Author Topic: ACA.. no out of network coverage!  (Read 9475 times)

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
ACA.. no out of network coverage!
« on: February 17, 2018, 12:12:29 PM »
My insurance dropped all out of network coverage during the sign up process (they have to cover ER visits).. like right around the start of the year.

This is causing me probably an unreasonable amount of anxiety as my mind immediately goes to the worse possible outcome. E.g while driving across country I have a heart attack.. go to ER (OK so far) then immediately get sent to the Cath lab.. Min of $15,000 right there.

Or even worse.. get involved in a wreck and end up in the ICU.... bye bye to $200k easy!

So does anyone have a reasonable solution to this?.. Most of our shitty insurance cost (like $1100/m) is paid with subsidies so dropping some money on a supplimental plan seems reasonable.. Either that or stay within ambulance distance of our local hospital!

Currently suppressing thoughts of how much longer we can stay in the USA.

v8rx7guy

  • Handlebar Stache
  • *****
  • Posts: 1410
  • Location: Bellingham, WA
Re: ACA.. no out of network coverage!
« Reply #1 on: February 17, 2018, 12:20:57 PM »
How about a health sharing ministry?   It would cost half that and not have the coverage issues.

Zamboni

  • Magnum Stache
  • ******
  • Posts: 2504
Re: ACA.. no out of network coverage!
« Reply #2 on: February 17, 2018, 12:32:48 PM »
Egad, that is scary!

I support universal healthcare and a single payer system. It just doesn't make sense to me that providers can be "out of network" for ACA insurance. This is the problem of letting the middle men, private insurance corporations, profit tremendously from what should be a public good. Our entire system in the USA is so completely messed up and not up to first world standards anymore.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #3 on: February 17, 2018, 12:46:15 PM »
How about a health sharing ministry?   It would cost half that and not have the coverage issues.

Hmm.. wonder if you could do both?.. interesting idea.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #4 on: February 17, 2018, 12:46:55 PM »
Egad, that is scary!

I support universal healthcare and a single payer system. It just doesn't make sense to me that providers can be "out of network" for ACA insurance. This is the problem of letting the middle men, private insurance corporations, profit tremendously from what should be a public good. Our entire system in the USA is so completely messed up and not up to first world standards anymore.

I agree entirely but lets face it.. This system is going to get a whole lot worse before it gets better (if it ever does). Too many rich people making money on the system.. as are we to be honest.

Part of the reason of getting my citizenship is the freedom to move to other countries without the extra special taxation of aliens.

There is also a piece of me that says... "well, we have a lot of money.. in fact our NW is increasing at the rate of $1M every 4 years (assuming 10%/year gains historical average). So in 4 years (and probably even now) if we did get hit with a $200k bill it wouldn't affect our FIRED status.

Its probably a pretty low risk too.. but it causes me a great deal of anxiety..
« Last Edit: February 17, 2018, 12:52:46 PM by Exflyboy »

lhamo

  • Walrus Stache
  • *******
  • Posts: 9904
  • Location: Seattle
Re: ACA.. no out of network coverage!
« Reply #5 on: February 17, 2018, 01:00:42 PM »
Do travel policies cover in-country travel?   I've only ever purchased them for overseas travel, but those tend to be not TOO expensive (like $30-50/month, depending on age).  As long as you aren't doing extensive, long-term travel (some have limits of 60/90/180 days at a time and often similar caps for an annual period, and the least expensive can only be renewed 3-5 years in a row and not after ages 65-70), maybe something like that can cover you for the big "what ifs?"

Dr Kidstache

  • Stubble
  • **
  • Posts: 196
Re: ACA.. no out of network coverage!
« Reply #6 on: February 17, 2018, 01:06:00 PM »
Got no advice, but plenty of sympathy. I'm in the same boat with my ACA plan. ACA was the only insurance option for me because I am disabled. Out of network deductible $15,000 and NO out of pocket maximum.
Support single payer healthcare!

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #7 on: February 17, 2018, 01:11:42 PM »
Do travel policies cover in-country travel?   I've only ever purchased them for overseas travel, but those tend to be not TOO expensive (like $30-50/month, depending on age).  As long as you aren't doing extensive, long-term travel (some have limits of 60/90/180 days at a time and often similar caps for an annual period, and the least expensive can only be renewed 3-5 years in a row and not after ages 65-70), maybe something like that can cover you for the big "what ifs?"

I don't think so.. I used these when doing overseas business trips but they did not cover "in Country" travel.. Probably because "in- Country" meant "In-USA".

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #8 on: February 17, 2018, 01:17:29 PM »
Got no advice, but plenty of sympathy. I'm in the same boat with my ACA plan. ACA was the only insurance option for me because I am disabled. Out of network deductible $15,000 and NO out of pocket maximum.
Support single payer healthcare!

Ugh.. thats awful..:(

I love living in the USA, in many ways its the best place in the World.. I have 5.5 acres, view of the mountains, can buy almost anything I want. Try buying Oxy-acetylene, or the 2.5 gallon jugs of farmer strength weedkiller in Europe.. Good luck, not going to happen!

