Wait...what? Out of network problems are gone now?

[Fermion]

This totally slipped by me...guess we have been too busy building a house:

"When receiving unexpected out-of-network care — including emergency care, elective procedures and even air ambulance — you’ll only be responsible for your normal in-network deductibles, copays or coinsurance.

As for the rest of the bill? Your insurance company and the out-of-network provider will have 30 days to settle the outstanding balance between themselves."


What? This takes effect Jan 1?

https://www.yahoo.com/finance/news/no-surprises-law-surprise-effect-190500463.html

 

[PaunchyPirate]

There seems to be a bit of an interpretation gap between the Yahoo article and the one here (from CMS.gov).

https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills

I see the government’s position as:

1. If a true emergency occurs, you will pay in network prices if you need to go to an out of network facility.

2. If you are treated for ANYTHING at an in network facility, you cannot be billed by someone who treats you as out of network.

3. Air ambulance services need to be billed as in network.

Number 2 is quite different from the Yahoo article saying if you get non-emergency, routine treatment at a out of network facility that it must be billed as in network. I don’t know of an elective procedure that is considered “unexpected”.

 

[Aerides]

This, I think, is the change to close the surprise billing gap. IE, you go to an in network hospital for an in-network procedure, but - surprise! - the dude on the left of your surgeon who handed him a scalpel is out of network.
The key is the "unexpected" part. This doesn't mean just go out of network for anything you like, but it means that you aren't stung by the crazy way things are setup.

Today, you can check into the ER, in network, with a doctor, in network, and find that your radiologist and who knows what - things you have no hand in deciding - could be out of network. This bill forces the insurance and providers to work it out, vs. forcing it to you to pay.

 

[John Galt III]

This is great news. I feel better about my 'cheap' Medicare Advantage HMO now. I kept hearing that the 'supplement' Medicare health insurance was better since there was no worry about networks. Now I don't need that protection, apparently. By the way, is ambulance coverage included in the new laws? I heard that ambulances can still rip you off with huge out of network charges.

 

[MichaelB]

Ground ambulance service is not covered in this new “no balance billing” law.

 

[GTFan]

The article I read in our local rag said that OON docs in an in-network facility can have you sign a balance billing waiver to perform service, and refuse if you don't sign. That's an allowed exclusion in the law.

Also said that CMS is still writing the rules for how this works since the AMA thinks the insurance co's. are going to screw them over in required arbitration for covered OON services.

https://epaper.ajc.com/popovers/dyn...campaign=pagesuite-epaper-html5_share-article - Surprise medical bills law kicks in Jan. 1

 

[Fermion]

The article I read in our local rag said that OON docs in an in-network facility can have you sign a balance billing waiver to perform service, and refuse if you don't sign. That's an allowed exclusion in the law.

Also said that CMS is still writing the rules for how this works since the AMA thinks the insurance co's. are going to screw them over in required arbitration for covered OON services.

There seem to be a lot of must do's though in that waiver. They have to spell stuff out clearly, they have a tight timeframe, there are things they can't have you sign away. Still, the article I read said a lot of people would sign the waiver. I expect some court battles.

 

[MichaelB]

Here’s a very good short summary of the new law by Kaiser Foundation (here)

This new regulation covers emergency service and non-emergency care where the facility (hospital, clinic, lab) is in-network. The facility can ask a patient to sign a waiver, the patient can refuse, and the facility can then elect to not provide a service, but only when the facility is in network and is not an emergency.

The big deal here is the emergency and post-emergency care. Hedge funds have invested heavily in buying emergency room operations, and have been very aggressive with pricing.

There seem to be a lot of must do's though in that waiver. They have to spell stuff out clearly, they have a tight timeframe, there are things they can't have you sign away. Still, the article I read said a lot of people would sign the waiver. I expect some court battles.

For sure. People who sign forms without reading them will regret doing so. In addition to court battles, investors and operators will be looking for even the smallest loopholes to get around this. There’s lots of money at stake here.

 

[John Galt III]

It always seemed to me that 'unethical but legal' gouging, like surprise out of network bills, was a big part of the profits in medicine. My first thought upon reading about the new law was "But where will they gouge us now? Surely they can't provide 'cheap' care to the many without gouging the naive few." The fact that hedgies are invested in ER's is telling.

 

[John Galt III]

GTFan wrote : " The article I read in our local rag said that OON docs in an in-network facility can have you sign a balance billing waiver to perform service, and refuse if you don't sign. That's an allowed exclusion in the law. " Almost always, at a specialist, and even my PCP, they want me to sign some form saying I agree to pay them whatever they bill me for, including balance billing, and that a collection agency will pursue me, if necessary, etc. Whenever I protest about it, they say they will accept whatever the ins co pays them, plus my copay. So I sign it, with my notes added, if it is paper. But why make me sign a form agreeing to balance billing? This has never made any sense to me. The last time I went to see my PCP I didn't have to sign anything. Things might be changing.

