How to get a flu shot with an HMO?

JumpinJack said:

You're arguing with yourself.

I cut and pasted BCBSTX's response. I merely reported a fact. If you take issue with that, you need to take it up with Blue Cross. I'm not the one in charge.

(I'll assume you're joking about giving you my personal information. Because that's pretty funny.) Listen, lady...I've got better things to do than make up lies about a flu shot. Maybe that's the sort of thing you would do. But I'm an over-60 former paraprofessional with about 40 years in the field. I'm not a teenager in mommy's basement having fun posting false info on forums.

As I said, I merely reported a fact. You can call BCBSTX on your own and ask generally about how to get a flu shot under their Texas HMO plans.

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Um, I'm a 55 yo dood, a policy/group number does not personally identify you (I didn't ask for your account number), and I already did call TX BCBS who cannot tell me the level of coverage and other particulars without policy/group numbers. Since your history here in debates on HI is replete with all sorts of falsehoods, anything you post is held at arms length. If you wont verify, fine....it is all anecdotal then.

JumpinJack said:

Okay, I've emailed Blue Cross a couple of times. I still don't understand how to get a flu shot at the local pharmacy.

I have a BCBS HMO. I just want to get a flu shot at the local pharmacy like I have in the past. So I emailed BC & asked if I could. They initially said yes and said how to locate a participating pharmacy...then added gobbledygook language about the PCP yada yada yada. So I emailed back to clarify, and asked again if their response meant that I could get a flu shot at the pharmacy. They responded back standard policy language about making sure that medical services are covered the insured must go through the PCP yada yada yada. I'm thinking this is a preventive thing, a flu shot. Surely they're not saying I have to go to my PCP to get a flu shot? Because the PCP wouldn't want to approve that, would he, when he could get the fee for that? (Besides which, I JUST located a PCP, so it doesn't take effect until next month.)

Does anyone know about the flu shot thing and HMOs? With an HMO you can't just get a flu shot at a local pharmacy, since it's preventive?

(I sent another email to BCBS but haven't heard back yet. So frustrating. Maybe I should just pay for the shot.)

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Yes, just go to the pharmacy and ask for the shot. They will bill your insurance, you should owe nothing. It's now the law that they have to provide preventative immunizations at no cost to you. It's one good thing in the PPACA, anyway. Get the pneumovax and zoster shots while you're at it if you are over 60. The pharmacy will ask you screening questions from a questionnaire to be sure the shots are appropriate for you.

Gimmesometruth said:

policy/group number does not personally identify you

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Actually, a policy number does personally identify. She can give you a group number, which does not, but it is unlikely BC/BS would give you details based on just a group number.

buck said:

Actually, a policy number does personally identify. She can give you a group number, which does not, but it is unlikely BC/BS would give you details based on just a group number.

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bcbs tx uses plan or policy numbers, those are different from an account number, ex, Blue Advantage Bronze HMO 006.

Gimmesometruth said:

bcbs tx uses plan or policy numbers, those are different from an account number, ex, Blue Advantage Bronze HMO 006.

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A policy number identifies a specific customer's policy. A plan or group number is different. Again, I could be wrong, but I doubt they would give you any details on just a group number. I know the insurance company I work for would not.

What Is a Health Insurance Policy Number? | eHow

A health insurance policy number identifies you as a unique member to your health insurance company.

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The group plan identifies the general area --- and, in some cases, the department serving your group plan --- while the policy number identifies you specifically.

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I truly thought this was common sense and known by all. Guess not.

LowDown said:

Yes, just go to the pharmacy and ask for the shot. They will bill your insurance, you should owe nothing. It's now the law that they have to provide preventative immunizations at no cost to you. It's one good thing in the PPACA, anyway. Get the pneumovax and zoster shots while you're at it if you are over 60. The pharmacy will ask you screening questions from a questionnaire to be sure the shots are appropriate for you.

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That is incorrect, according to BCBS. I am allowed to get preventive treatment, incl. certain immunizations, at no cost. But that has nothing to do with procedure. BCBS has a procedure for its "managed care" plans. Authorization for any and all care, incl. immunizations, must be done by or approved by the PCP. Since it took me so long to locate a dr. who would take the plan, I didn't have a chance previously to have my first appt with the PCP (the PCP requires a "meet and greet" appt, and then a later appt for an actual exam).