But this Healthcare thing (along with the National debt) is a major crisis that is getting exponentially worse. The ACA is certainly going to be dismantled at some point and then what are normal people without jobs going to do?.. Die or go bankrupt I assume.

PKate

  • 5 O'Clock Shadow
  • *
  • Posts: 84
  • Location: Northern New England
Re: ACA.. no out of network coverage!
« Reply #9 on: February 17, 2018, 01:30:48 PM »
Due to pre existing conditions and other restrictions the health sharing ministries were not a good fit for us but I know quite a few people who have been happy with them for many years. 

Since my DH is self employed we don't qualify for subsidies  in our state and we have very limited options.   Since I need access to lots of specialists the ACA plans would not work for us since most of the hospitals and doctors dropped the all the ACA plans at the beginning of the  year.  None of the ACA plans cover out of network providers in my state.

We wound up getting an individual plan off the ACA exchange due to the changes in the law that allows these plans again. It is crazy expensive $1371 per month for 2 adults and a $14,000 deductible/co pays per year. I live in a small HCOL state with very few insurance options so this is what we chose to go with. This won't change once my DH retires due how crappy the ACA options are in my state. 

It may be worth looking into off the ACA plans.  I had found them by searching the various insurance companies for them since they are not on the exchange.   
« Last Edit: February 18, 2018, 12:26:16 PM by PKate »

Laserjet3051

  • Pencil Stache
  • ****
  • Posts: 764
  • Age: 91
Re: ACA.. no out of network coverage!
« Reply #10 on: February 18, 2018, 10:21:39 AM »
Your posing gravely concerns me. My family and I have an ACA plan and my specific liability for services from an out of network provider is not clear. The summary of benefits and coverages only vaguely touches on my responsibilities for out of network services. I guess I will have to read the very long and detailed policy and then discuss this at length with a rep on the phone. I have found that things are described somewhat ambiguously in the policy which I guess affords the insurance company great lattitude in coverage.

The thought that if I drive down the road 30 minutes (and across the state line), and need emergency services, and the out of pocket maximum does not apply is frightening to say the least.

Paul der Krake

  • Magnum Stache
  • ******
  • Posts: 4647
  • Age: 11
  • Location: USA
Re: ACA.. no out of network coverage!
« Reply #11 on: February 18, 2018, 10:47:57 AM »
Wouldn't the ICU be considered as an ER visit?

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #12 on: February 18, 2018, 11:15:47 AM »
Wouldn't the ICU be considered as an ER visit?

Why would it?.. the ICU is definitely a different department within a hospital. I think any opportunity an insurer has to not pay they will jump on.

Maybe there is some rule somewhere that if you go directly to the ICU as a result of illness/injury that brought you into the ER must be covered, but I've not come across it.

RedefinedHappiness

  • Stubble
  • **
  • Posts: 157
Re: ACA.. no out of network coverage!
« Reply #13 on: February 18, 2018, 11:33:22 AM »
Exflyboy - have you called your insurance company?  Seems like you have a lot of anxiety (reasonable BTW) about the potential issue of being away from home and having an emergency. Perhaps you can ask them about what would happen if you have an ER visit out of network, but then are sent out of that hospital for care. Ask them all of your what if questions so you are prepared in the rare case this happens to you.

If you don't get the answers that make you feel more comfortable, are there other ACA options?

lhamo

  • Walrus Stache
  • *******
  • Posts: 9904
  • Location: Seattle
Re: ACA.. no out of network coverage!
« Reply #14 on: February 18, 2018, 11:39:56 AM »
This part of the underlying law that allows for out-of-network emergency room treatment without extra cost seems to indicate that care needs to be provided until the condition is stabilized:

"If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an "appropriate" transfer of the patient to another hospital must be done in accordance with the EMTALA provisions."

See https://www.acep.org/news-media-top-banner/emtala/#sm.0000xf4hf63otefxr1h24e1v9saq6

Does your policy include medivac coverage?  Or would adding that as a separate policy ease your concerns?


SnackDog

  • Handlebar Stache
  • *****
  • Posts: 1284
  • Location: Latin America
Re: ACA.. no out of network coverage!
« Reply #15 on: February 18, 2018, 11:45:00 AM »
It's not just ER visits that are exempt, it is "Emergency Care" which implies you don't have time to request authorization or select an in-network location without risking your life.  If you voluntarily select out of network care in an instance when it would not have affect your immediate well-being, it's on you.

chasesfish

  • Magnum Stache
  • ******
  • Posts: 3282
  • Age: 37
  • Location: Texas
Re: ACA.. no out of network coverage!
« Reply #16 on: February 18, 2018, 11:45:59 AM »
I'd like to know what you come up with.  I am struggling with one of my potential "short term" destinations in Early Retirement in Virignia only has a single ACA option offered by and restricted to an individual hospital network.  The challenge is my wife has a pre-existing condition primarily researched by and treated at a university hospital in NC.  NC and VA also have obscene insurance rates compared to Texas or Georgia.

Have you considered moving over to California for better options?

RedefinedHappiness

  • Stubble
  • **
  • Posts: 157
Re: ACA.. no out of network coverage!
« Reply #17 on: February 18, 2018, 11:49:26 AM »
I suspect when you call your insurer, they will outline exactly what lhamo found.