 

[disneysteve]

The out of network issue at an in network facility has always been a problem. If my in network surgeon is operating on me at an in network hospital, how am I supposed to know the the contracted anesthesia group at that hospital is out of network? Or that the contracted radiologist who read my CT scan done at that in network hospital is out of network? It's not like I get to pick and choose those things.

 

[MBSC]

This is great news. I feel better about my 'cheap' Medicare Advantage HMO now. I kept hearing that the 'supplement' Medicare health insurance was better since there was no worry about networks. Now I don't need that protection, apparently.

The new law does not apply to original Medicare or Medicare Advantage. They already have patient protections in place.

Medicare Advantage has never allowed 'surprise medical bills' by out-of-network providers at in-network facilities. When an MA member goes to an in-network hospital, they pay an inpatient/outpatient/ER copay that is inclusive of physician services. Both HMOs and PPOs pay the OON physicians so they appear to be in-network from the member's perspective. Balance billing has never been allowed.

Non-emergency services at out-of-network hospitals are still not covered by the MA HMO. The MA PPOs (and some HMO-POS plans) include this coverage although cost sharing is usually higher.

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 110.1.3 – Services for Which MA Plans Must Pay Non-contracted Providers and Suppliers

<snip>When an enrollee visits an in-network provider, even though that in-network provider may work with an out of network provider, then the enrollee is only responsible for in-network cost-sharing.

Section 50.5 – Guidance on Other Enrollee Out-of-Pocket Liability

No balance billing: As indicated in section 170 below, an enrollee is responsible for paying non-contracted providers only the plan-allowed cost-sharing for covered services.

Section 170 – Balance Billing

When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing.

MA plans must clearly communicate to enrollees through the Evidence of Coverage (EOC) and Summary of Benefits (SB) their cost-sharing obligations as well as the enrollees’ lack of obligation to pay more than the allowed plan cost-sharing as described above.

Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

 

[zinger1457]

Almost always, at a specialist, and even my PCP, they want me to sign some form saying I agree to pay them whatever they bill me for, including balance billing, and that a collection agency will pursue me, if necessary, etc. Whenever I protest about it, they say they will accept whatever the ins co pays them, plus my copay. So I sign it, with my notes added, if it is paper. But why make me sign a form agreeing to balance billing? This has never made any sense to me. The last time I went to see my PCP I didn't have to sign anything. Things might be changing.

Seems strange that your PCP would make you sign a form like that, never seen that at the PCP's I've used. Just give them my latest insurance card and they bill the insurance company, never had to sign anything.

 

[travelover]

The out of network issue at an in network facility has always been a problem. If my in network surgeon is operating on me at an in network hospital, how am I supposed to know the the contracted anesthesia group at that hospital is out of network? Or that the contracted radiologist who read my CT scan done at that in network hospital is out of network? It's not like I get to pick and choose those things.

The petty crooks wear hoodies, the big crooks wear suits.

 

[DawgSavr]

ACA Healthcare Plans and Travel

Before I posted this as a separate post, I saw this thread and thought maybe this answers my questions. Does it?

Curious as to how those that are have "early retired" handle traveling outside of your ACA Health Insurance Providers Network whether domestically or internationally. As my DW and I contemplate early retirement in 2022, we notice that many, if not all, of the plan documents indicate "not covered" under the "Out of Network Provider" column. We are 58, live in MO and obviously part of plans to retire early are to travel and explore while we are still healthy and active to do so. I suppose we can supplement our coverage with a "supplemental plan" (i.e., Aflac or similar) or take out specific travel insurance to cover an unforeseen emergency or illness.). Curious as to what others do to mitigate that risk? Anyone experience an illness/or injury using an ACA plan out of network?

 

[PaunchyPirate]

Before I posted this as a separate post, I saw this thread and thought maybe this answers my questions. Does it?

Curious as to how those that are have "early retired" handle traveling outside of your ACA Health Insurance Providers Network whether domestically or internationally. As my DW and I contemplate early retirement in 2022, we notice that many, if not all, of the plan documents indicate "not covered" under the "Out of Network Provider" column. We are 58, live in MO and obviously part of plans to retire early are to travel and explore while we are still healthy and active to do so. I suppose we can supplement our coverage with a "supplemental plan" (i.e., Aflac or similar) or take out specific travel insurance to cover an unforeseen emergency or illness.). Curious as to what others do to mitigate that risk? Anyone experience an illness/or injury using an ACA plan out of network?

Well, as you’re finding out, many (but not all ACA plans) do not include out of network (and/or outside a geographic region) coverage. It’s not an ACA requirement that they do or do not. But a lot of the insurance companies have chosen not to offer that coverage. It varies greatly by geographic area what plan coverages are offered and by what insurers.

It IS an ACA requirement that plans cover true emergency care in out of network situation within the USA. You are expected to quickly get to medical help, get treated, and get out without fear of out-of-network expenses.

