How much is out of network coverage worth?

[DaMa]

Hi.  I'm enrolling in ACA plan on 1/1 and have narrowed it down to two choices, a Blue Cross PPO which includes out-of-network coverage and an HMO with network only coverage.  The PPO will cost me $4100 and the HMO $1400.  The out-of-network benefit on the PPO has an OOP max of $1300 which would be in addition to the $4100. 

I'm fine with staying in network, so this would only be an issue for non-emergency care while traveling.  Is it worth $2700 to have coverage when I travel?  Ideally, I would be traveling 12-20 weeks per year.

This seems like too much to me, but I have no personal experience.  I would appreciate the thoughts of other mustachians.

[seattlecyclone]

You will be traveling beyond your regular network boundaries for a pretty significant fraction of the year, so you're right to at least consider this. That price difference does seem a bit steep for just the out-of-network benefits. This seems like something you would use mostly in an urgent care situation, where you get a minor injury or illness while traveling and need some care for it, but nothing rising to the level of a true life-threatening emergency. You can pay cash for quite a few urgent care visits for $2,700. Is there any other additional quality benefit you see for the PPO over the HMO that would help make up the gap in costs?

[DaMa]

Is there any other additional quality benefit you see for the PPO over the HMO that would help make up the gap in costs?

Not really.  The HMO network means changing my primary care doctor.  It's a new doctor I've only seen for a year, so that's not a problem.  If my previous doctor hadn't retired in 2019, it would be a factor.

[Anon in Alaska]

Hi.  I'm enrolling in ACA plan on 1/1 and have narrowed it down to two choices, a Blue Cross PPO which includes out-of-network coverage and an HMO with network only coverage. 
I'm fine with staying in network, so this would only be an issue for non-emergency care while traveling.

What happens if and when you have an emergency and the ambulance takes you to a hospital that is out of network? What happens if you go to an in network hospital but the doctor you see normally works at another hospital and therefore they count as out of network? This could easily cost you thousands or even tens of thousands of dollars (it could be hundreds of thousands or even millions if your stay is long enough). I would go with the plan including out of network coverage.

[jim555]

The new law on surprise billing comes into effect soon.

https://www.nytimes.com/2021/09/30/upshot/surprise-billing-biden.html

[jac941]

Hi.  I'm enrolling in ACA plan on 1/1 and have narrowed it down to two choices, a Blue Cross PPO which includes out-of-network coverage and an HMO with network only coverage. 
I'm fine with staying in network, so this would only be an issue for non-emergency care while traveling.

What happens if and when you have an emergency and the ambulance takes you to a hospital that is out of network? What happens if you go to an in network hospital but the doctor you see normally works at another hospital and therefore they count as out of network? This could easily cost you thousands or even tens of thousands of dollars (it could be hundreds of thousands or even millions if your stay is long enough). I would go with the plan including out of network coverage.

Out of network coverage doesn’t necessarily cover that. I was badly injured this year with what I thought was excellent employer based health coverage. Many many out of network expenses were not fully covered despite me being in an in network hospital. They only cover the amount that they would have covered with an in network provider and don’t count any costs past that towards the out of network maximum. I was charged out of network fees for some doctors who were in network of I had seen them at another location. I’ve blown way past both my in network and out of network out of pocket maximums and the insurance still says I haven’t met my out of network out of pocket maximum. I’m up to around $50k in out of pocket expenses that I’m on the hook for.

The new law on surprise billing comes into effect soon.

https://www.nytimes.com/2021/09/30/upshot/surprise-billing-biden.html

I live in California which has had a surprise billing law for several years. It doesn’t cover ambulance rides, so plan to pay for those. I also learned that the health insurance that we have is exempt from those laws after filing a complaint with the state insurance board. So proceed with caution and make sure the policy you choose is subject to the law or you have no recourse when they refuse to pay.

ETA - I don’t think out of network coverage is worth much because it hardly covers anything in an emergency. It does cover about half the cost of a regular out of network therapist, so if you have a regular person you like to see for routine care who is out of network and want to save on that, it could be worth it.

[DaMa]

Out of network coverage doesn’t necessarily cover that. I was badly injured this year with what I thought was excellent employer based health coverage. Many many out of network expenses were not fully covered despite me being in an in network hospital. They only cover the amount that they would have covered with an in network provider and don’t count any costs past that towards the out of network maximum. I was charged out of network fees for some doctors who were in network of I had seen them at another location. I’ve blown way past both my in network and out of network out of pocket maximums and the insurance still says I haven’t met my out of network out of pocket maximum. I’m up to around $50k in out of pocket expenses that I’m on the hook for.

So sorry to hear you are going through this.  I hate this industry so much.  Do you have a Blue Cross plan?

I live in California which has had a surprise billing law for several years. It doesn’t cover ambulance rides, so plan to pay for those. I also learned that the health insurance that we have is exempt from those laws after filing a complaint with the state insurance board. So proceed with caution and make sure the policy you choose is subject to the law or you have no recourse when they refuse to pay.

Is your policy a employer self-funded plan?  I'll bet the surprise billing law doesn't apply to ERISA plans.  (Which is more F*@!ing BS.) 

[jac941]

So sorry to hear you are going through this.  I hate this industry so much.  Do you have a Blue Cross plan?

Is your policy a employer self-funded plan?  I'll bet the surprise billing law doesn't apply to ERISA plans.  (Which is more F*@!ing BS.)

I’m irritated by the whole thing, but fortunately we have the money and won’t be left destitute or anything. I was hit by a car, so while we’re paying bills now, in the end my uninsured motorist insurance will reimburse me (I’m sure I’ll have to fight about that too and possibly hire a personal injury attorney). I just have to wait for everything to shake out to make the claim.

The health insurance is an employer level funded plan, which I now know is a form of self funding (and therefore not insurance). We were absolutely shocked to find out that the employer had this kind of insurance. It’s a small company - maybe 100 or so employees. And not all in California. It’s my spouse’s employer, and he has complained a bit but not raised the holy hell I would be raising.

I actually told him that 2022 we go to a covered California plan instead of the employer insurance despite the extra cost. I’m insuring against becoming destitute from medical bills. $10k of medical bills is no fun but pretty easily absorbed. $50k is getting into serious money!