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Old 11-06-2015, 07:52 PM   #101
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Utrecht: which if you didn't have as an option before could mean the difference between being wiped out financially or not
Well, yea, but beside that .........
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Old 11-06-2015, 08:09 PM   #102
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Utrecht: which if you didn't have as an option before could mean the difference between being wiped out financially or not
Yeah, we used to say being uninsurable was one way to risk a financial wipeout. Now the wipeout comes with being insured, but accidentally or unintentionally being given care by providers who are no longer in your networks.

"Out of network" is becoming the new "uninsured", or at least it feels like it's going that way. And it's becoming less of a question of "do you keep working for health insurance" as it is "do you keep working to have a decently large PPO network".
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Old 11-07-2015, 08:32 AM   #103
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Just as an FYI, plans have been changing long before Obamacare... I used to approve the health plan during my last job... every year we would get a new proposal... some years it was almost the same, some there were lots of changes.... so the promise of 'if you like your plan you can keep it' was never going to happen....

Just sayin....


I do agree that finding if a doctor is in plan or not is horrible.... heck, they still list my old PCP as 'in plan' even thought she moved almost two years ago.... we also went to an opthamologist I had been going to for years.... they insisted they were part of my network... so, we went to our PCP to get a referral and lo and behold.... he is NOT in network... so even the Dr's office can give bad info.... and they had my insurance card to check....
I just had the same experience. Using the HC.gov website, I clicked on an HMO plan, then clicked on the list of in-network providers, found all my doctors there. Then, I made a a phone call to the HMO (Capital Blue Cross) and actually asked the guy to verify that the doctors were indeed in network, and one of them was not. unbelievable. One useful thing the phone rep pointed out was that your doctor can leave the network voluntarily at any time, but must notify you in writing 30 days prior.
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Old 11-07-2015, 08:46 AM   #104
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What every happened to if you like your plan you can keep it, and this will make healthcare more affordable
Same thing as before the ACA -- you're at the insurance company's mercy. You can have their insurance as long as they feel like selling it to you.
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Old 11-07-2015, 09:01 AM   #105
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It's pretty hard to defend the US healthcare system IMO. My primary doc bitched to me last year because he had a heart attack out of town and he got dinged by several out of network docs that he had no idea of what they did for him. In quick discussion with orthopedist he too expressed dissatisfaction and couldn't figure out where all the money was going.

I'm lucky in that when I left municipal employment at 60 was allowed to retain their HC plan, albeit at full cost of $1064 a month for DW and me. Did just get first notice of an increase of ~$200 a month after four years. DW and I are now studying the medicare options since we both eligible in 2016. Other than a broken collarbone a few years ago that required surgery, I'd say the health "insurance" companies have done really well by us.

This thread just reinforces to me how messed up HC is in US. Having it primarily structured around ones employment just doesn't make much sense to me. And then there's the bizarre increases in drugs and the fact that they charge Americans ~twice what they charge elsewhere. Yeah, a lot of those companies (health insurers, pharma) are held in my assortment of mutual funds to my benefit, but something serious needs to be done about this system.
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Old 11-08-2015, 08:23 AM   #106
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Same thing as before the ACA -- you're at the insurance company's mercy. You can have their insurance as long as they feel like selling it to you.
Yes, we are still at the insurance company's mercy. Before ACA, the issue was if you had any pre-existing condition in their opinion, the insurance company could deny you insurance. Post ACA, the insurance companies are scaling down their in-network doctors so much that plans give only a false sense of security.
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Old 11-08-2015, 08:37 AM   #107
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We all scare ourselves with out of network potential charges, but can anyone on here give us a personal example of it happening? I can see that it could be a big expense, but I am not sure it is the "wipe us out financially" type expense. From the surveys on here, most of us have at least $1m net worth.

A "wipe out" to me would mean reducing net worth by 25% to 50%, forcing us to go back to work or cut back seriously. How would you manage $250,000 to $500,000 in non-emergency expenses that were out of network? The only thing I can think of is you agree to buy a cancer drug that is $500,000 a treatment or something.