The other question you should probably ask your insurer is how this policy change impacts your out of pocket maximum. Ask them specifically if you were to spend x amount at an out of network facility/provider, how much of x would apply to your OOP maximum. If all, perhaps that can add some perspective to your concerns.

CrustyBadger

  • Pencil Stache
  • ****
  • Posts: 839
Re: ACA.. no out of network coverage!
« Reply #18 on: February 18, 2018, 12:02:04 PM »
I have heard of travel insurance for domestic trips.  One woman who had to travel for work asked her employer to buy her travel insurance when she traveled for work just for this reason.

Here's a company that offers 90 day insurance for travel within the US.  I don't know if there are others with shorter plans.

https://www.gninsurance.com/ihc-secure-short-term-medical-insurance/

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #19 on: February 18, 2018, 12:18:50 PM »
 just read the ACA regulation that applies to "emergency care" not just visits to an emergency room.. so thats good.

I guess in this day where you can be balanced billed even when you go to an ER in network, but get treated by an out of network doctor in that same hospital (for $thousands) then where does this end? Does not give me warm and fuzzy feelings at all.

I mean.. You go to an ER out of network.. the insurance company pays their standard amount and you get billed the balance for every damn service in the ER! I can't see what stops them doing this?

As to how to handle this situation?.. Well taking road trips across the US?.. No I don't think so.. Way too risky because the odds of being involved in a serious accident in the car are far higher than if you are in an airliner.. Sadly of course you can be "out of network" just 20 minutes down the road.. I guess the ambulance ride back to an in-network hospital when your situation is stabilised is cheaper the nearer you are.

Foreign vacation are less risky because cheap travel insurance is available.. but not if you are travelling across the US as far as I can tell.

@RedefinedHappiness  OOP is not relevant out of network. All of the ACA policies around here say there is NO coverage for out of network (but emergency services are covered... by law).. So any service you receive that is outside their definition of "emergency services".. or anything they can balance bill you for.. Well you're wide open. Our $6500 OOP max is irrelevant.

The question becomes if you can't be moved out of an ICU I assume means that your condition is not stabilised so would be covered under the "emergency services" provision.. To the extent that you are not balanced billed.

Thinking of moving to California?... We are thinking of moving out of the USA, which is a damn shame and maybe a little extreme..:)

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #20 on: February 18, 2018, 12:23:11 PM »
I have heard of travel insurance for domestic trips.  One woman who had to travel for work asked her employer to buy her travel insurance when she traveled for work just for this reason.

Here's a company that offers 90 day insurance for travel within the US.  I don't know if there are others with shorter plans.

https://www.gninsurance.com/ihc-secure-short-term-medical-insurance/

Good resource.. thanks.. I just priced a 90 day policy for us at $412.... Holy S......:)

CrustyBadger

  • Pencil Stache
  • ****
  • Posts: 839
Re: ACA.. no out of network coverage!
« Reply #21 on: February 18, 2018, 12:51:27 PM »
I have no experience with the company, just sharing as an example.

But did you experiment with higher deductibles and such?  If you are just taking a 2 week trip and are in decent health, you are just trying to insure for catastrophic accidents, right?

Mr. Green

  • Handlebar Stache
  • *****
  • Posts: 1986
  • Age: 36
  • Location: Wilmington, NC
Re: ACA.. no out of network coverage!
« Reply #22 on: February 18, 2018, 03:03:13 PM »
You can absolutely get travel insurance for trips inside the US if if would help you feel better. In 2016 when I quit my job and planned to hike the Appalachian Trail, I considered travel insurance to cover me for those 5 months rather than paying the ACA premiums since I had made enough money that I would be paying full boat. I would have been covered anywhere that was farther than 100 miles from home.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #23 on: February 18, 2018, 06:08:58 PM »
Well Oregon has passed legislation to prevent balance billing from In-network providers that starts March 1st.

Does nothing to prevent BB from out of network providers though, but its something.

https://www.beckershospitalreview.com/finance/oregon-legislature-passes-balance-billing-legislation.html

Zamboni

  • Magnum Stache
  • ******
  • Posts: 2504
Re: ACA.. no out of network coverage!
« Reply #24 on: February 18, 2018, 06:29:15 PM »
Two of the three best doctors I've ever had . . . have recently chosen to opt out of the system.

Our children's pediatrician let us know that it was simply no longer financially viable to have a solo practice. He always spent adequate time at appointments to take care of the root of the problem and explain what is happening and why. He closed his practice and is taking at least 6 months off before deciding what to do. My kids loved him, so it is sad, but they are probably past needing a pediatrician now.

Our general practitioner simply no longer accepts insurance. He gave us plenty of warning that this would happen, and continued to see my ex- for 6 months after the official deadline due to extensive ongoing problems, so I don't really begrudge him. Again, can't make the numbers work with insurance pay levels, which he said was drastically diluting his ability to provide good care by cutting into time length of all appointments. This why so many physicians are becoming out of network providers who balance bill. He is not even out of network . . . just doesn't take insurance at all. But, there are enough wealthy people near his office that he believes he can survive by offering "concierge" service. Of course, most of the people he sees have to have insurance anyway in case of massive medical problems. A student of mine recently told me that his physician dad, in another state, is doing the same thing.

