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Out-of-network limit for health insurance
March 25, 2014 5:31 PM   Subscribe

I am trying to pick between two health plans. The higher deductible plan makes more sense for me except for one thing – there is no out-of-pocket limit for out-of-network treatment. This seems like a big flashing warning sign to me, but I’m not sure how avoidable out-of-network care is. For example, would being taken to an out-of-network hospital after a car accident start triggering unlimited expenses that I would be entirely responsible for? Is this a plan I should stay away from?
posted by parallellines to Health & Fitness (12 answers total)
 
For example, would being taken to an out-of-network hospital after a car accident start triggering unlimited expenses that I would be entirely responsible for?

Yes (well, maybe not the best example, because auto insurance will sometimes cover that depending on who was at fault, but let's say you're talking about a heart attack). Also, you could go to an in-network hospital and be seen by out-of-network providers- totally terrible and unfair, and totally something that happens. I would be very wary of a plan that doesn't cap your out-of-pocket costs.
posted by ThePinkSuperhero at 5:36 PM on March 25 [1 favorite]


Stay far away from this plan. Aside from the situations where patients are essentially forced to accept out-of-network care, consider having a disease where the difference between a top-ranked surgeon who has done thousands of the procedure you need versus whoever is available because s/he happens to be in network is the difference between life and death.
posted by Ralston McTodd at 6:00 PM on March 25


I am all about heavy duty health insurance (without it my out of pocket costs in the past two years would have been in excess of $1M), but heavy duty health insurance really is not the right plan for everyone. The decision has to do with your current health, the prices of the policies, as well as your risk tolerance. Keep in mind that many, many insurance plans do not have any out of network coverage at all, let alone an out of pocket limit for out of network coverage.

If you want absolutely bomb proof coverage, by all means go for the more comprehensive/expensive policy. But it's wrong to say that just because one policy has less risk involved it's necessarily the right policy for you.
posted by telegraph at 6:19 PM on March 25 [1 favorite]


I would check the network to see who is in and out. I got a cheap plan (hmo) and my closest in network GP doctor is 15 miles away and I live in the suburbs of a major city. This was through blue cross and blue shield too. At least I do not get too sick and only need it for a few months.

Planning ahead should help but it might cause more of a head ache than you may want.
posted by Jaelma24 at 7:04 PM on March 25


Two suggestions if you like the high deductible plan better:

1) call the HMO provider and ask about how in-network emergency care is handled. Most have some provisions for this, as well as for accidents that happen when you travelling far from home. Don't just assume there's a big gaping hole around the coverage there.

2) Check out if you have access to a Health Savings Account (HSA) in conjunction with your high deductible in network plan. These are a great deal as HSAs allows you to save pre-tax via payroll deduction to cover the out of pocket costs (i.e. deductibles, copays, prescriptions). Without it, you'd have to pay that stuff out of your net paycheck. And, unlike healthcare reimbursement accounts which must be used by the end of the year or you lose any remaining unused portion, with a HSA account, you could conceivably keep the funds all the way to retirement if you don't end up using the funds when you are younger. (Healthcare reimbursement accounts only work with low deductible plans; HSA's are for high deductible plans only)

Good luck with your research. I've done this comparison myself and I always feel like I need another college degree to consider all the angles.
posted by Sonrisa at 7:29 PM on March 25


I would sign up for a plan with no maximum out of pocket for out-of-network under virtually no circumstances.
posted by Justinian at 8:41 PM on March 25


This is from healthcare.gov:
The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

The maximum out-of-pocket cost limit for any individual Marketplace plan for 2014 can be no more than $6,350 for an individual plan and $12,700 for a family plan.
I'm not sure what is meant by "balance billing amounts for non-network providers and other out-of-network cost-sharing," though.
posted by Conrad Cornelius o'Donald o'Dell at 10:19 PM on March 25


Not all insurance plans are on the exchange, though.
posted by postel's law at 5:20 AM on March 26


For example, would being taken to an out-of-network hospital after a car accident start triggering unlimited expenses that I would be entirely responsible for?

Yes (well, maybe not the best example, because auto insurance will sometimes cover that depending on who was at fault, but let's say you're talking about a heart attack).


Thanks to the ACA, as long as the plan is not "grandfathered" (most are not still grandfathered) this isn't true anymore (and, before the ACA, many plans treated actual emergency treatment expenses as in-network, regardless of where it was incurred).

http://www.dol.gov/ebsa/faqs/faq-aca.html

Q15: Public Health Service Act (PHS Act) section 2719A generally provides, among other things, that if a group health plan or health insurance coverage provides any benefits for emergency services in an emergency department of a hospital, the plan or issuer must cover emergency services without regard to whether a particular health care provider is an in-network provider with respect to the services, and generally cannot impose any copayment or coinsurance that is greater than what would be imposed if services were provided in network. At the same time, the statute does not require plans or issuers to cover amounts that out-of-network providers may "balance bill". Accordingly, the interim final regulations under section 2719A set forth minimum payment standards in paragraph (b)(3) to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of-network emergency service provider who, in turn, could simply balance bill the patient.
posted by Pax at 6:14 AM on March 26


I'm not sure what is meant by "balance billing amounts for non-network providers and other out-of-network cost-sharing," though.

"Balance billing" is an evil practice. It works like this...
• Provider A bills insurance $5000 for your treatment
• Insurance says they pay only $1000 for this particular treatment.
• Provider A bills you for the $4000 balance.

Balance billing happens when an insurance company doesn't negotiate fees with providers. Rather, they simply cap what they will pay for any given service, and you are on the hook for the difference. Before ACA, there were many "affordable" insurers offering low-cost, no network policies. They were almost always balance-billing policies, but that fact was often hidden behind a lot of "now you have an affordable choice!" marketing.

.......

Before you sign, make sure you investigate to see if the doctors and hospitals you currently use are in-network for the specific policies you're considering. Different policies from the same insurer can often have widely different lists of in-network providers.

When we investigated policies available to us through the .gov marketplace, we were shocked to discover that none of the local doctors we use, nor our only hospital, were in-network for any of the policies we were offered.
posted by Thorzdad at 6:37 AM on March 26 [1 favorite]


So according to the info from Pax, emergency care would not fall under the out-of-network category, and I would only incur out-of-network costs if I made an active choice to seek care from a doctor not in my network? Is that an accurate interpretation?
posted by parallellines at 7:57 AM on March 26


That depends on if you consider having an out-of-network anesthesiologist show up at your procedure by an in-network doctor to be an "active choice" to go out of network. Usually you don't get a choice as to who your anesthesiologist is.
posted by Ralston McTodd at 4:18 PM on March 26


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