After being told by Anthem Blue Shield Blue Cross that my abdomen MRI to check for cancer spread was deemed NOT a medical necessity, I put them on blast out of desperation and pure rage: the audacity of a massive company charging me inflated self-pay premiums only to DENY vital life saving imagery. As the post went viral, I was suddenly contacted by Anthem, who apologized and immediately approved the scan. They don't like it when their nefarious ways are boosted in the public sphere. The philosophy of "let's deny critical care until we get caught" is an ugly one.

In August, I severely injured my left foot, and have been in acute pain and confined to a huge walking boot. The boot does offer some temporary relief, but try walking your 11 year-old to school through downtown Brooklyn in the boot featured in the images, and you'll understand that it's not a longterm solution.

After a two week battle to get an in-network podiatrist authorization (yes, it takes that along), I was able to see a surgeon who immediately ordered an Xray. Based on the images, which showed a hairline fracture as well as damaged areas of the achilles tendon or muscles that wraps around the heal, she ordered an MRI so she can determine the exact nature of my injury, and devise a treatment plan based on this critical information. In the meantime, I'll have to make do with the boot, pain meds and crutches as needed.

I was told I needed to schedule the MRI myself once it was called into the imaging center, and that they would get any pre-authorizations required by Anthem. Given my past troubles, I was sure this would not be a problem. My podiatrist assured me as well as SHE IS THE DOCTOR HERE, NOT ANTHEM. And the MRI was needed ASAP.

Well... SURPRISE... with a straight face, Anthem informed me yesterday that my MRI has been DENIED, deemed to be NOT a "medical necessity" by some imaginary Anthem "doctor" who somehow, without even reviewing the X-rays, determined what care is in my best interest.

I am livid. My scan is scheduled for Tuesday October 20th at 5PM. I'm working now to get through to both the provider, the imaging center and Anthem's appeal department (they only offer an "appeal portal" with no timeframe on when the Anthem Supreme Care Court might rule on my case).

In the meantime, the message I'm getting is this:

"Thank you for paying our massive premiums and meeting your huge deductible. We really appreciate your money. Since you met your massive deductible, we don't feel like paying for anything else until January, when your deductible resets and YOU will be responsible for scans of this nature, not us. This is how we become rich. Enjoy your pain, and good luck getting your daughter to school safely. Best, Anthem."

Attached is an image of my boot. How have others handled these situations where insurance "doctors" -- who have NOT examined injuries -- decide if the care requested by a specialist is a medical necessity?

I'd love to hear other stories, and how they were resolved, or not resolved. I'm going to fight this battle, even if I have to go out of pocket for the scan, and then invoice Anthem for reimbursement so I can share that story, too. Today, I can afford the scan, but millions of Americans being treated similarly or worse cannot afford a scan, are are left to suffer or die by ruthless, greedy insurance companies that could give AF about the care of their policy-holders.

He's Claiming North Texas Cities Are Getting Ripped Off for Millions by PBMs, I looked more into it and he owns a company called BetterBuy R & the prescription prices on there look pretty cheap. Any one heard of it?

I checked out the rest of this guys social his name is Don daud, hhes been going around to city councils in, I think just around Texas talking about how their self funded health plans are getting screwed by the PBM contracts. He specifically called out Frisco saying they're losing around $5 million a year because of the way their PBM deal works. He said the cost are going up yearly not because employees got sicker or anything, just because of a middleman markup that charges the city whatever they want.
Don't know if it's true or not but interesting stuff to dig in a rabbit hole of lots of info. Didnt know what PBM's are before this but I just found out we are the ONLY country in the world using them!!

Anyways someone of those prices on that website are lower than my health insurance deductible. By a lot. What the hell am I paying for. I wish out of pocket cash expenses could go towards my deductible if I used these coupons… what do you think about these big three PBM influence in health insurance, they seem to use them to process prescription drugs for all of us?

My wife and I will be on private insurance likely in the next few years.

She needs a Skyrizi prescription which is a speciality drug. Cost without insurance is about $30k per dose and is taken 4 times per year. Thankfully we have employee insurance that covers everything.

With that said, when we move onto private insurance (for personal reasons), we will hit our out of pocket max cost every year paying for this drug under all insurance plans.

Knowing that we will hit the OOP max every year, my question is when selecting a private health insurance plan, is it as simple as choosing the plan with the lowest total cost for “monthly premium“ + “OOP MAX”? Our goal is to minimize health care expenses.

Thanks in advance for helping us!

We got a denial letter for Medicaid, but I am waiting on them to decide after I questioned some things. I am worried that my kids won't have insurance in two weeks. It's just for them. So what happens if I sign up for ACA now, but in the next two weeks Medicaid approves them. What if I already paid for an ACA plan? I think you can cancel anytime, but would they refund it?

