Author Topic: ACA.. no out of network coverage!  (Read 9487 times)

boarder42

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Re: ACA.. no out of network coverage!
« Reply #50 on: February 20, 2018, 02:27:34 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.

correct we can argue til we are blue in the face about who's paying the bill but the real problem is the cost. 

katsiki

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Re: ACA.. no out of network coverage!
« Reply #51 on: February 20, 2018, 06:46:54 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?

It was about $1,100 as I recall.

This was before ACA if that matters at all.

EFB, I agree with you.  I wish folks would think out of the box in the govt or get out of the way.  I am intrigued by Amazon/JPMorgan idea but I need to learn more about it.

Rural

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Re: ACA.. no out of network coverage!
« Reply #52 on: February 21, 2018, 06:30:21 AM »
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?

It was about $1,100 as I recall.

This was before ACA if that matters at all.

EFB, I agree with you.  I wish folks would think out of the box in the govt or get out of the way.  I am intrigued by Amazon/JPMorgan idea but I need to learn more about it.


I paid $1,600 out of pocket for an ambulance ride a couple years after ACA started, in a rural, extreme LCOL area. Of course, it was about 25 miles (nearest hospital to the area I was travelling to at the time). It did count toward my deductible on a high deductible plan. That probably means it was in network or (more likely) was counted as such because of the emergency situation.

boarder42

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Re: ACA.. no out of network coverage!
« Reply #53 on: February 21, 2018, 06:38:22 AM »
There are more and more healthshares starting to pop up as it seems the ACA mandate will be gone opening the door for new ones not grandfathered. 

Altura and Sedera are 2 new ones i've seen popup ... i think the healthshare side of the world will fix this. - no insurance red tape - just a group of people who call the doctors and hospitals to negotiate the services down.  eventually if enough people transition to this model it will be the death of insurance and hospitals and doctors will just start charging rates to maintain profit and you can eliminate the people who call or at least use a computer alogrithm to determine what claims seem excessive and scale back the negotiator pool.  This all leads to more clear and upfront pricing while allowing people to be covered the way insurance was intended - people helping people  when others are down.

The individual mandate killed the free market - so while i understand its intentions were good- i think it actually hurt the people who work for smaller companies or those who own small business or were like those here - retired prior to medicaid.
« Last Edit: February 21, 2018, 06:41:22 AM by boarder42 »

katsiki

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Re: ACA.. no out of network coverage!
« Reply #54 on: February 21, 2018, 11:35:21 AM »
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?

It was about $1,100 as I recall.

This was before ACA if that matters at all.

EFB, I agree with you.  I wish folks would think out of the box in the govt or get out of the way.  I am intrigued by Amazon/JPMorgan idea but I need to learn more about it.


I paid $1,600 out of pocket for an ambulance ride a couple years after ACA started, in a rural, extreme LCOL area. Of course, it was about 25 miles (nearest hospital to the area I was travelling to at the time). It did count toward my deductible on a high deductible plan. That probably means it was in network or (more likely) was counted as such because of the emergency situation.

You may be right.  We were young and confused back then :)

It was odd in that a previous ambulance trip was "free" under the same insurance locally.  This was a short trip but in an expensive state.

Dr Kidstache

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Re: ACA.. no out of network coverage!
« Reply #55 on: February 21, 2018, 11:53:44 AM »
... i think the healthshare side of the world will fix this. - no insurance red tape - just a group of people who call the doctors and hospitals to negotiate the services down.  eventually if enough people transition to this model it will be the death of insurance and hospitals and doctors will just start charging rates to maintain profit and you can eliminate the people who call or at least use a computer alogrithm to determine what claims seem excessive and scale back the negotiator pool.  This all leads to more clear and upfront pricing while allowing people to be covered the way insurance was intended - people helping people  when others are down.

Unless you have a pre-existing condition, have cancer (some of them exclude coverage for cancer), believe that reproductive health care is a human right,  etc.... The healthshares may be a good option for some healthy folks who can self-insure for many medical costs and have no issue with religious restrictions on healthcare. But they leave out huge swaths of the population who need health care and shift all the cost/risk to ACA insurers and government insurance.

chasesfish

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Re: ACA.. no out of network coverage!
« Reply #56 on: February 21, 2018, 02:20:59 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?

It was about $1,100 as I recall.

This was before ACA if that matters at all.

EFB, I agree with you.  I wish folks would think out of the box in the govt or get out of the way.  I am intrigued by Amazon/JPMorgan idea but I need to learn more about it.