That is where we are now in the USA. And, as you say, it seems that in the foreseeable future it is only going to get worse.
« Last Edit: February 18, 2018, 08:45:02 PM by Zamboni »

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #25 on: February 18, 2018, 08:16:45 PM »
I think your spot on Zamboni.. The wheels are coming off the US healthcare system. Sadly as always its the people without resources (namely money) that come off the worse. These folks are the one ones with not much of a voice either.

It seems kinda crazy but if a $200,000 ER/ICU bill came from a "balanced billed" freak accident out of network, there are lots of folks who can afford this.. We might not like it but we can afford it.

On the very bottom end of the economic spectrum I guess you can't get blood out of a stone so likely if this happened to a really poor person then their lot can't be much worse.

The ones in the middle I guess just go bankrupt.. Like they always did.

Add to that the providers that are opting out of the insurance system and I guess eventually we will all have to simply pay out of pocket.

What a freaking mess this system is!.. Just avoid needing serious healthcare seems to be the answer!

FrugalZony

  • Handlebar Stache
  • *****
  • Posts: 1472
Re: ACA.. no out of network coverage!
« Reply #26 on: February 18, 2018, 08:33:06 PM »
When we looked at ACA we realised that none of the very very limited options in AZ offered any coverage outside AZ.
We already knew we'd be travelling within the US but outside of AZ most of the year, so we purchased travel insurance.

If you are in the UK regularly you may want to see what travel health insurance are offered through UK insurers, which may get you a better deal than what US insurers offer.

We pay 500 ish Euros per year for that, it's actually pretty good coverage.
You have certain limitations to qualify, which I won't go into detail, because it's probably not relevant to you, as it is from another country.

However, you may be able to get something similar in the UK for "travels" in the US.

Zamboni

  • Magnum Stache
  • ******
  • Posts: 2504
Re: ACA.. no out of network coverage!
« Reply #27 on: February 18, 2018, 09:06:48 PM »
"The Racines wanted access to care when they needed it."

https://www.dukehealth.org/treatments/duke-signature-care

For a low subscription fee of $2500 per person, per year, you can have access to a primary care physician who will have same day or next day appointments available when you are sick. You still have to pay for all of the appointment costs additionally, of course. The subscription fee is just to have the option to be able to get an appointment with your doctor, who is familiar with your healthcare, instead of seeing the random doc in a box at an urgent care.

Huh, I kind of thought that was the whole point of primary care physicians. Silly me.

Unfortunately, exflyboy, this won't help at all when traveling . . .

boarder42

  • Walrus Stache
  • *******
  • Posts: 7849
Re: ACA.. no out of network coverage!
« Reply #28 on: February 19, 2018, 06:47:54 AM »
again healthshare is the WTG it seems as the US still struggles to figure this out.  as more doctors stop accepting insurance - the non for profit healthsharing companies will continue to grow.  Really would be cool to start an RE one where you just had to believe in the freedom of financial independence vs some higher power. 

katsiki

  • Handlebar Stache
  • *****
  • Posts: 1451
  • Age: 39
  • Location: La.
Re: ACA.. no out of network coverage!
« Reply #29 on: February 19, 2018, 06:57:42 AM »
"The Racines wanted access to care when they needed it."

https://www.dukehealth.org/treatments/duke-signature-care

For a low subscription fee of $2500 per person, per year, you can have access to a primary care physician who will have same day or next day appointments available when you are sick. You still have to pay for all of the appointment costs additionally, of course. The subscription fee is just to have the option to be able to get an appointment with your doctor, who is familiar with your healthcare, instead of seeing the random doc in a box at an urgent care.

Huh, I kind of thought that was the whole point of primary care physicians. Silly me.

Unfortunately, exflyboy, this won't help at all when traveling . . .

Wow!  This is $50-60 per month in my neck of the woods.

Holyoak

  • Bristles
  • ***
  • Posts: 447
  • Age: 53
Re: ACA.. no out of network coverage!
« Reply #30 on: February 19, 2018, 10:43:25 AM »
Your situation, my situation, and countless others with regard to healthcare concerning OON, and a myriad of other concerns, demonstrates exactly just how eff'd up the entire system is.  I just received my new plan paperwork, I mean 82 front and back pages 'book' - you gotta be kidding me.  The OON section was vauge, cryptic, and I felt like I needed an attorney in order to decipher it.  The very first thing I do when considering a potential move, is to first check the healthcare cost/availability...  So many times I will be recommended a place, only to find the healthcare options are a complete joke, so scratch another one.

How I envy places where you can be employed at whatever level of income, be ER even, and not fear being wiped out by a hospital stay, financially ruined by a costly diagnosis, or being limited to venture out because of our crappy system.  I don't see how the entire system can last much longer, be it ACA, or otherwise.  This system now is complete madness...  So you are medically saved (If you are lucky), just to wiped out financially...  No wonder suicide and hard drug abuse is on the rise for some in this country, and the absolute crime in that it seems this is the best that can be done?