I'm dealing with pretty severe sciatica pain right now, and I'm getting really frustrated trying to get an MRI scheduled.

It's been almost thee weeks since my PCP said he put in an MRI order, but when I called my insurance company, they told me they haven't received anything from his office. Apparently, they're still waiting for the doctor to send the order over so they can begin the authorization process.

My PCP's office has honestly not been great about things in the past and visits are always incredibly brief and not very personal (comes in, shakes hand, types a bunch of the computer, gives me med refills, doesn't ask me if there's anything new so if I don't say something he'll just shake my hand and then leave) so I'm not particularly confident that this is going to get resolved quickly without me constantly following up. Meanwhile, I'm in a lot of pain, and I still can't even get the MRI process moving.

I'm not sure what my next step should be. Should I keep calling my doctor's office and pushing them to send the order, or is there another way to get this moving? Would it make sense to contact another doctor or switch PCPs altogether? At this point I want to switch PCPs but then I worry that I'll have to start this whole process over again. an MRI out of pocket would be $1260 if I don't use insurance.

I'm just exhausted from being in pain and feeling like I'm the one who has to coordinate everything to get basic medical care. I've been doing so much leg work on this yet no one is lifting a finger for me.

Has anyone dealt with something similar? What did you do to get your doctor to actually submit the MRI order for insurance authorization?

I almost wish I could sue my provider at this point because this is torture.

I am going to turn 26 at the end of December and will be off of my parent's insurance. I honestly do not know what to do or how to get insurance (or anything related to insurance as I never had to deal with it).

I am still a college student going to Oregon State University (Online). I also have a part-time job, and they are stingy on giving people a full-time position. It's a minimum wage job ($14/hr) so I don't make much money.

I live in TN.

I worry I won't be able to afford health insurance, as I can barely live with my current wage (it would be impossible if my partner wasn't making significantly more money and helping out). Marriage is not even close to a possibility.

Is getting Medicare/medicaid through the government an option since my work doesn't offer benefits unless you're full-time 🙄 ? If so, how would I go about that and how early should I start on that, or do I need to wait until I have no insurance?

I am worried as I am a woman, and I need to be able to afford to get my BC and the medications I need. This has been worrying me for a while, and I've not really been getting any help from anyone I know when I talk and ask about this.

Could someone please help explain the next steps, what my best options are, and whatever else I need to know going forward?

So my spouse got a new job with "affordable" health insurance for her but it's not affordable for the three of us (per the online calculator. Anyway, the new insurance through the employer is effective November 1st, 2026 but the kiddo and I will remain on our ACA plan. I plan on calling the Marketplace later today and setting up a cancellation for the ACA plan for my wife with an effective date of November 1st - we are paid up on our current ACA plan through the end of October so I don't want her insurance coverage to lapse at all but also don't want to have to pay the November ACA premium for all 3 of us either.

That being said, when I call this should be pretty straight forward correct? All I want to do is remove my spouse from our ACA plan and keep myself and our kiddo on our current ACA plan. I just want to make sure that they don't 'accidentally' cancel the ACA plan for all three of us. Any guidance in this regard would be helpful. Also do I need to contact Blue Cross (our ACA insurer) of the change as well?

I'm not sure how all this plays out in regards to an adjustment to our ACA premium and subsidy as we are going from (3) on the ACA plan to (2) but so our household size will go from 3 to 2 but I think my wife's income will still count so our subsidy will be less but our premium for November and December should be less as well correct? Will the Markeplace be able to tell me that new subsidy and premium information for November and December when I call?

Any guidance on this matter would be beneficial before I call as I don't want to screw anything up:)

Hello,

 I am in the union for 25 years. When I retire in about 6 years my family and I get lifetime medical insurance until Medicare kicks in at 65 then it becomes secondary.

This I assume is a big deal as if I was with “private” company I would not get this. I make around $200k a year but had some offers from private firms for almost double the salary.

What are my health insurance options in retirement(until 65) if I did not have my union insurance to cover my family(wife and child) ? Just pay out of pocket correct? Which I assume is about $2k month. Thanks for any input.

Pension is another story but have that under control. Just looking for health insurance advice.

I need some advice,I'm due to have surgery Nov 2.Im having the above procedure done and a hysterectomy.Which for that I have to put 1000 down.

I cant get charity assistance since the hospital said until after surgery. I have Anthem bluecross blueshield and im extremely depressed because im not able to come up with this. It is hard as it is coming up with the 1000 to put down to get my hysterectomy. I'm in pain and just sad because im not able to afford this. Any advice?

Hi there im 23 and just starting my first job! I will need health insurance and having a hard time picking one.