Certainly you are not going to continue your vacation in Bumtwizzle, SD and see your out of network doctor for months racking up these charges? I think the more likely scenario is $10,000 to $30,000 of out of network charges, which while painful, would not wipe most of us out.
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Old 11-08-2015, 09:11 AM   #108
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Well that's survivorship bias. A wiped out person is probably not on an early retirement forum .

I can imagine something like... One of my kids getting cancer when I am not covered. that could take out millions and is not beyond the realm of possibility.

I'm not worrid about braces or broken legs... I'm worried about 1/100,000 types of events and I think its because of those that insurance and healthcare systems need to be built to cover outliers.

Imagine if fire and police were like health and if you didn't have fire insurance your house and everything/everyone burned down and the department could decide if they are willing to cover you. Or if police could so that and if you weren't covered you could just get robbed and murdered at will but. Oh well... Sorry no police coverage.

I agree fire and police are more critical but not that much more

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Old 11-08-2015, 09:24 AM   #109
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But you don't wait for months or years for the fire to burn down your house, it happens in the span of an hour. I can't see how you could unknowingly rack up $500,000 in out of network charges in an hour. I know doctors are paid a lot, but not that much! I can see them sneaking in a specialist during your in network surgery which might end up costing you $30k or so, but I would fight the charges personally if I had done my due diligence for the previously planned operation (emergency operations would be covered by almost all ACA insurance, in network or out of network). So I am ready to hear about out of network $500,000 charges if anyone on here has experienced that.
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Old 11-08-2015, 09:30 AM   #110
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I found this, too. We've had HSA plans for the last 2 years and now they are more expensive than the non-HSA and that makes no sense.

For us this year the HSA plans are all $200-$300 more per month than comparable non-HSA ones.

I've been very happy with the ACA so far but this year our bronze choices are all HMOs and not HSA eligible.

Just shaking my head over how this has all changed in just 2 years.

It must be a specific area issue. I buy the rock bottom cheapo plan. Well the second lowest one, the HSA. It is only $10 a month higher than the cheapest bronze plan so it is still cost effective to go with HSA.


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Old 11-08-2015, 09:53 AM   #111
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I can't see how you could unknowingly rack up $500,000 in out of network charges in an hour. I know doctors are paid a lot, but not that much! I can see them sneaking in a specialist during your in network surgery which might end up costing you $30k or so, but I would fight the charges personally if I had done my due diligence for the previously planned operation (emergency operations would be covered by almost all ACA insurance, in network or out of network). So I am ready to hear about out of network $500,000 charges if anyone on here has experienced that.
Perhaps it's not the 25%-50% hit to Net worth that people are afraid of, but rather the 50%+ of an entire year's living expenses that could 'easily' pop up in some scenarios.

You or a loved one breaks a bone. It is not life threatening..but you are probably in pain and need to get help fast. You go to the ER, they fix you up and send you out. There could be 4 different doctors that touch your file and put their names on the billing invoices, 2 or 3 different rooms they put you in for the various tests/services.

By the end of it all, your 'out of network' experience for a broken something could very well total $20k-$30k if it's not in-network, using various rack-rates for healthcare services. Perhaps even more. Imagine if your homeowner's coverage only covered certain fires, and you don't know until after the fire if the incident is covered or not. Wouldn't you be a little more nervous about shopping around for homeowner's coverage?

Was it a life-threatening experience that required you to go to the nearest ER whether in network or not? I would assume that it is NOT covered...since even if you have a heart attack and go to the nearest ER, all they cover is to "stabilize" you.

And consider the heart attack - if you go to the nearest ER in a life-threatening emergency and they stabilize you, are you really going to get transferred to the nearest in-network hospital as soon as you are considered "stabilized", or are you going to wait a day or two at the out-of-network hospital to get just a little more stable?

I don't know if there even is a definite point where you say "ok, now this patient is "stabilized" for health insurance purposes, they can be moved to a network hospital now - in a life threatening situation, there will likely be various tests and procedures they do on you over the course of several days. If you go to the ER on day 1, they could do a procedure on day 1 or day 2 that they need to wait 24-48 hours to review your progress on. On day 3, you are "stabilized", and ask to be transferred to a network facility, but they don't recommend discharging or transferring you until day 4 when the day 2 procedure results are known. In the meantime, they put you in an ICU room.