Zamboni

  • Magnum Stache
  • ******
  • Posts: 2504
Re: ACA.. no out of network coverage!
« Reply #31 on: February 19, 2018, 11:19:43 AM »
I'm not surprised that the no longer offer OON coverage.

tl;dr: they never wanted to pay the OON claims in the first place!

Insurance companies often won't even pay their portion of the OON when that is in your contract. I had a c-section at an in-network hospital (and the OB-GYN I chose was in network). But, a couple of months later I learned that, SURPRISE, the anesthesiologists at that hospital are all OON. Still, my insurance at that time was supposed to cover a very high percentage of it.

Insurance then played a paperwork game. They would deny the claim for improper procedure code, then the next time deny for improper dose code. They alternated these two "improper code" reasons for more than 2 full years . . . denying the claim more than a dozen times. This whole time, the doctor's office was also sending me bills for the full amount, which was thousands of dollars. I would call each time and patiently chat with people at both the doctor's office and insurance company.

Then, by chance, I saw in the newspaper that the state had fined this particular insurance company tens of millions of dollars for not paying OON claims they were supposed to pay. Now I knew that I did have some recourse: I finally got fed up and filed a formal complaint with my state's department of insurance (DOI), submitting copies of all of the paperwork I had on the claims denials and all of the phone notes I had (at that point I'd probably talked to the doctor's billing office and the insurance office more than 5 times each over the two years, each time being polite as I could be, and I took meticulous notes each time: date, time, name of person to whom I spoke, exactly what they said to me, in quotations.)

Insurance paid the claim less than 2 weeks after I was contacted by a social worker from the DOI who had reviewed my paperwork; at this point their new reason for why they hadn't paid before was that the doctor's office was mailing the claims to the wrong address all along. . . even though I had statement of benefits documents showing their detailed rationale for denying each of those claims (claims which they now say had been mailed to wrong address, what a joke.) It would be funny if it was not so ridiculous.

New strategy since then is that I just take a short cut on the phone with the insurance company the first time:
"I have made a good faith effort to follow proper procedures, and it is clear to me that the provider has also made a good faith effort. If this claim doesn't get paid this time, then my next step will be to file a formal complaint with the state's Department of Insurance." This language seems to get their full effort in paying the claim. Ridiculous that it has come to this.

Recently I had the problem where my work insurance refused to pay their portion of my urgent care claim while I was traveling on business. Again, round and round and round. My DOI threat seemed to fall on deaf ears (probably the insurance company doesn't operate in the state of the provider in this case.) Eventually it got sent to collections, and I wrote back to the collections agency that the remaining balance was in dispute. I sort of feel like a shit for doing this . . . it was only a few hundred dollars, and the doc is the one getting screwed.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #32 on: February 19, 2018, 11:48:02 AM »
Well in effect there is zero OON coverage.. Yes they say that by law they have to provide OON for emergency services, but that simply means they will pay a small percentage of the claim and then you will be "balanced billed: for the rest of it.

Namely OON coverage for any service, emergency or otherwise is worthless.. or close to worthless.

v8rx7guy

  • Handlebar Stache
  • *****
  • Posts: 1410
  • Location: Bellingham, WA
Re: ACA.. no out of network coverage!
« Reply #33 on: February 19, 2018, 02:16:31 PM »
again healthshare is the WTG it seems as the US still struggles to figure this out.  as more doctors stop accepting insurance - the non for profit healthsharing companies will continue to grow.  Really would be cool to start an RE one where you just had to believe in the freedom of financial independence vs some higher power.

"The religion of MMM"... I think that could work for a new health share, right?  Interestingly, I was listening to the ChooseFI podcast on friday, and it seems someone who has some experience in the area is thinking about it.  We will have to see if anything actually comes of it, I believe there is an open door now that there is no longer a penalty for no "insurance" coverage.

FrugalZony

  • Handlebar Stache
  • *****
  • Posts: 1472
Re: ACA.. no out of network coverage!
« Reply #34 on: February 19, 2018, 07:59:13 PM »
The "beef" I have with healthshare is that all I looked into are faith based and thus can refuse a bunch of things that are against their beliefs,
which does not sit well with me.
Also technically they are legally not required to pay.
So there's that.

The thing is you cannot start a new one now, we have tossed the idea around before, because the healthshares that are grandfathered in to qualify as ACA compatible are several years old and there is a requirement, that they had to be around for a certain number of years before that.

Otherwise, starting a non faith based one would be a good idea.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #35 on: February 19, 2018, 09:34:10 PM »
After a few days of thinking about this I come to the following conclusions... Its not much and I don't like it but its the best I got for now.

Two options..

1) Move out of the country.. Literally this is about the only real solution.

2) financially protect ourselves in some manner from a big fat medical bill for the freak accident event.. which means..

a)  Take out supplimental in country travel insurance ($412/month for us)
b)  Make sure you can drop $100 to 200K should you end up in the ICU after a accident/stroke/flesh eating bacterial event more than 50 miles from home.
c) Never be more than say 20 miles from an in network hospital.
d) Possibly go with a HC ministry but @FrugalZony pointed to issues that align with my own thoughts.