I paid $1,600 out of pocket for an ambulance ride a couple years after ACA started, in a rural, extreme LCOL area. Of course, it was about 25 miles (nearest hospital to the area I was travelling to at the time). It did count toward my deductible on a high deductible plan. That probably means it was in network or (more likely) was counted as such because of the emergency situation.

$1500 for 3 miles in the City of Dallas last year.  No discounted rate with insurance.  Insurance paid $1200 and we paid $300.  I see why people take uber to the ER

Rural

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Re: ACA.. no out of network coverage!
« Reply #57 on: February 21, 2018, 05:51:20 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?

It was about $1,100 as I recall.

This was before ACA if that matters at all.

EFB, I agree with you.  I wish folks would think out of the box in the govt or get out of the way.  I am intrigued by Amazon/JPMorgan idea but I need to learn more about it.


I paid $1,600 out of pocket for an ambulance ride a couple years after ACA started, in a rural, extreme LCOL area. Of course, it was about 25 miles (nearest hospital to the area I was travelling to at the time). It did count toward my deductible on a high deductible plan. That probably means it was in network or (more likely) was counted as such because of the emergency situation.

$1500 for 3 miles in the City of Dallas last year.  No discounted rate with insurance.  Insurance paid $1200 and we paid $300.  I see why people take uber to the ER


Yeah, I do, too. But in my situation 1) no Uber in the sticks and 2) I needed paramedics. I just paid it without too much complaining.

marcela

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Re: ACA.. no out of network coverage!
« Reply #58 on: February 22, 2018, 09:23:52 AM »
... i think the healthshare side of the world will fix this. - no insurance red tape - just a group of people who call the doctors and hospitals to negotiate the services down.  eventually if enough people transition to this model it will be the death of insurance and hospitals and doctors will just start charging rates to maintain profit and you can eliminate the people who call or at least use a computer alogrithm to determine what claims seem excessive and scale back the negotiator pool.  This all leads to more clear and upfront pricing while allowing people to be covered the way insurance was intended - people helping people  when others are down.

Unless you have a pre-existing condition, have cancer (some of them exclude coverage for cancer), believe that reproductive health care is a human right,  etc.... The healthshares may be a good option for some healthy folks who can self-insure for many medical costs and have no issue with religious restrictions on healthcare. But they leave out huge swaths of the population who need health care and shift all the cost/risk to ACA insurers and government insurance.

DING, DING, DING! Healthshares will never be an option for me because I have chronic health issues that have in the past led to extremely expensive multiple month hospital stays. I wasn't able to get insurance on the individual market either back before the ACA. Luckily I'm covered through work now, but if I were to lose my job and healthshares were my only option I'd be SOL.

boarder42

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Re: ACA.. no out of network coverage!
« Reply #59 on: February 22, 2018, 10:22:26 AM »
... i think the healthshare side of the world will fix this. - no insurance red tape - just a group of people who call the doctors and hospitals to negotiate the services down.  eventually if enough people transition to this model it will be the death of insurance and hospitals and doctors will just start charging rates to maintain profit and you can eliminate the people who call or at least use a computer alogrithm to determine what claims seem excessive and scale back the negotiator pool.  This all leads to more clear and upfront pricing while allowing people to be covered the way insurance was intended - people helping people  when others are down.

Unless you have a pre-existing condition, have cancer (some of them exclude coverage for cancer), believe that reproductive health care is a human right,  etc.... The healthshares may be a good option for some healthy folks who can self-insure for many medical costs and have no issue with religious restrictions on healthcare. But they leave out huge swaths of the population who need health care and shift all the cost/risk to ACA insurers and government insurance.

DING, DING, DING! Healthshares will never be an option for me because I have chronic health issues that have in the past led to extremely expensive multiple month hospital stays. I wasn't able to get insurance on the individual market either back before the ACA. Luckily I'm covered through work now, but if I were to lose my job and healthshares were my only option I'd be SOL.

healthshares are popping up to get around insurance red tape and dont exclude pre existing conditions. 

insurance is a business to make a profit in all other models you're risk profiled and it appears we've decided this isnt acceptable in healthcare.  its like buying insurance after the house burned down to insure people for profit who have pre existing conditions.  a non profit approach would be much better,  There are many people who use healthshares that exclude pre existing conditions who have them b/c they are still more economical to self insure against those conditions. 

