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Co-insurance question
Old 12-05-2015, 07:32 PM   #1
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Co-insurance question

I really have to bite the bullet this week and sign up for insurance for 2016. As a resident of Texas (Travis County), I am caught in the vanishing BCBS PPO conundrum. Sigh.

I don't use much in the way of medical services. This year I had a BCBS HSA-Eligible bronze plan 006 with the deductible nearly at the OOP max for in network. It also had 0% coinsurance. I will have only spent about $1000 for medical services.

My biggest concern is protection if I have a significant medical event -- so essentially catastrophic insurance.

How does coinsurance work? I thought I understood, but ...

One broker has told me that if I select a plan with, say, 20% coinsurance after deductible, it is capped by the OOP max. In this case, coinsurance doesn't worry me; I have stop-loss protection. Another broker has said that the OOP max does not apply to coinsurance. It is this latter case that bodes financial ruin.

Someone must be wrong. So how does coinsurance work?

I'm looking on and off exchange for a policy that does not require PCP referrals to a specialist (I don't want a Bozo PCP saying "no, you cannot see your ophthalmologist for a potential detached retina.") .

My carefully-constructed income would qualify me for an on-exchange policy in 2016 unless I receive an inherited IRA with RMD -- which now seems likely. I am tempted to buy on-exchange nonetheless if there is an appropriate policy, and square up with the IRS at tax time.

Note that in Texas, your insurance card is marked with "QHP" if you buy a policy on-exchange. The Scarlet X, screaming "needs federal subsidy, may not pay bills."

And I'm looking to move to another state by 2017....

Thanks!
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Old 12-05-2015, 07:56 PM   #2
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If the deductible and the max OOP are the same, you pay no coinsurance. So that's where you might see something like 0% coinsurance quoted.

Coinsurance is % you owe between the deductible and the max OOP.

Also note that deductibles, coinsurance, and max OOP are different for out-of-network versus in network, and some plans have no limit for max OOP out of network.

Out of network is always chancy anyway, as even with coinsurance a the insurance company will only pay the % of to what they deem as fair, and you may be subject to balance billing - the provider sending you bills for what the insurance comaony declined to pay.

OOP max does apply to coinsurance. When you pay enough coinsurance, above your deductible, that you reach the max OOP, you're done. In other words, max OOP = deductible + coinsurance.
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Old 12-05-2015, 07:58 PM   #3
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Was going to reply, but yeah, pretty much what Audrey said. On many high deductible plans, especially bronze-level plans, the deductible and the OOP max are the same, which means you pay 100% until you hit the deductible, then *nothing* for covered in-network services. That's when you'd see 0% coinsurance, since coinsurance is what you pay after the deductible but before hitting the OOP max.
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Old 12-05-2015, 08:20 PM   #4
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Thanks. You've confirmed what was my understanding of coinsurance -- until broker #2 said that the OOP max didn't apply to coinsurance.

No need to speak to (clueless) broker #2 again!

Out of network and balance-billing are the big elephants in the room. I felt I had some protection with Blue Card when I traveled -- even in Europe -- but now the networks I have are incredibly geographically limited.

I guess the good news is that the hospitals in network for most providers include the big players.

Whodathunk in 2014 that two years later I would be mourning the loss of a plan with $6000 deductible, an OOP max not much higher, a reasonably large network, and with a non-subsizided cost of $600/month for one 50-something person?

I had been planning to move home to New Mexico in 2016, but alas the insurance situation for individuals isn't much better there.
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Old 12-05-2015, 08:26 PM   #5
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Originally Posted by BarbWire View Post
Thanks. You've confirmed what was my understanding of coinsurance -- until broker #2 said that the OOP max didn't apply to coinsurance.

No need to speak to (clueless) broker #2 again!

Out of network and balance-billing are the big elephants in the room. I felt I had some protection with Blue Card when I traveled -- even in Europe -- but now the networks I have are incredibly geographically limited.

I guess the good news is that the hospitals in network for most providers include the big players.
Well, the important thing is that all the providers are in-network, because there can be separate deductibles for in-network and out-of-network services. The OOP max generally includes your deductibles plus all co-insurance.