It's similar to a preventive annual exam. I am allowed to get one at no cost. But that doesn't mean I can go to any doctor. Under the BCBS HMO plan, I must get it from the PCP.

I thought there might be an exception for a flu shot, but apparently not, per BCBS. But I can't say I'm that surprised, since the whole point of HMOs is to run all care through one principal provider. The patient is not allowed to go anywhere s/he wants or get care that the patient wants but is not approved. All that is decided on by the PCP and BCBS.

So I just didn't get it. Flu season's over, anyway.

JumpinJack said:

That is incorrect, according to BCBS. I am allowed to get preventive treatment, incl. certain immunizations, at no cost. But that has nothing to do with procedure. BCBS has a procedure for its "managed care" plans. Authorization for any and all care, incl. immunizations, must be done by or approved by the PCP. Since it took me so long to locate a dr. who would take the plan, I didn't have a chance previously to have my first appt with the PCP (the PCP requires a "meet and greet" appt, and then a later appt for an actual exam).

It's similar to a preventive annual exam. I am allowed to get one at no cost. But that doesn't mean I can go to any doctor. Under the BCBS HMO plan, I must get it from the PCP.

I thought there might be an exception for a flu shot, but apparently not, per BCBS. But I can't say I'm that surprised, since the whole point of HMOs is to run all care through one principal provider. The patient is not allowed to go anywhere s/he wants or get care that the patient wants but is not approved. All that is decided on by the PCP and BCBS.

So I just didn't get it. Flu season's over, anyway.

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Just go to the pharmacy and ask for it anyway. They'll tell you if you need authorization from a PCP; they'll probably call the PCP to get authorization for you.

Seems pretty silly to require authorization. Like the PCP won't allow it? Ridiculous.

JumpinJack said:

So I just didn't get it. Flu season's over, anyway.

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Honestly? I think you got rotten directions from an underpaid call center worker.

Because truthfully I have never, ever heard this before. And apparently nor has anyone else on this forum.


Edit:
Health Insurance Plans | Blue Cross and Blue Shield of Texas
2016 INDIVIDUAL AND FAMILY PLANS
BLUE ADVANTAGE HMO / BLUE ADVANTAGE PLUS HMO
Preventive Services
Many long-term illnesses can be prevented or managed when found early. With the Affordable Care Act, most health insurance plans must cover a range of preventive services with no out-of-pocket costs like a copayment or coinsurance. Services include certain screenings, immunizations, and other types of care, like:
Flu and pneumonia shots



I think you need to blame the call center worker for this one.

buck said:

A policy number identifies a specific customer's policy. A plan or group number is different. Again, I could be wrong, but I doubt they would give you any details on just a group number. I know the insurance company I work for would not.

What Is a Health Insurance Policy Number? | eHow




I truly thought this was common sense and known by all. Guess not.

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FFS, yer getting so pedantic, BCBS uses a MEMBER ID NUMBER to identify the MEMBER.

I'm not asking for that, never did. I asked for the POLICY NUMBER, BCBS uses a NUMBER SYSTEM for each of the policies they have under the ACA approved plans, I just got done giving you an example of the NUMBER used to identify the plan/policy.....it is completely different from the MEMBER ID NUMBER.

JumpinJack said:

That is incorrect, according to BCBS. I am allowed to get preventive treatment, incl. certain immunizations, at no cost. But that has nothing to do with procedure. BCBS has a procedure for its "managed care" plans. Authorization for any and all care, incl. immunizations, must be done by or approved by the PCP. Since it took me so long to locate a dr. who would take the plan, I didn't have a chance previously to have my first appt with the PCP (the PCP requires a "meet and greet" appt, and then a later appt for an actual exam).

It's similar to a preventive annual exam. I am allowed to get one at no cost. But that doesn't mean I can go to any doctor. Under the BCBS HMO plan, I must get it from the PCP.