i understand getting insurance was difficult with out having a job for those with pre existing conditions - and this is a blessing for you all b/c you can basically just let healthy people pay for your conditions that existed prior to being insured.  but it doesnt work with the insurance models its been proven over this ACA debockle.  i have no issue if we were to go to a full govt run health system with covering those who have pre existing conditions - i have a problem being told i have to have coverage and pay for insurance company profits so i can help pay someone elses bill too.
« Last Edit: February 22, 2018, 10:25:36 AM by boarder42 »

Dr Kidstache

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Re: ACA.. no out of network coverage!
« Reply #60 on: February 22, 2018, 02:04:52 PM »
@boarder42 , I defer to the other ACA thread in which your misstatements about healthshares and misconceptions about medical insurance have been roundly discussed:
https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/4050/


boarder42

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Re: ACA.. no out of network coverage!
« Reply #61 on: February 22, 2018, 03:05:06 PM »
@boarder42 , I defer to the other ACA thread in which your misstatements about healthshares and misconceptions about medical insurance have been roundly discussed:
https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/4050/

my misinformation about healthshares? there is no misinformation i didnt say all include pre existing conditions i said new ones are popping up that do.  And the ACA is wildly out of balance and a determent to society as can be seen by the issue posed by this post.  You're obviously extremely biased due to your condition which is fine we're all self serving, but i'm sure what you're paying for health insurance under the ACA pails in comparison to what you are actually receiving in payments for your condition.  and in my case what i would pay would be a gross over payment for the coverage i receive once i FIRE and if its not fixed there will be issues around my FIRE plans of traveling frequently with our younger children.  all so the pre existing conditioned people can sit at home and recieve the care they need and insurance companies can make profits - no thanks. 

i'll take a non profit central payer system that has health incentives attached to it that anyone is able to meet for tax deduction purposes - unless you smoke then you just pay more.
« Last Edit: February 22, 2018, 03:13:13 PM by boarder42 »

rnco206

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Re: ACA.. no out of network coverage!
« Reply #62 on: May 02, 2018, 09:32:23 AM »
New poster here but a lurker on the forum for a while. I stumbled on this thread searching for any information about this dilemma, as my husband and I are taking the summer off from working to travel around the US and are realizing how terrible the options for health coverage are for this situation - we're going to be biking so definitely want some sort of coverage in case of an accident. The big thing I'm still confused about is if, say, a hospitalization in the ICU is the result of an emergency visit, whether that counts as "emergency services", which are covered out of network, or "hospitalizations", which per most plans are not covered if out of network or have very high co-insurance. Has anyone found the answer to this? Or maybe it just depends on the situation and how difficult the insurance company wants to be about it...

I had also found the link a few posts above about Blue Cross Blue Shield having national coverage, but for anyone else looking into that I just called Blue Cross Blue Shield and was told they discontinued that Blue Card program for 2018, so emergency care is the only thing covered out of network. It seems like a short term insurance policy or travel insurance may be our best option, although those have coverage limits - like $50,000 max benefits or $2000/day for hospitalization, etc, in some I've looked at - so you could still end up with a big bill with a long hospitalization.

I'm an ER nurse and see every day how messed up the healthcare system is at the moment and how much an unexpected illness/accident can devastate someone's life - it's discouraging to realize that there's pretty much no way to buy insurance that has good coverage for a catastrophic incident unless you stay close to home all the time.

Exflyboy

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Re: ACA.. no out of network coverage!
« Reply #63 on: May 02, 2018, 10:48:45 AM »
Your insurance company will do whatever they can to avoid a 6 figure payment on care I would suspect. Then you get into what services should have been pre-approved and wern't (well I was unconscious at the time!).

The reading of the ACA specifically states that its whatever you nee to stabilise the condition.. So in theory 10 days in the ICU with a hole drilled in your head.. Covered until you can driven home.

The problem of course is that your insurance company will only pay the hospital the in network rate they have negotiated... Your OON hospital with then simply balance bill you the rest.

Bottom line, you can still end up losing your house if you have an accident out of network.

Maybe better off taking foreign vacations and buying travel insurance sadly.

Mr. Green

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Re: ACA.. no out of network coverage!
« Reply #64 on: May 02, 2018, 11:41:47 AM »
Your insurance company will do whatever they can to avoid a 6 figure payment on care I would suspect. Then you get into what services should have been pre-approved and wern't (well I was unconscious at the time!).

