situation?

  1. Choose from the HMO plans available
    • Choose your PCP right away and schedule appointments as far ahead as possible.
      If you don’t like your PCP, you can usually change to a different one the first of the next month.
      Try to be patience and positive, remember millions of people in the U.S. receive their healthcare with HMOs.
    • If trying to get an expensive medication approved, be ready to provide your current doctor record of failed attempts at step therapy with lower cost medications.
    • Know you can still see your current doctor; ask for the private pay (reduced) fee schedule.
      Consider a Health Saving Account with the HMO plan. HSA (pre-tax saving) can be used to pay for medical expenses for care outside the HMO network.
  2. Clients without pre-existing conditions may want to consider a lower cost alternative plan. A pre-existing condition is usually defined as something the individual has been treated for, consulted a doctor for or taken medication for in the previous 5 years. These plans have large national networks and cost approximately 50% of the Obamacare HMOs. Be careful and think through the effect of the pre-existing exclusion.
  3. We encourage clients to see if a Group Health Plan might work. They still offer the big national POS networks, good benefits and slightly lower cost.

Let’s all try to hang in there; we’ll be working from our end to help our clients navigate through these changes.

Joe LePage

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