The Money Mustache Community

Learning, Sharing, and Teaching => Ask a Mustachian => Topic started by: Exflyboy on February 17, 2018, 12:12:29 PM

Title: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: v8rx7guy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Zamboni 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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..
Title: Re: ACA.. no out of network coverage!
Post by: Dr Kidstache 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!
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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".
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: PKate 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.   
Title: Re: ACA.. no out of network coverage!
Post by: Laserjet3051 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.
Title: Re: ACA.. no out of network coverage!
Post by: Paul der Krake on February 18, 2018, 10:47:57 AM
Wouldn't the ICU be considered as an ER visit?
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: RedefinedHappiness 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?
Title: Re: ACA.. no out of network coverage!
Post by: SnackDog 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.
Title: Re: ACA.. no out of network coverage!
Post by: chasesfish 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?
Title: Re: ACA.. no out of network coverage!
Post by: RedefinedHappiness 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.
Title: Re: ACA.. no out of network coverage!
Post by: CrustyBadger 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/
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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..:)
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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......:)
Title: Re: ACA.. no out of network coverage!
Post by: CrustyBadger 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?
Title: Re: ACA.. no out of network coverage!
Post by: Mr. Green 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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
Title: Re: ACA.. no out of network coverage!
Post by: Zamboni 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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!
Title: Re: ACA.. no out of network coverage!
Post by: FrugalZony 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.
Title: Re: ACA.. no out of network coverage!
Post by: Zamboni 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 (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 . . .
Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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. 
Title: Re: ACA.. no out of network coverage!
Post by: katsiki 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 (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.
Title: Re: ACA.. no out of network coverage!
Post by: Holyoak 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?
Title: Re: ACA.. no out of network coverage!
Post by: Zamboni 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: v8rx7guy 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.
Title: Re: ACA.. no out of network coverage!
Post by: FrugalZony 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: obstinate 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.
Title: Re: ACA.. no out of network coverage!
Post by: FrugalZony 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).
Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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.
Title: Re: ACA.. no out of network coverage!
Post by: Meowmalade 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
Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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.
Title: Re: ACA.. no out of network coverage!
Post by: v8rx7guy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Paul der Krake 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.

Title: Re: ACA.. no out of network coverage!
Post by: Meowmalade 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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?...:)
Title: Re: ACA.. no out of network coverage!
Post by: katsiki 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.

Title: Re: ACA.. no out of network coverage!
Post by: Meowmalade 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?
Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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. 
Title: Re: ACA.. no out of network coverage!
Post by: katsiki 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.
Title: Re: ACA.. no out of network coverage!
Post by: Rural 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.
Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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.
Title: Re: ACA.. no out of network coverage!
Post by: katsiki 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.
Title: Re: ACA.. no out of network coverage!
Post by: Dr Kidstache 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.
Title: Re: ACA.. no out of network coverage!
Post by: chasesfish 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
Title: Re: ACA.. no out of network coverage!
Post by: Rural 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.
Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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.
Title: Re: ACA.. no out of network coverage!
Post by: Dr Kidstache 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/

Title: Re: ACA.. no out of network coverage!
Post by: boarder42 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.
Title: Re: ACA.. no out of network coverage!
Post by: rnco206 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Mr. Green 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?
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Mr. Green 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Mr. Green 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/
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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!
Title: Re: ACA.. no out of network coverage!
Post by: Mr. Green 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?
Title: Re: ACA.. no out of network coverage!
Post by: Paul der Krake 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.
Title: Re: ACA.. no out of network coverage!
Post by: chasesfish 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
Title: Re: ACA.. no out of network coverage!
Post by: Paul der Krake 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?
Title: Re: ACA.. no out of network coverage!
Post by: Mr. Green 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.
Title: Re: ACA.. no out of network coverage!
Post by: Paul der Krake 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 (http://newsroom.mission-health.org/2017/10/mission-health-now-network-blue-cross-blue-shield-north-carolina/) 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.
Title: Re: ACA.. no out of network coverage!
Post by: Exflyboy 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.
Title: Re: ACA.. no out of network coverage!
Post by: Paul der Krake 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.
Title: Re: ACA.. no out of network coverage!
Post by: RedefinedHappiness 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.
Title: Re: ACA.. no out of network coverage!
Post by: Schaefer Light 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.