The reading of the ACA specifically states that its whatever you nee to stabilise the condition.. So in theory 10 days in the ICU with a hole drilled in your head.. Covered until you can driven home.

The problem of course is that your insurance company will only pay the hospital the in network rate they have negotiated... Your OON hospital with then simply balance bill you the rest.

Bottom line, you can still end up losing your house if you have an accident out of network.

Maybe better off taking foreign vacations and buying travel insurance sadly.
To be fair, the same thing would happen with OON insurance through an employer, correct?

Exflyboy

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Re: ACA.. no out of network coverage!
« Reply #65 on: May 02, 2018, 12:10:57 PM »
Depends.. When we had employer insurance last year I think it had a max out of pocket for OON.. At least I think it did.

My ACA policy definitely doesn't.

Mr. Green

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Re: ACA.. no out of network coverage!
« Reply #66 on: May 02, 2018, 12:54:57 PM »
Depends.. When we had employer insurance last year I think it had a max out of pocket for OON.. At least I think it did.

My ACA policy definitely doesn't.
All insurance policies that have acutal  OON coverage have a Max OOP, but does that stop balance billing? That's where I'm confused. I know you're specifically talking about a policy that has no OON coverage but it made me think about balance billing even with OON coverage and I'm wondering.
« Last Edit: May 02, 2018, 12:57:14 PM by Mr. Green »

Exflyboy

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Re: ACA.. no out of network coverage!
« Reply #67 on: May 02, 2018, 02:31:41 PM »
Depends.. When we had employer insurance last year I think it had a max out of pocket for OON.. At least I think it did.

My ACA policy definitely doesn't.
All insurance policies that have acutal  OON coverage have a Max OOP, but does that stop balance billing? That's where I'm confused. I know you're specifically talking about a policy that has no OON coverage but it made me think about balance billing even with OON coverage and I'm wondering.

Actually I am talking about policies where they do cover OON emergency care (which I guess by ACA rules they all have to) but then have no OOP for such care.

Thats a good question though for where a max OOP for OON care is published.. I would suspect (because I am the suspicious type) that the max OOP only applies to the part that your insurance company actually pays.

I mean, otherwise the OON provider will send you a bill for say $100,000 for a 10 day stay in the ICU.. Then you will try to get that out of your insurance company.. I highly doubt they are going to cut you a check.

Mr. Green

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Re: ACA.. no out of network coverage!
« Reply #68 on: May 02, 2018, 03:21:50 PM »
Depends.. When we had employer insurance last year I think it had a max out of pocket for OON.. At least I think it did.

My ACA policy definitely doesn't.
All insurance policies that have acutal  OON coverage have a Max OOP, but does that stop balance billing? That's where I'm confused. I know you're specifically talking about a policy that has no OON coverage but it made me think about balance billing even with OON coverage and I'm wondering.

Actually I am talking about policies where they do cover OON emergency care (which I guess by ACA rules they all have to) but then have no OOP for such care.

Thats a good question though for where a max OOP for OON care is published.. I would suspect (because I am the suspicious type) that the max OOP only applies to the part that your insurance company actually pays.

I mean, otherwise the OON provider will send you a bill for say $100,000 for a 10 day stay in the ICU.. Then you will try to get that out of your insurance company.. I highly doubt they are going to cut you a check.
I believe all real (not short term or other garbage) healthance plans, ACA or otherwise, require OON emergency coverage. However, for plans that actually have an OON component, where there is a deductible and a Max OOP, it would appear that you can still be balance billed. So you could have the best health insurance in the US and if you end up in an out of network hospital for 10 days you could be just as fucked as the guy with the cheapest insurance plan with no OON component at all. After all, the amount the insurer agrees to pay is typically only a fraction of the "retail price" so you'd still be on the hook for most of the balance. When you've been balance billed for $100,000, knowing your insurance spared you from $20,000 in charges isn't much of a consolation prize.

https://www.healthinsurance.org/glossary/balance-billing/

Exflyboy

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Re: ACA.. no out of network coverage!
« Reply #69 on: May 02, 2018, 03:36:20 PM »
Seems to me the best idea is to be destitute and without any health insurance at all..

Worked from my BIL a few years back!

