Traveling Healthcare Emergency ACA Plan

[littleb]

While traveling last month I encountered a medical condition that prompted a visit to a hospital emergency room. The dr. admitted me overnight and many tests were done to determine the cause of my symptoms. They ruled out stroke, heart attack and aneurysm but I was not conscious until the next day.

Imagine my surprise when I received an EOB from the insurance company stating my share of the hospital bill was 13,000. I called BCBS and the rep confirmed that was my share of the bill. I explained that it was a medical emergency while traveling and should be covered at 100%. At least in the past most insurance policies always covered true emergencies while traveling.

Pulled out my policy and I was shocked to read that my ACA plan thru BCBS of Tennessee covers out of network emergencies with a 5,000 deductible and 18,000 out of pocket yearly maximum.

I researched online and found the hospital was in the Blue Cross family of networks throughout the country. I called another rep at BCBS and told her about the hospital being in network and should be processed at in network benefits. It took two more phone calls to BCBS to get someone to understand this entire in network out of network situation. Finally the claim has been reprocessed correctly as an in network facility. The fact that I knew more about how the benefit should have paid than the reps at BC was concerning.

If the hospital had billed me the 13,000 I found a law that was passed in the state of Mississippi (hospital was located) where the hospital or dr. cannot balance bill a patient if the insurance company makes a partial payment against an out of network facility or dr.

Unfortunately, only a few states have passed the balance bill out of network law. This has been eye opening and educational for me since we travel to other states all the time.

 

[candrew]

Your experience reminds me of the importance of travel insurance. Though I suspect that in your case, the travel insurance company would attempt to deny the claim due to a "pre-existing condition."

 

[Rianne]

OP, Wow. That situation is a huge consideration when choosing a HC plan. I cringe b/c emergency visits only cover the ER, not if you are admitted. I noticed none of the 2017 plans offered to us had the ER cap (including if you are admitted) that 2016 plans had.

You were unconscious. I've thought about telling ER doctors, fly me home to my in network drs."


My DSI was in Florida, lives in Illinois, and had a colon attack. She refused to go to the ER because of what you just said. She suffered until she got home and ended up in the hospital for over a week with diverticulitis. All her care was then in network. Was it worth it? This is an excellent point you bring up. If you travel, you are screwed re healthcare. How many hours did it take for you to solve the issue?

 

[explanade]

But travel insurance is secondary coverage, unless you pay a lot for primary coverage.

Not sure if that even exists.

I bought a $40 plan which has something like $50k in secondary coverage so if your ACA insurance declines, who knows what the secondary insurer would do.

They have exclusions for preexisting conditions too.

 

[Rianne]

This video was on CBS morning, exactly what we're talking about and cannot be explained by Kaiser.
https://khn.org/news/watch-what-happened-to-that-109000-heart-attack/

 

[littleb]

Watching that video of the man who received the 100,000 bill brought back all the stress I encountered trying to get my hospital bill resolved. I spent weeks researching the situation. The hospital never billed me but the BC rep explained my balance was 13,000 which was due to out of network hospital.

Online I found if you have the little suitcase on your BCBS card you should have in network coverage in every state if the hospital is in the BCBS family. Finally a rep at BCBS took the time to review the situation and call the out of state hospital and inform them how to process the bill in network. It was processed in network NOT because it was an emergency but because it was an in network hospital under BCBS of Mississippi.

During my research I found the balance billing issue for out of network benefits a nightmare when traveling or emergency care. Many states have passed laws to protect consumers from balance billing practices but these are loose laws. The hospital or facility may write off the balance but might not. Only 6 states have comprehensive balance billing laws to protect the patient. They are CT, NY, MD, IL, CA and FL.

Here is a map that addresses the balance billing laws by state.

https://www.insidearm.com/news/00043325-most-states-still-dont-have-comprehensive/

This map may not be up to date since the article was written in October 2017. Tennessee passed a patient protection law in July 2018.

During the research I found that air ambulance carriers are not in network and your insurance company may pay a few thousand dollars but the patient will be balance billed. One person who had a stroke was billed 32,000 after his insurance paid a small amount. He negotiated the bill down to 12,000.

Who has this kind of money especially if you are retired?

 

[ncbill]

Yep, this is why I'm paying $125/month to cover one kid at their out-of-state college under its gold-level plan.

When I was away at college it was closer to $125/year.

 

[littleb]

The funny thing about this situation is I worked in the health insurance benefits department years ago and understand how insurance works. I assumed emergency care was covered at 100% when traveling because that was the standard in the industry years ago. I was shocked to see under my policy it is covered at in network and out of network which in my case is 50% coverage after the deductible was met. Out of network has a huge deductible and out of pocket maximum annually.

Under the ACA the insurance companies have carved out so many benefits that the cost falls back to the patient. This is even with paying the lowest premium available of 1800 monthly for two people ages 63 and 57. Thankfully we are receiving a subsidy this year but in the past we paid 1500 + each month for ACA insurance.

 

[LOL!]

Thanks for telling us your story. I have found that insurance / doctors / facilities do not always do the right thing, so unfortunately one has be a pseudo-expert in order to navigate getting sick or ill.

Here is something I found out: Our family out-of-pocket maximum is $6800, but out-of-network deductible is $7,000. Thus one will hit $6800 and never hit the $7,000. Go figure.

 

[Dreaming of Freedom]

I am terrified that someday my husband and I will be very underinsured no matter how much I try to protect us. The ACA plans in my area have tiny networks with no out of network coverage, and an extremely narrow definition of life-threatening event for out of network ER visits. Because of the high cost of crappy health insurance, we are already saving $1 million, but I am thinking we probably need to save another $500,000 to cover these balanced billing and out of network gotchas. My husband is only 5 years from Medicare, but I am 23 years away from Medicare if it even exists by then. I just don't know what else to do besides move to another country. How are you guys protecting yourselves from financial ruin or early death due to health insurance limitations & high cost of healthcare in the US?

 

[athena53]

I'm on Medicare now but one of the things that drive e crazy was the out-of-network provisions on the ACA policies, which got worse every year at renewal. A few had no limit on out-of-pocket expenses for out-of-network coverages. I had to choose carefully.

On my trips out of the US I get travel insurance that's primary (Medicare covers nothing outside the US, and my supplement has a fairly small lifetime max outside the US).

 

[NYEXPAT]

I am terrified that someday my husband and I will be very underinsured no matter how much I try to protect us. The ACA plans in my area have tiny networks with no out of network coverage, and an extremely narrow definition of life-threatening event for out of network ER visits. Because of the high cost of crappy health insurance, we are already saving $1 million, but I am thinking we probably need to save another $500,000 to cover these balanced billing and out of network gotchas. My husband is only 5 years from Medicare, but I am 23 years away from Medicare if it even exists by then. I just don't know what else to do besides move to another country. How are you guys protecting yourselves from financial ruin or early death due to health insurance limitations & high cost of healthcare in the US?

I moved overseas 15 years ago and will move back next year when I am medicare eligible. I travel to the USA a few times a year and always pick up 1 million in health coverage for myself and family.

 

[kimcdougc]

We pay over $1,600 a month for DH age 60 any myself 58. It does not cover our or network except for emergencies. I haven't looked too closely at our policy to see how much it covers if out of network for emergencies.

Come November, I will be looking closely for that.