Author Topic: How to minimize risk from out-of-network charges with ACA plans?  (Read 1350 times)

electriceagle

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How to minimize risk from out-of-network charges with ACA plans?
« on: November 23, 2015, 12:36:51 PM »
I'm planning to sign up for an ACA health insurance plan for the first time.

My biggest concern is about involuntary use of out-of-network services. If I am ever in a situation where I am admitted to a hospital that is in-network, I could be subject to billing from any number of doctors who are out of network. (This is an issue for non-ACA plans as well, but it gets more severe with narrow networks and low/no out of network coverage.)

http://www.latimes.com/business/la-fi-healthcare-watch-20150717-story.html
http://healthaffairs.org/blog/2015/11/03/a-tale-of-two-deliveries-or-an-out-of-network-problem/

My other concern is about identifying doctors who are in network. Some doctors take "Insurer Name" but aren't in network for the lower-cost ACA plans. I'm not sure that I can sort through that in a non-emergency, but urgent situation.

I'm thinking of taking coverage from an HMO (Kaiser) to partially solve both of these problems. I don't like Kaiser, but at least I know that everyone in the Kaiser building is part of their plan.

Also, California has a law which prohibits emergency room balance billing when the patient is with an HMO. I'm not sure if the law applies to non-HMO coverage. I don't think it covers non-emergency hospital charges.

My questions:

1) Has anyone already sorted through this and gotten an answer?

2) For the HMO option, what happens if I have an emergency, go to the hospital and need extended care? I know that the emergency portion is covered wherever I go, but do I need to find my way to an in-network hospital afterwards?

3) Can I be confident that all of the doctors/services in the Kaiser building are part of Kaiser's bronze coverage network?

kendallf

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Re: How to minimize risk from out-of-network charges with ACA plans?
« Reply #1 on: November 23, 2015, 01:01:22 PM »
I don't know if California has protections that we lack here in FL, but my experience with a gov't Blue Cross policy (sort of the "gold standard" for comparisons) here was that I had to negotiate my way through a mess of such charges even when admitted to our primary in network hospital. 

In one instance, my daughter was seen by an in network ER doc after cutting the base of her thumb in an accident.  When she followed up a week later, the same doctor saw her and determined she'd severed a tendon and would need reconstructive surgery.  We went through the surgery at his (non hospital) facility.  I even talked to the facility prior to the surgery and confirmed that they "took" BCBS.  I was balance billed for nearly $10k as the surgical facility was out of network!  They accepted the BCBS negotiated rate after I balked, but they could've pursued it..

All that to say, yes, I think you have to confirm they're in-network in basically every instance other than ER admission.