I dont have any really bad health issues. I do get allergy shots every 6 months, see a dermatologist for acne issues, and check ins with my doctor (and vaccines)

Here are my options:

Kaiser HMO
- 0 deductible
- 1,5000 OOPM

$ 80.40 every biweekly paycheck

BCBS EPO
- 500 deductible
- 3,500 OOPM

$100.17 every biweekly paycheck

BCBS PPO
- 750 deductible
- 5,000 OOPM

$110.98 every biweekly

BCBS is a more for copay. For example emergency care is 200 for BCBS and 100 for KAISER. Just stuck because I really only care for my allergy doctor. Any opinions would be AMAZING

Hey everyone, I’m feeling so overwhelmed right now. With open enrollment coming up and everything changing so fast, I spent the last 3 hours looking at HealthCare.gov and comparing plans (Kaiser, Blue Shield, etc.), and honestly? My brain is melting. The jargon, the deductibles, the hidden fees... it’s too much.

How do you guys deal with this? Is there any simple way, tool, or checklist you use to figure out which plan actually fits your budget without getting screwed over? Would love to know how you survive this process

Is there anything I can do about this? I’m frustrated I’m on the hook for $600+ when all I got out of it was a go buy something off Amazon we can’t help you

Hoping this group can help with which plan to change to. My employer sponsored plans are changing for 2027 and I’m not sure which is the best financially.

Current 2026 plan:

• Family plan for $344 a month
• High deductible so I contribute to my HSA
• Only recurrent medication I get is a GLP one for $25

2027 option A:

• Stay on the HSA plan for $404 a month
• $60 monthly increase
• GLP-1 is no longer covered. I’m responsible for the full price which looks like good RX has it for $149 a month.

2027 option B:

• higher deductible plan (increases from $3k to $6k deductible)
• not HSA eligible
• GLP -1 is covered but at $100 a month which is still a $75 increase

If my long-term strategy is to use an HSA as a Retirement vessel, would I be better off paying the higher GLP-1 cost now and keeping the HSA?

My husband quit his job in April which included a 100% employer-funded basic group policy plan. Got in writing that his end date would be with last date of employment, so we got a joint plan on Marketplace in his name (same plan I was already on individually but now combined and in his name). He just received a COBRA notice from his work insurance plan stating the termination date was in August. Confirmed with the insurance this was correct in their systems that the employer didn’t terminate until then. We’re unsure of what to do in this situation. Are there any steps to take or legal recourse for us to get the 3 months of premiums paid for another plan back? We’ve paid $1500 just for his portion of our joint premiums in the time the policy was supposed to end vs. actually did. Anyone been in this situation before?

We live in Illinois and through my husbands work have had BSBC Alabama for the last 20 years. We just received notice that the company is switching to Anthem BCBS. I have a chronic illness and have regular infusions and MRI to monitor this and have never experienced an insurance switch like this.

What should I expect during this change? Should I be worried? Does anyone have any experience on a switch like this or dealing the Anthem BCBS?

I run HR for a small company (28 employees) on a level funded health plan. Every month, our pharmacy claims report from kanurra lands in my inbox, and it lists employee names alongside their specific filled prescriptions.

Figured I would ask here too. I get Medicaid through the United healthcare community plan. I'm going to be losing my insurance in a couple months so I've been trying to get my wisdom teeth removed before then because they've been hurting more often.

I haven't been to my dentist in 4 years and the last time I was there, he gave me a referral to a surgeon but I got scared and didn't make the appointment.

I was going to make an appointment with my dentist for a cleaning and then mention my wisdom teeth, but they can't get me in until January which is after I lose my insurance.

I'm not sure what to do. I read most surgeons won't make me an appointment without a referral, and I also read Medicaid won't cover the surgery without a referral and an updated evaluation.

Can I ask my dentist to give me a referral over the phone even if I haven't been there in 4 years? What should I do?

So I started a new job last month, meaning as of the 1st of this month (October) I became eligible for medical insurance with them. I didn’t sign up until after October 1st, because there’s still another 2 weeks until my enrollment period ends. When I enrolled though, on the paperwork for most of the plans the coverage start date listed is still October 1st (one of the other plans has a start date of when I enrolled).

I haven’t gotten the member ID card in the mail yet and when I called the insurance, they said they couldn’t find a record of me and to contact my HR (who hasn’t replied yet). I have an appointment coming up I want to use my insurance for, so I guess I’m wondering if they still don’t have me in the system by the day of the appointment, does the retroactive coverage date listed still count? And if so, could I pay myself and then get reimbursed by my insurance?

On Marketplace insurance now and subsidized through 2026. In 2027, my income will not support a subsidy as it will be too high. I am eligible for Medicare 3-1-2027. The costs for the cheapest coverage is thousands per month. Do I just bubble wrap and keep living life clean for 59 days until I have my Medicare coverages in place? What to do?

Can’t play the Cobra game.