Amerihealth Mercy/PA help needed

[quentina]

I am trying to determine how this insurance works. If anyone is in PA and has it, I would appreciate your input (as they are closed today).

My two smallest children were adopted from foster care. With the adoption, they get self insured medical insurance until they are 18. They have Ameri-health mercy. I think this is considered medicaid (not sure).

The rest of the family has BC/BS. I was advised to not add them to my plan as AHM will not pay any remaining balances/out of pockets. Can anyone confirm this?

My daughter takes a very expensive medication and is special needs so, her medical OOP for me would be quite high if they did not pick up difference. However; she needs braces and they have denied it stating that she scored 12 on the test and the minimum score required is 25. So, I am going to appeal however; I have amazing dental which will pay 50% of orthodontics with no cap. This is a huge amount....the problem is, I need to add her to the medical in order to get her on dental. I have confirmed this through our service center at work

I know I need to speak to the insurance company to confirm however; I am looking to see if anyone here as any first hand knowledge.

Thanks!

 

[laurie31]

Can you get advice from the social worker who was involved in your adoption? It sounds like you need to sit down and figure out the cost of taking her onto your BC and dental vs. leaving her on the state plan. A medical social worker would probably be your best source of info. My guess is, the risk of paying huge medical bills would outweigh the benefit of the orthodontic coverage but of course I don't know that for a fact.

As an aside, that's a huge bummer that your benefits are tied together like that. Ours aren't. Medical, dental, and vision are all totally separate.

 

[quentina]

Can you get advice from the social worker who was involved in your adoption? It sounds like you need to sit down and figure out the cost of taking her onto your BC and dental vs. leaving her on the state plan. A medical social worker would probably be your best source of info. My guess is, the risk of paying huge medical bills would outweigh the benefit of the orthodontic coverage but of course I don't know that for a fact.

As an aside, that's a huge bummer that your benefits are tied together like that. Ours aren't. Medical, dental, and vision are all totally separate.

Well, I tried a different number to AHM and got a live person. They tell me that.....they will pay any out of pocket that we have. We have to have the BCBS as primary and they will pay what is not covered. SHe stipulated that the provider would need to bill them. Then, I hung up and called back, got someone else who told me the same thing.

Our medical, dental, vision are seperate....what's not is the dependent's. It is a associate and children plan, family plan etc. I can't have 3 kids on the dental and only 1 on the medical. They are not able to seperate the kids. In the past it was OK as I only used theirs however; 50% of orthodics plus the discounted, in network rate is huge!!

As open enrollment ends Monday, time was of the essence! I added them...worst case scenerio, I get stuck with out of pocket. As I would be paying for the braces anyway, it will probably all work out to the same thing. No matter what their test says....she needs them, ASAP. Teeth are coming in almost vertical as there is no room for them.

 

[Cyndibear]

Just a little info, I work in the billing office of a Gastroenterologist and the patient's that come to our office require a referral from their primary care Doctor. Even if they have Amerihealth Mercy as a secondary insurance a referral is required to get any balance paid at the in network rate otherwise this would be considered out of network and you would be responsible for the balance. Not sure how dental works though.

Cyndi

 

[quentina]

Just a little info, I work in the billing office of a Gastroenterologist and the patient's that come to our office require a referral from their primary care Doctor. Even if they have Amerihealth Mercy as a secondary insurance a referral is required to get any balance paid at the in network rate otherwise this would be considered out of network and you would be responsible for the balance. Not sure how dental works though.

Cyndi

OOH, that's good to know. They do need referral's to go to some doctors. I will keep that in mind when making appts. Thanks!

 

[quentina]

OOOHHH another question....can you have an HSA and medicaid? I am embarrased to be asking this as I actually do the benefits presentations for my company however; no one ever brought this up before.

I do have an HSA. I can pick a regular PPO however; there were some great incentives to the HSA this year so, I wanted to take it.