can’t figure out logical way to approach health insurance decision
December 15, 2018 1:47 AM   Subscribe

My family buys individual health insurance. Due to watching my friend die while locked into a crappy hospital system’s health insurance, I have some traumatic stress around this issue/have never felt safe with an insurance policy that didn’t partially cover out of network charges. This year, I need help figuring out how to approach my family’s choice logically. Details inside.

Basically I need to choose between two plans.

Plan A covers all my family’s existing doctors, is $100 a month cheaper, and gives zero coverage out of network.

Plan B has some of our current doctors out of network, costs $100 a month more, but does give partial coverage out of network.

Plan A is definitely a better plan for a “normal year,” the year I hope we will have. But what if one of us gets a weird cancer and there’s nothing good for us in-network? What if we have an accident and wind up in an out of network ER? (If I were more rational about this I would have researched the ER question earlier but it just freaks me the hell out.)

So my question is, is there a logical way I can make this decision? How can I think coldly about this because I just panic when I think about it.

If you know about out of state and ER related coverage under our current laws that would be great too. I’m in Oregon. Thanks
posted by hungrytiger to Health & Fitness (4 answers total) 4 users marked this as a favorite
Disclaimer: I'm not an insurance expert. I am an extremely anxious person who buys insurance through the exchange, and does a lot of research about it. I also have semi-complicated health needs, so think about this sort of thing a lot. The following is my understanding of the current system, but shouldn't be taken as gospel.

The good news is that if you get care from an out-of-network emergency room, your insurer can't charge you more for it, nor can they require that you get preauthorization to do so. Your copay and coinsurance there legally have to be the same as it is for an in-network ER.

The bad news is that while the ER can't be treated as an out-of-network visit, the doctors can be, and sometimes (but not always) are. My experience is that if this happens, you can often negotiate those bills down with the doctors, or get your insurance to pay part of it by contacting them and providing proof that it was a life-threatening emergency and you had no other options. It's worth mentioning that doctors can be out of network at an in-network emergency room or hospital, as well--you'll be treated by whomever's available, and that person may or may not be considered in network. This is especially common at community or university hospitals hospitals, and less common at ones owned by specific providers.

In the event that someone gets a rare supercancer and no one in network is qualified to work on it, my understanding is that you'll fall into a network adequacy gap, and should be able to get treatment by applying with your insurer for a coverage gap exception (or waiver). You send over something saying "I have rare supercancer x, cancer is covered on my plan, and no one in this network is qualified to treat it." Your insurer can't just say, "Oh, there are no rare supercancer specialists in network, guess you'll die," they have to actually provide coverage for the things that they cover. (Technically I believe you can also apply for a coverage gap exception for things like, "The only available doctor is a hundred miles away from me," or "The next in-network appointment is a year away.) For obvious reasons, this isn't a thing that insurers advertise, but it should be possible.

As for the decision itself, I think that everyone makes insurance choices based on their personal risk tolerance and financial situation--I don't believe that there is an entirely logic-based way to purchase insurance in our system. Were I in your shoes, I'd probably go with Plan A, because I feel like continuity of care is really important, I hate finding new doctors, and in a worst-case scenario, I'm ok aggressively appealing to the insurance company. Plan B might give you, personally, more peace of mind, and you have to decide if the value of that to you is worth $100 a month plus either the loss of continuity or the additional fees to see your usual doctors.

It doesn't sound like either of these choices are objectively bad--I don't think that you can make an objectively wrong choice, here. You can make the choice that feels better to you, and that will be a good choice. You're doing a good job engaging with this, and I hope that this helps relieve some of the stress that it's clearly causing you.

I'm sorry about your friend, both for their suffering and for your loss. Please be kind to yourself.
posted by mishafletch at 2:57 AM on December 15, 2018 [5 favorites]

While this won't help for normal medical expenses, you could check if your employer and/or credit card(s) offer any coverage for travel insurance or travel assistance for medical problems you may have when away from home; many credit card companies offer some limited form of travel assistance automatically.
posted by nicebookrack at 1:10 PM on December 15, 2018

My wife has Type 1 diabetes, and navigating that with insurance has made us experts in health insurance fuckery. What I have learned to pay attention to is the out-of-pocket maximums. The monthly premium by itself is meaningless. What are the out-of-pocket maximums, and how does that change with respect to in network vs. out of network? The $100 difference in premium isn't what will bankrupt you - it's the $20,000 difference in out of packet max between two plans that you weren't paying attention to.
posted by COD at 1:23 PM on December 15, 2018 [5 favorites]

Thank you for these answers, they helped (especially mishafletch’s answer which those very detailed what-if scenarios soothed me enough to go with Plan A). I appreciate your kindness, mefites.
posted by hungrytiger at 11:21 PM on December 20, 2018 [1 favorite]

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