I don't think I will insure against such an event, its too rare and when you start paying for insurance you are guaranteeing losing nearly $5000/year. I think if dropping $200k on such an event would devastate us financially then I'd probably be buying the insurance, but even though the thought of such an event pisses me off basically you better make sure you got this kind of money because it could happen.

obstinate

  • Pencil Stache
  • ****
  • Posts: 916
Re: ACA.. no out of network coverage!
« Reply #36 on: February 19, 2018, 09:46:00 PM »
The "beef" I have with healthshare is that all I looked into are faith based and thus can refuse a bunch of things that are against their beliefs,
which does not sit well with me.
Also technically they are legally not required to pay.
So there's that.
They will also all eventually go bankrupt as their long-standing members become sick and their costs go up.

FrugalZony

  • Handlebar Stache
  • *****
  • Posts: 1472
Re: ACA.. no out of network coverage!
« Reply #37 on: February 19, 2018, 09:51:53 PM »
After a few days of thinking about this I come to the following conclusions... Its not much and I don't like it but its the best I got for now.

Two options..

1) Move out of the country.. Literally this is about the only real solution.

2) financially protect ourselves in some manner from a big fat medical bill for the freak accident event.. which means..

a)  Take out supplimental in country travel insurance ($412/month for us)
b)  Make sure you can drop $100 to 200K should you end up in the ICU after a accident/stroke/flesh eating bacterial event more than 50 miles from home.
c) Never be more than say 20 miles from an in network hospital.
d) Possibly go with a HC ministry but @FrugalZony pointed to issues that align with my own thoughts.


I don't think I will insure against such an event, its too rare and when you start paying for insurance you are guaranteeing losing nearly $5000/year. I think if dropping $200k on such an event would devastate us financially then I'd probably be buying the insurance, but even though the thought of such an event pisses me off basically you better make sure you got this kind of money because it could happen.

A couple of other options:
1) Instead of leaving the country, consider becoming resident of a different state that may have better coverage / national coverage,
which is easier in some states than in others
2) Get underwritten, non ACA coverage, which means you'll forego the subsidy in case you are eligible
3) Get world travel insurance based on being a UK citizen as well (will usually be limited to a certain number of years, but can be reset by revisiting the UK, will probably need a UK address to qualify, which should be easily doable, considering you have family there)
4) self insure for freak stuff, until you can get back into your network, which considering your NW is certainly an option (would be painful, sure but not the end of the world).

boarder42

  • Walrus Stache
  • *******
  • Posts: 7849
Re: ACA.. no out of network coverage!
« Reply #38 on: February 20, 2018, 05:46:22 AM »
The "beef" I have with healthshare is that all I looked into are faith based and thus can refuse a bunch of things that are against their beliefs,
which does not sit well with me.
Also technically they are legally not required to pay.
So there's that.

The thing is you cannot start a new one now, we have tossed the idea around before, because the healthshares that are grandfathered in to qualify as ACA compatible are several years old and there is a requirement, that they had to be around for a certain number of years before that.

Otherwise, starting a non faith based one would be a good idea.

in all likelihood the ACA will be dismantled and that option would be available again.  all the technicalities you mention are so they dont have to abide by the govt laws for insurance regulations which allows for them to operate much cheaper.  at the end of the day any reasonable person could see expansion of medicare or some medicare like service for all would likely be the cheapest path for everyone - while offering tax incentivized credits for getting annual physicals, preventative care, and meeting certain healthy requirements or taking health coaching classes.  but the insurance companies line the pockets of politicians on both sides of the aisle so this isnt likely to happen.

lhamo

  • Walrus Stache
  • *******
  • Posts: 9904
  • Location: Seattle
Re: ACA.. no out of network coverage!
« Reply #39 on: February 20, 2018, 07:37:13 AM »
I did a fair amount of googling about this yesterday.  It looks to me that most people who have run into problems are bureaucratically savvy enough to be able to get any unreasonable charges waived once they challenge them.  In a couple of cases, reporting the insurance company to the state regulatory body for insurance was the ticket.

I know the whole healthcare/insurance situation is frustrating, but I really don't think this is going to be a problem for you, Frank.  If you decide you want to move back to the UK for other reasons as well, that is fine.  But I don't think this should be the issue that drives your decision-making. 

FWIW, my mom had a 5-day hospital stay near the end of her life,including 2 days in the level just under the ICU because they wanted higher-level monitoring of her heart function when she first was admitted.  I haven't seen the bills, but my sister tells me it was around $35k total.  My mom's share came to around $1500.  Yes, that was in a local, in-network facility.   But even if she had been billed for the whole thing she would have been fine financially.