I thought there might be an exception for a flu shot, but apparently not, per BCBS. But I can't say I'm that surprised, since the whole point of HMOs is to run all care through one principal provider. The patient is not allowed to go anywhere s/he wants or get care that the patient wants but is not approved. All that is decided on by the PCP and BCBS.

So I just didn't get it. Flu season's over, anyway.

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Again, this is bs, flu shots do not need referrals or "authorization", it is a preventative care requirement all ACA plans include, it is not a specialist visit.

You won't give me info on your plan, yer just spreading lies.

Gimmesometruth said:

FFS, yer getting so pedantic, BCBS uses a MEMBER ID NUMBER to identify the MEMBER.

I'm not asking for that, never did. I asked for the POLICY NUMBER, BCBS uses a NUMBER SYSTEM for each of the policies they have under the ACA approved plans, I just got done giving you an example of the NUMBER used to identify the plan/policy.....it is completely different from the MEMBER ID NUMBER.

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Member number = policy number.

You are thinking of the group or plan number.

I've been in insurance for over 20 years, with FLMI and ICA certificates.

And, simply put, you are wrong.

LowDown said:

Just go to the pharmacy and ask for it anyway. They'll tell you if you need authorization from a PCP; they'll probably call the PCP to get authorization for you.

Seems pretty silly to require authorization. Like the PCP won't allow it? Ridiculous.

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I'm not set up yet with the PCP. I just located one recently who would take the policy. So his name is on my card, but the PCP requires you go in for a meet and greet, to get set up.

brothern said:

Honestly? I think you got rotten directions from an underpaid call center worker.

Because truthfully I have never, ever heard this before. And apparently nor has anyone else on this forum.


Edit:
Health Insurance Plans | Blue Cross and Blue Shield of Texas
2016 INDIVIDUAL AND FAMILY PLANS
BLUE ADVANTAGE HMO / BLUE ADVANTAGE PLUS HMO
Preventive Services
Many long-term illnesses can be prevented or managed when found early. With the Affordable Care Act, most health insurance plans must cover a range of preventive services with no out-of-pocket costs like a copayment or coinsurance. Services include certain screenings, immunizations, and other types of care, like:
Flu and pneumonia shots



I think you need to blame the call center worker for this one.

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What you quote has to do with what the ACA will PAY for, but not the process required to get the care. Are you familiar with HMOs? I think that's the difference from others on this forum. They are thinking it's a regular ins. policy. It's not. It's an HMO. It's "managed care." The point is that the patient can't get care on his/her own, without going to or through one particular doctor that BCBS has approved. His name is on the ins. card, even. That one dr is responsible for ALL care of the patient. He may refer you to a specialist, or he may decide he wants to treat a pulled ligament or whatever.

In my case, I haven't actually been to the PCP yet, so I'm not set up with his office. That's the deal. If I were set up, the pharmacy might call him. I could try, but after spending hours just trying to locate a dr who would take the plan, and then communicating with BC about the flu shot, I got tired and just gave up.

I actually rec'd three emails from different people at BCBS that all said I had to get authorization from the PCP. The first two were worded in not so plain language, that I asked them twice to clarify. The third email was more forthright and quite plain. I then followed up with a phone call. Phew!

I could stop in the pharmacy and ask them to call and see what happens, but like I said, flu season is over, anyway. (I can't imagine pharmacies have time to call drs. for everyone who comes in for something.)

Gimmesometruth said:

Again, this is bs, flu shots do not need referrals or "authorization", it is a preventative care requirement all ACA plans include, it is not a specialist visit.

You won't give me info on your plan, yer just spreading lies.

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I reported info on my plan. I cut and pasted BCBS's response to me. As I have said numerous times, I have a BCBS HMO plan.

Have you ever had an HMO individual policy?

JumpinJack said:

I reported info on my plan. I cut and pasted BCBS's response to me. As I have said numerous times, I have a BCBS HMO plan.

Have you ever had an HMO individual policy?

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I already told you that I am and I'm dealing with my parents HMO. We did not need authorization for flu shots, it is not a specialist procedure. It is part of base policy, it is the same as when they had a ppo. Since you won't allow me to confirm, your argument has no standing.