And while you're at the out-of-network hospital, they do a myriad of follow-up tests once you are somewhat stabilized, give you various drugs, and a staff of various people come by your room to examine you.

All of this while you are half-drugged and perhaps not in a sound, clear mind.

And even if you are moved to an in-network hospital for a major incident after your are "stabilized", there could still be a variety of people that are billed to your account that may not be covered. Or a variety of drugs that aren't in your network formulary that the house doctor decided to proscribe, without checking first to see if they are in your drug formulary plan.

I haven't personally encountered this level, but have seen various stories of people encountering this on a lesser degree for relatively more minor incidents (example: appendix removal), where just 1 or 2 bills were "out of network" and suddenly skyrocket in cost. Extrapolate it out for a more serious incident involving 2x-4x as many specialists and doctors and procedures, and your 'out of network' costs grow exponentially.
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Old 11-08-2015, 10:01 AM   #112
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CoveredCA has some interesting data/summaries of rate increases:

* The average rate increase for the lowest price silver/bronze plan is 3.3 and 1.5%
* weighted average change for whole state is 4.0% assuming enrollees stay on same plan
* Norcal sees a 7.0% increase compared with 1.8% for Socal
* CoveredCA attributes this to a lack of competition: "Provider competition (or area provider monopolies) is a primary driver of the difference in premiums between northern and southern California. Close to 70 percent of the 25 largest general acute care hospitals are in the southern region of the state compared to the north."

From http://www.coveredca.com/PDFs/7-27-C...tes-prelim.pdf

The doc also summarizes pricing changes for each region in CA.
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Old 11-08-2015, 10:14 AM   #113
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<snip long but good scenarios>

I haven't personally encountered this level, but have seen various stories of people encountering this on a lesser degree for relatively more minor incidents (example: appendix removal), where just 1 or 2 bills were "out of network" and suddenly skyrocket in cost. Extrapolate it out for a more serious incident involving 2x-4x as many specialists and doctors and procedures, and your 'out of network' costs grow exponentially.
Ok, but we should be able to get a story or two from this forum from members who have experienced this scenario if it has a 1% chance of happening. The odds would be we would have 3 or 4 stories of this considering the amount of members of ER.org.

Or is it more like 0.1% chance? Firecalc only gives me around a 97% chance of fulfilling our retirement needs. Am I ok with 96.9% and stop really stressing over the out of network issue? Just do your due diligence and fight any unfairness, like substitution of doctors you did not approve while you are under sedation.
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Old 11-08-2015, 10:44 AM   #114
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Ok, but we should be able to get a story or two from this forum from members who have experienced this scenario if it has a 1% chance of happening. The odds would be we would have 3 or 4 stories of this considering the amount of members of ER.org.

Or is it more like 0.1% chance? Firecalc only gives me around a 97% chance of fulfilling our retirement needs. Am I ok with 96.9% and stop really stressing over the out of network issue? Just do your due diligence and fight any unfairness, like substitution of doctors you did not approve while you are under sedation.
There have always been 'out of network gotchas', but consider all of the following variables:

-Guessing that a majority of the people who actively post on the forum are still working, and they likely have group plans (even some ERs have retiree group plans from work). Group plans are often less restrictive than individual plans, and perhaps have larger networks.
-It seems the super tightening of networks for individual policies (and group policies) is perhaps more recent than in years past. So not as many years of people in such tight networks for "out of network" incidents to occur.
-Major health incidents that could result in massive bills are usually heart attacks, cancer, and massive physical trauma from accidents. The heart attacks and cancer are much more prevalent in the 50+ age bracket. The number in accidents for the younger set are likely relatively low. This results in a small sample size, when taken in conjunction with the number of posters on the forum that are 50+.
-Not everyone is reading every post on this thread, and even fewer probably read your request on page 11 of a long thread for anecdotal stories of such incidents.