Meowmalade

  • Handlebar Stache
  • *****
  • Posts: 1579
  • Location: Portland, OR
  • Like "Marmalade". Not like an ailing French cat.
Re: ACA.. no out of network coverage!
« Reply #40 on: February 20, 2018, 09:48:43 AM »
We might be in the same position in a few years... Blue Cross Blue Shield seems widely accepted across America.  I checked and all the doctors Iím currently using (with Providence insurance) also accept BCBS.  Itís not available on ACA but might be worth paying the premium!
https://www.bcbs.com/articles/coverage-goes-where-you-go-travel-worry-free-blue-cross-blue-shield

boarder42

  • Walrus Stache
  • *******
  • Posts: 7849
Re: ACA.. no out of network coverage!
« Reply #41 on: February 20, 2018, 10:13:41 AM »
We might be in the same position in a few years... Blue Cross Blue Shield seems widely accepted across America.  I checked and all the doctors Iím currently using (with Providence insurance) also accept BCBS.  Itís not available on ACA but might be worth paying the premium!
https://www.bcbs.com/articles/coverage-goes-where-you-go-travel-worry-free-blue-cross-blue-shield

they dont even show me an option to buy health insurance as an individual other than short term dental or travel.  its pretty absurd what the ACA has done to the healthcare system.  The way it was implemented made it not sustainable if any other political view to healthcare were to take office.  i still think the issue will be solved by the time i reach retirement age. in 5-6 years the landscape will be dramatically different but i do feel for all those FIREes dealing with this now- my boss wants to retire and probably would have 3-4 years ago but he's working til he can buy our company insurance.

v8rx7guy

  • Handlebar Stache
  • *****
  • Posts: 1410
  • Location: Bellingham, WA
Re: ACA.. no out of network coverage!
« Reply #42 on: February 20, 2018, 10:26:21 AM »
The "beef" I have with healthshare is that all I looked into are faith based and thus can refuse a bunch of things that are against their beliefs,
which does not sit well with me.
Also technically they are legally not required to pay.
So there's that.

The thing is you cannot start a new one now, we have tossed the idea around before, because the healthshares that are grandfathered in to qualify as ACA compatible are several years old and there is a requirement, that they had to be around for a certain number of years before that.

Otherwise, starting a non faith based one would be a good idea.

If you're not willing to play by the rules, then don't get it.  It's a great opportunity for people who live low risk lifestyles and that's why it works.  It's my opinion that it would also work great in a group like the MMM who generally live healthy low-risk lifestyles too.  In all technicalities, they don't have to pay... but as far as I know, that does not (ever?) happen.  And there are heath shares that have been around for a long time.  Radical Personal Finance has a great podcast on Health Shares, and it is his current form of insurance.  It's worth a listen.

I was under the impression that new health shares were allowed, they just wouldn't be grandfathered into the exemption from the ACA individual mandate.  That was at least what I found when I researched it.

Paul der Krake

  • Magnum Stache
  • ******
  • Posts: 4647
  • Age: 11
  • Location: USA
Re: ACA.. no out of network coverage!
« Reply #43 on: February 20, 2018, 10:55:53 AM »
I'm not too worried either. My plan is to buy a decent plan with some out-of-network coverage, and wing the rest. I don't worry about helicopter coverage when I go out in the mountains. I just do it, and if shit happens we'll deal with it.

As lhamo said, you can negotiate this shit down to "reasonable" levels, because all the prices are pure BS to begin with. They know full well that hospital prices are not grounded in reality and are just throwing shit at the wall to see what sticks. Bury them in paperwork, appeals, and counteroffers. Offer to pay them $100 per month until you die if it comes to it. As an early retiree, you have access to time and money that isn't available to the other poor suckers who get dragged into this.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #44 on: February 20, 2018, 11:20:13 AM »
I did a fair amount of googling about this yesterday.  It looks to me that most people who have run into problems are bureaucratically savvy enough to be able to get any unreasonable charges waived once they challenge them.  In a couple of cases, reporting the insurance company to the state regulatory body for insurance was the ticket.

I know the whole healthcare/insurance situation is frustrating, but I really don't think this is going to be a problem for you, Frank.  If you decide you want to move back to the UK for other reasons as well, that is fine.  But I don't think this should be the issue that drives your decision-making. 

FWIW, my mom had a 5-day hospital stay near the end of her life,including 2 days in the level just under the ICU because they wanted higher-level monitoring of her heart function when she first was admitted.  I haven't seen the bills, but my sister tells me it was around $35k total.  My mom's share came to around $1500.  Yes, that was in a local, in-network facility.   But even if she had been billed for the whole thing she would have been fine financially.

Agreed, I know I go to the extreme when it comes to risk. From my googling yesterday I was finding the ICU's charge between $10k and $25k per day depending on the level of intervention required. Lets say the in network negotiated rate is $5k then that means the balance of up to $20k per day would probably be balanced billed directly.. Then the negotiations start.

So a financial exposure in the $200k range is quite feasible.. But then, Am I likely to ride a motorcycle across country after this revelation?.. Heck NO! In other words one does what one can to minimise the exposure to high risk situations.

Last year I drove a car across country for some friends who were moving... I probably wouldn't do that now without buying some kind of travel insurance.

Even a $200k hit would not derail us financially and its a "black swan" event so we can live with it for now. Like you say, its not a big enough reason to move to a different country in itself.