Mr. Green

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Re: ACA.. no out of network coverage!
« Reply #70 on: May 02, 2018, 04:11:05 PM »
It's so disheartening realizing this. I guess your in-network network could be large enough that you're pretty safe no matter where you go but it sounds like there will always be risk. Does medicaid cover you in another state since it's a federal program? I always thought that only gave you coverage for the state that's administering it. From what I understand they can't go after retirement accounts so I suppose if you had pretty much all your money tied up in pre-tax accounts and no property you'd be fairly safe, other than the wrecked credit that comes from a bankruptcy?

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Re: ACA.. no out of network coverage!
« Reply #71 on: May 02, 2018, 04:14:45 PM »
It's so disheartening realizing this. I guess your in-network network could be large enough that you're pretty safe no matter where you go but it sounds like there will always be risk. Does medicaid cover you in another state since it's a federal program? I always thought that only gave you coverage for the state that's administering it. From what I understand they can't go after retirement accounts so I suppose if you had pretty much all your money tied up in pre-tax accounts and no property you'd be fairly safe, other than the wrecked credit that comes from a bankruptcy?
If I were in that situation, I'd just purposely keep income low and enroll in an income-based repayment plan with the hospital. Pay them $50 a month until I die or whatever.

chasesfish

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Re: ACA.. no out of network coverage!
« Reply #72 on: May 02, 2018, 06:14:58 PM »
Been researching this quite a bit...if I park my residency in NC, they have broad network plans from Anthem

Paul der Krake

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Re: ACA.. no out of network coverage!
« Reply #73 on: May 02, 2018, 06:29:05 PM »
Forgetting the issues of drive-by-billing and the occasional out of network specialist, are there *any* hospitals with a real ICU in the country that are out-of-network for broad plans from major insurers like the BCBS family, United, or Aetna?

Mr. Green

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Re: ACA.. no out of network coverage!
« Reply #74 on: May 02, 2018, 06:51:30 PM »
Forgetting the issues of drive-by-billing and the occasional out of network specialist, are there *any* hospitals with a real ICU in the country that are out-of-network for broad plans from major insurers like the BCBS family, United, or Aetna?
For a couple months in 2017 the Mission Hospital system could not reach an agreement with BCBS, the major insurer in NC, so everything in that system became out of network. I don't know how common it is for healthcare systems to fight with insurers and have contracts lapse.

Paul der Krake

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Re: ACA.. no out of network coverage!
« Reply #75 on: May 02, 2018, 09:49:55 PM »
Forgetting the issues of drive-by-billing and the occasional out of network specialist, are there *any* hospitals with a real ICU in the country that are out-of-network for broad plans from major insurers like the BCBS family, United, or Aetna?
For a couple months in 2017 the Mission Hospital system could not reach an agreement with BCBS, the major insurer in NC, so everything in that system became out of network. I don't know how common it is for healthcare systems to fight with insurers and have contracts lapse.
That's an interesting case, thanks for bringing it up.

I found this statement on Mission's website that seems to imply that true emergencies and "care for patients whose care would otherwise be unduly delayed because of a lack of access to physicians or facilities" would still be in network.

Soooo... maybe Exflyboy's nightmare scenario would be covered?

I think the takeaway from all this is, from the perspective of a traveling early retiree, is to go with a plan from a major national insurer that doesn't have a limited local network.

Exflyboy

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Re: ACA.. no out of network coverage!
« Reply #76 on: May 02, 2018, 10:22:16 PM »
Except such a plan is not listed when I punch in my locale on the ACA website.

Paul der Krake

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Re: ACA.. no out of network coverage!
« Reply #77 on: May 02, 2018, 10:46:37 PM »
Are you on Providence?

It looks like Kaiser will cover anything deemed urgent and stabilizing, then they will require pre-authorization before allowing further operations, and may decide that you're healthy enough to go to their clinics. Sounds pretty reasonable to me.

Other solution (really practical I know), live in a larger metro area with a more robust individual market. Who knows if there will be any next year.

RedefinedHappiness

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Re: ACA.. no out of network coverage!
« Reply #78 on: May 03, 2018, 05:32:44 AM »
Balance billing for OON exists, but is meant to fight against the egregious non emergency charges. I think what biking poster should do is call insurance company and ask if balance billing is a risk to their specific biking example. I would suspect it would be covered without balance billing opportunities, but always safest to confirm.

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Re: ACA.. no out of network coverage!
« Reply #79 on: May 03, 2018, 08:04:41 AM »
Seems to me the best idea is to be destitute and without any health insurance at all..

Worked from my BIL a few years back!

Being flat broke probably is the only way to avoid the risk of owing huge amounts of money for hospitalization.