Add up all of the above variables, and you aren't left with many people that would be able to produce an out-of-network shock story. But, rest assured, the current conditions with health insurance network restrictions are building to allow such an incident more easily compared to years past.
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Old 11-08-2015, 10:59 AM   #115
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There have always been 'out of network gotchas', but consider all of the following variables:

-Guessing that a majority of the people who actively post on the forum are still working, and they likely have group plans (even some ERs have retiree group plans from work). Group plans are often less restrictive than individual plans, and perhaps have larger networks.
-It seems the super tightening of networks for individual policies (and group policies) is perhaps more recent than in years past. So not as many years of people in such tight networks for "out of network" incidents to occur.
-Major health incidents that could result in massive bills are usually heart attacks, cancer, and massive physical trauma from accidents. The heart attacks and cancer are much more prevalent in the 50+ age bracket. The number in accidents for the younger set are likely relatively low. This results in a small sample size, when taken in conjunction with the number of posters on the forum that are 50+.
-Not everyone is reading every post on this thread, and even fewer probably read your request on page 11 of a long thread for anecdotal stories of such incidents.

Add up all of the above variables, and you aren't left with many people that would be able to produce an out-of-network shock story. But, rest assured, the current conditions with health insurance network restrictions are building to allow such an incident more easily compared to years past.

I have one of those narrow networks. If anything happens to me and I live to tell, I will post the pricing experience. Only one hospital in a 20 mile radius of my house and it is in-network. So I am hoping and assuming I would wind up stumbling upon that location financially speaking. As far as surviving any medical procedure there...well that may be a different story.


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Old 11-08-2015, 11:56 AM   #116
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I have read one story total which caused somewhat of a financial ruin and it was not from this site. IIRC it was about a woman on vacation who went into early labor and had some pretty big hospital bills from the local out of network hospital. I think it was on the order of $50k to $100k, which would wipe out most Americans but might be withstood from most on ER.org. IIRC she is fighting the charges too.

So I see it as a valid concern but perhaps not the 'OMG we are all going bankrupt next year' type of concern.

Besides, there are evil options even if this does happen to you. Your 401K and some other IRA assets are protected from creditors during bankruptcy, so if your total net worth is $1 mil and you get $500k in out of network charges but have $900k of your net worth in your 401k, declare bankruptcy after you spend the $100k in taxable and make the out of network people eat the rest.
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Old 11-08-2015, 01:13 PM   #117
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If you receive emergency care out if network, you are not supposed to pay additionally because it is out of network.

https://www.healthcare.gov/health-ca...y-room-access/

Anyone who receives out of network emergency care is supposed to be billed in-network rates.



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Old 11-08-2015, 01:31 PM   #118
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If you receive emergency care out if network, you are not supposed to pay additionally because it is out of network.

https://www.healthcare.gov/health-ca...y-room-access/

Anyone who receives out of network emergency care is supposed to be billed in-network rates.
Yes, this is true -- but as far as I know it doesn't prevent balance billing. All it means is that all emergency care needs to be paid on the same schedule as in-network care.

In other words, if an in-network ER incident would pay out 90% of an allowable amount of $20,000, but you went out of network at a place that bills for $30,000, the insurer will pay $18,000 (90% of their $20K allowance) but you can still be billed the remaining $10K, for a total of $12K instead of $2K.

If you live in a state that forbids balance billing for emergency services, and there are a few, you can probably breathe a little easier. But for the rest of us, not necessarily:

http://kff.org/private-insurance/sta...are-enrollees/
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Old 11-08-2015, 02:22 PM   #119
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If you receive emergency care out if network, you are not supposed to pay additionally because it is out of network. Anyone who receives out of network emergency care is supposed to be billed in-network rates.
You might want to check out this article (not the video): https://blog.getinsured.com/answers/...mergency-care/

Also: http://www.healthinsurancecolorado.n...lance-billing/
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Old 11-08-2015, 03:40 PM   #120
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CoveredCA has some interesting data/summaries of rate increases:

* The average rate increase for the lowest price silver/bronze plan is 3.3 and 1.5%
* weighted average change for whole state is 4.0% assuming enrollees stay on same plan

Statistics can be misleading when the carriers change deductibles/copays/Out of pocket max for a plan. Factor those items in when comparing year over year and I suspect the increases would be much more substantial.
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