Hi, I'm in Georgia, USA, and have a pretty crappy health insurance plan (Aetna CVS Health marketplace plan). Previously, with a different but equally crappy plan that did not have good coverage in my area (i.e., within 50 miles) for some basic things like speech therapy, I was able to get in-network coverage rate by filing a "Network Adequacy Form", also sometimes called a Network Deficiency Form. However, it seems that in Georgia, unlike some other states, there is no real regulations or policy on what kind of coverage your plan needs to have. For instance, other states have policies that if you don't have X kind of provider within X miles (usually 30-50, or 1 hour driving time) they will allow you to see a closer out of network provider, at an in network rate, by filing a adequacy/deficiency form.
Is anyone aware of any regulations like this in Georgia? I am currently going through an epic battle with new crappy insurance plan (Aetna) to keep seeing some of the providers I've built relationships with, for a rather complex issue. They are also trying to give me the run-around, saying that even out of network providers must be in and "registered" within their system as "out-of-network", to be able to be covered under a defiiciency form (or even a transition of care form). To be registered, the provider must send a letter of intent with basic info plus a W-9 form to Aetna. I know several of my providers won't do this, because they don't do anything with insurance. I was able to get in to see them because coverage under my last plan was equally crappy, but it was easier to get a deficiency approved because they didn't have to "register" with my last insurance.
I can't find any info on this last policy (about "registering" in their system) ANYWHERE in my policy documents, forms, etc. It seems like it's just a way they can use to deny coverage, particularly for out of network providers.
Any insight on how to push back on either or both of these issues? I've spent hours on the phone with them and it is not resolving anything.
Is anyone aware of any regulations like this in Georgia? I am currently going through an epic battle with new crappy insurance plan (Aetna) to keep seeing some of the providers I've built relationships with, for a rather complex issue. They are also trying to give me the run-around, saying that even out of network providers must be in and "registered" within their system as "out-of-network", to be able to be covered under a defiiciency form (or even a transition of care form). To be registered, the provider must send a letter of intent with basic info plus a W-9 form to Aetna. I know several of my providers won't do this, because they don't do anything with insurance. I was able to get in to see them because coverage under my last plan was equally crappy, but it was easier to get a deficiency approved because they didn't have to "register" with my last insurance.
I can't find any info on this last policy (about "registering" in their system) ANYWHERE in my policy documents, forms, etc. It seems like it's just a way they can use to deny coverage, particularly for out of network providers.
Any insight on how to push back on either or both of these issues? I've spent hours on the phone with them and it is not resolving anything.