Medicaid(medi-cal)/anthem insurance question

I am a member of the other site but figured I'd post here too.

Has anyone had a switch done through medicaid, specifically medi-cal, that wasn't straight medi-cal? I have anthem/medi-cal and am experiencing difficulties from the anthem portion.

Thanks!

I cannot answer your specific question, but I do want to wish you luck with getting your approval and surgery.

Maddie

What are the difficulties you are experiencing? Are you using their network provider or wanting to go out of network? Since it is a government funded medicaid plan there may be less funds available to pay for a higher cost surgeon or that surgeon may be unwilling to accept the medicaid payment.

When are you eligible to change from anthem medicaid to traditional medicaid?

I hardly make any money so when I received medi-cal (medicaid) they also gave me anthem for free and the anthem I get isn't the kind that others get, it is through a state sponsored program, as it states on the card. I am told medi-cal (medicaid) is my primary but I have to go through anthem for things like referrals and pcps. The anthem supposedly covers what the medi-cal doesn't , though the whole process confuses me. Also, I am not able to change to straight medi-cal (medicaid) without having a significant out of pocket expense that I cannot afford.

The anthem makes you be part of a medical group and that medical group has specialists. The medical group is also only located locally to where you live. My medical group has 1 bariatric surgeon, however, he does not perform the procedure I wish to get and also deemed me a poor candidate due to back pain. They keep sending me to that guy when I ask for a new referral because it is the only doctor available in the medical group.

The lady I spoke to with anthem said that if there is not a specialist in the group you can do the access to care and they will make a one time approval but is this the best route to go?

So today I called to check up on my access to care thing the drs office told me they were doing on monday...

Now she says they just resubmitted a referral again....

I told her I needed to go outside of the medical group and if we do the same thing as before they are just going to send me to the same surgeon , the only surgeon they have, who doesn't perform the DS but she said this is the only thing they can do for me and ultimately it is up to the medical group, that they have to send me outside....

I don't know what to do!

Anyone have any ideas how to go outside of the medical group/network? I am guessing it is like a network anyhow. Would getting a second opinion be better?

This smiley sums up how these office people are making me feel:

are you not a candidate for other weight loss surgery?

I just recently found out an old doctor said that I wasn't so going to a new one to dispute that bologne (sp?). Still can't get a referral for a consult with a ds surgeon in network as there are none and they refuse to send me out of network. It's going through the DMHC now. Thanks for asking.