Meowmalade

  • Handlebar Stache
  • *****
  • Posts: 1579
  • Location: Portland, OR
  • Like "Marmalade". Not like an ailing French cat.
Re: ACA.. no out of network coverage!
« Reply #45 on: February 20, 2018, 11:35:41 AM »
We might be in the same position in a few years... Blue Cross Blue Shield seems widely accepted across America.  I checked and all the doctors Iím currently using (with Providence insurance) also accept BCBS.  Itís not available on ACA but might be worth paying the premium!
https://www.bcbs.com/articles/coverage-goes-where-you-go-travel-worry-free-blue-cross-blue-shield

they dont even show me an option to buy health insurance as an individual other than short term dental or travel.  its pretty absurd what the ACA has done to the healthcare system.  The way it was implemented made it not sustainable if any other political view to healthcare were to take office.  i still think the issue will be solved by the time i reach retirement age. in 5-6 years the landscape will be dramatically different but i do feel for all those FIREes dealing with this now- my boss wants to retire and probably would have 3-4 years ago but he's working til he can buy our company insurance.

BCBS goes through different providers depending on your state, so you'd have to look that up-- in Oregon it's Regent.  I just posted that link that shows that BCBS is accepted nationwide by 90% of providers.  From other sources that I googled, it looks like the best option for having the most in-network providers across America.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #46 on: February 20, 2018, 11:56:04 AM »
We might be in the same position in a few years... Blue Cross Blue Shield seems widely accepted across America.  I checked and all the doctors Iím currently using (with Providence insurance) also accept BCBS.  Itís not available on ACA but might be worth paying the premium!
https://www.bcbs.com/articles/coverage-goes-where-you-go-travel-worry-free-blue-cross-blue-shield

they dont even show me an option to buy health insurance as an individual other than short term dental or travel.  its pretty absurd what the ACA has done to the healthcare system.  The way it was implemented made it not sustainable if any other political view to healthcare were to take office.  i still think the issue will be solved by the time i reach retirement age. in 5-6 years the landscape will be dramatically different but i do feel for all those FIREes dealing with this now- my boss wants to retire and probably would have 3-4 years ago but he's working til he can buy our company insurance.

BCBS goes through different providers depending on your state, so you'd have to look that up-- in Oregon it's Regent.  I just posted that link that shows that BCBS is accepted nationwide by 90% of providers.  From other sources that I googled, it looks like the best option for having the most in-network providers across America.

As others have pointed out, the ACA s probably going to die a death in the next few years like it or not. One of the advantages if it were to be replaced with nothing (hard to imagine the backlash if that happened) is that in theory one would be "free" to buy any policy you wanted.

Assuming the Government kicked in some $$ to ease the transition then maybe the BCBS option might even be partially Government funded.

Wonder if we can get our income below the Medicaid cut off?...:)

katsiki

  • Handlebar Stache
  • *****
  • Posts: 1451
  • Age: 39
  • Location: La.
Re: ACA.. no out of network coverage!
« Reply #47 on: February 20, 2018, 12:27:15 PM »
I would be careful assuming BCBS or anyone else will solve this issue.  I got a big fat bill for out of network ER & ambulance service years ago, despite being in a Blue cross coverage area.  (It was in another state).  The ER work did eventually get covered but the ambulance was out of pocket.  Fought it for about a year before declaring defeat.

Exflyboy

  • Walrus Stache
  • *******
  • Posts: 6500
  • Age: 58
  • Location: Corvallis, Oregon
  • Expat Brit living in the New World..:)
Re: ACA.. no out of network coverage!
« Reply #48 on: February 20, 2018, 01:01:57 PM »
I would be careful assuming BCBS or anyone else will solve this issue.  I got a big fat bill for out of network ER & ambulance service years ago, despite being in a Blue cross coverage area.  (It was in another state).  The ER work did eventually get covered but the ambulance was out of pocket.  Fought it for about a year before declaring defeat.

I don't there is any real solution.. Pretty much what every insurance, provider, Government is doing right now is pushing around paper and not dealing with the underlying issue.. i.e that HC is just too damned expensive. I.e figuring out who will pay the ever increasing costs, not reducing those costs... Which just leads to huge bills like your landing in the Patients lap.

Pretty much all we can do right now is to try to avoid/insulate ourselves from financial ruin.. I.e don't do risky things in places where you have no coverage, and/or have a shitpile of money big enough to drop on any eventuality without is undermining one's FI status... If not, buy extra insurance or take the risk.

I did see on Yahoo that HC costs are still rising fast.. Sooner or later ordinary people simply won't be able to afford HC.


Meowmalade

  • Handlebar Stache
  • *****
  • Posts: 1579
  • Location: Portland, OR
  • Like "Marmalade". Not like an ailing French cat.
Re: ACA.. no out of network coverage!
« Reply #49 on: February 20, 2018, 02:15:22 PM »
I would be careful assuming BCBS or anyone else will solve this issue.  I got a big fat bill for out of network ER & ambulance service years ago, despite being in a Blue cross coverage area.  (It was in another state).  The ER work did eventually get covered but the ambulance was out of pocket.  Fought it for about a year before declaring defeat.

Ugh  :(  Would you mind sharing how much the ambulance cost?