Out of network remains the gorilla in the room.
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Old 12-06-2015, 06:46 AM   #6
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Well, the important thing is that all the providers are in-network, because there can be separate deductibles for in-network and out-of-network services.
Many (all?) plans have a separate oop max for out of network (in the case of my plan, it's double), as well as a separate deductible.
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Old 12-06-2015, 06:52 AM   #7
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Many (all?) plans have a separate oop max for out of network (in the case of my plan, it's double), as well as a separate deductible.
Not HMOs. They have no out of network coverage at all.
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Old 12-06-2015, 07:06 AM   #8
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I'm looking on and off exchange for a policy that does not require PCP referrals to a specialist (I don't want a Bozo PCP saying "no, you cannot see your ophthalmologist for a potential detached retina.") .
Off-exchange in Travis County, Baylor/Scott & White has a PPO plan and UHC and Aetna have EPO plans.
https://finder.healthcare.gov/

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Note that in Texas, your insurance card is marked with "QHP" if you buy a policy on-exchange. The Scarlet X, screaming "needs federal subsidy, may not pay bills."
Any on-exchange plan must have a mirror plan off-exchange. The off-exchange plan does not qualify for subsidies but will not contain the mark.

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As you may know, federal law requires that every plan offered in the exchange also be offered off the exchange, using the same provider network.

In the case of Blue Shield (CA), the insurer offers 12 separate products linked to its exchange network, which it calls the "Exclusive PPO Network" or "Exclusive EPO Network." These products, whether purchased on or off the exchange utilize the Blue Shield "Exclusive" (aka exchange) networks. While plans purchased through Covered California will have the CoveredCA logo on them, the "off exchange" versions of these plans will not. However, regardless of whether they were purchased on or off the exchange, these plans will all utilize the insurer's "Exclusive" exchange networks.
My BCBSSC BlueCard on-exchange EPO plan has no out-of-network coverage. Fortunately, 97% of hospitals and 92% of doctors nationwide are in its network.
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Old 12-06-2015, 07:39 AM   #9
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Off-exchange in Travis County, Baylor/Scott & White has a PPO plan and UHC and Aetna have EPO plans.
https://finder.healthcare.gov/

Any on-exchange plan must have a mirror plan off-exchange. The off-exchange plan does not qualify for subsidies but will not contain the mark.

My EPO plan has no out-of-network coverage either. Fortunately, 97% of hospitals and 92% of doctors nationwide are in its network.
That's a terrific network (similar to what I had under BCBS with Blue Card, before that was killed).

If I could find a policy with a network like that, I'd stop worrying about out of network coverage/stop loss. Finding policies with OON stop loss -- even $50K -- is almost impossible. Scott and White has OON stop loss, but their own network is tiny.

Thanks for the finder.healthcare.gov link for off-exchange plans -- I had only found the on-exchange portal. Hence the calls to two brokers to find out my off-exchange options.

I still don't understand the purpose of branding the cards for policies bought on exchange. Does an insurance company reimburse less to a provider for services if the policy was bought on exchange than off, even if ostensibly the policies are the same?

Meanwhile I've had mail from BCBS informing me that they have assigned me to an HMO (at a higher premium than my 2015 PPO) which I don't want, so that will be a few hours on hold on the phone trying to undo that.
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Old 12-06-2015, 10:52 AM   #10
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I still don't understand the purpose of branding the cards for policies bought on exchange. Does an insurance company reimburse less to a provider for services if the policy was bought on exchange than off, even if ostensibly the policies are the same?
Texas passed a branding law for political reasons. Not all states require that. The off-exchange mirror plans are exactly the same as the on-exchange plans. Same provider network, benefits, non-subsidized premium rate, and same provider reimbursement rates. There may be another off-exchange only plan with a somewhat similar name and different provider reimbursement rates but the premium will reflect the difference.

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Meanwhile I've had mail from BCBS informing me that they have assigned me to an HMO (at a higher premium than my 2015 PPO) which I don't want, so that will be a few hours on hold on the phone trying to undo that.
This should be the 'default' plan you're put into if you don't make another selection on the exchange before Dec. 15th. You will not be put into that plan if you use the exchange to make another selection before then.
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Old 12-06-2015, 10:59 AM   #11
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Texas passed a branding law for political reasons. Not all states require that. The off-exchange mirror plans are exactly the same as the on-exchange plans. Same provider network, benefits, non-subsidized premium rate, and same provider reimbursement rates. There may be another off-exchange only plan with a somewhat similar name and different provider reimbursement rates but the premium will reflect the difference.
Wow, had no idea. We bought off-exchange,so I wouldn't have seen it.
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