But it is always a gray area as to when emergency care turns into non-emergency additional care (which isn’t covered without out-of-network coverage). So one risks a back and forth battle with insurers and providers in these situations.

So, when you travel in the USA, you’re covered in a true emergency. But after that, it will depend on how lucky you are to have a good plan in your location.

Internationally, you almost certainly want to consider additional travel insurance. Domestic travel insurance isn’t all that common, but you can find it.

For the first 2 years of my early retirement, I was able to pay higher premiums to get a PPO plan that had true out of network coverage (at higher copays, deductible, coshares, etc., of course). In my 3rd year, that company went all-HMO in my location. And the only other ACA insurer didn’t offer a PPO either. 10 miles away, in another county, both of them continued to offer a full PPO. So last year, I had added risk. I just risked only having the emergency care when I traveled.

Luckily, this year, one of the insurers has again offered out of network coverage by again offering a PPO. It’s the BC/BS affiliate, and they also offer their Blue Card feature in this plan. This means that care at most hospitals around the country that take BC/BS are actually billed at in-network rates. So I’m much happier this year.

All you can do is research, research, research and supplement if you feel the need.

 

[MichaelB]

Before I posted this as a separate post, I saw this thread and thought maybe this answers my questions. Does it?

Curious as to how those that are have "early retired" handle traveling outside of your ACA Health Insurance Providers Network whether domestically or internationally. As my DW and I contemplate early retirement in 2022, we notice that many, if not all, of the plan documents indicate "not covered" under the "Out of Network Provider" column. We are 58, live in MO and obviously part of plans to retire early are to travel and explore while we are still healthy and active to do so. I suppose we can supplement our coverage with a "supplemental plan" (i.e., Aflac or similar) or take out specific travel insurance to cover an unforeseen emergency or illness.). Curious as to what others do to mitigate that risk? Anyone experience an illness/or injury using an ACA plan out of network?

The primary focus of this regulation is emergency care billing, so if you are outside of your network, need emergency care, and have health care insurance, you are protected from excess billing. You still are liable for your cost sharing part of the expenses.

The bill does not cover non-emergency expenses by out of network providers. For this you need either an insurance plan with a wider provider and geographic network, or a travel supplement.

Most insurance does not cover providers in other countries. Travel insurance helps.

Here are a couple of threads discussing coverage away from home for snowbirds. You will find other discussions with the search function.

https://www.early-retirement.org/forums/f38/aca-for-snowbirds-112018.html
https://www.early-retirement.org/fo...ce-for-aca-person-for-snowbirding-105653.html

 

[Fermion]

Are we thinking that this would largely prevent the previous fears of having a major health incident while in the USA but not near your network? Say you are traveling in Florida but live on the west coast and you break a leg.

Before this law, they could balance bill you for the care I think?

 

[Aerides]

Are we thinking that this would largely prevent the previous fears of having a major health incident while in the USA but not near your network? Say you are traveling in Florida but live on the west coast and you break a leg.

Before this law, they could balance bill you for the care I think?

I wouldn't count on this law for that sort of thing, unless you find it in the fine print. I don't think it's meant for end-to-end event coverage, but the surprise stuff - you roll up to a covered facility but then have non-covered services and staff assigned to you, often while you're in no shape to refuse.

I don't think this covers true non-covered stuff like you describe. I would think that's the responsibility of the person to first have made reasonable efforts at coverage? Granted I haven't read that much detail as your scenario doesn't apply to me, as I do have out-of-network coverage while travelling in the US.

 

[RetMD21]

AMA is standing with the doctors and services that have surprise billing as a business model. Unfortunate but not unexpected.

 

[MBSC]

Say you are traveling in Florida but live on the west coast and you break a leg.

I wouldn't count on this law for that sort of thing, unless you find it in the fine print. I don't think it's meant for end-to-end event coverage, but the surprise stuff - you roll up to a covered facility but then have non-covered services and staff assigned to you, often while you're in no shape to refuse.

I don't think this covers true non-covered stuff like you describe.

The No Surprises Act (NSA) has three main components.

1. Out-of-network physicians at in-network hospitals, as you described.

2. Covered emergency room services at OON hospitals and freestanding ER centers.

Insurance companies are given some discretion in deciding what a layperson thinks is an emergency. My plan considers long bone fractures (arm,leg) and open fractures to smaller bones to be covered emergencies.

3. Post-Stabilization Services.

The NSA defines emergency services to include post-stabilization services, except under certain conditions. This means that patients are generally protected from balance bills for post-stabilization services. These services fall under the NSA regardless of where in a hospital such services are furnished; they may be provided as part of outpatient observation or an inpatient or outpatient stay if provided together with emergency services.

Post-stabilization services are not treated as emergency services under the NSA if certain conditions are met. Patients could face balance bills for post-stabilization services if the patient’s attending emergency physician or treating provider determines that the patient can travel to an in-network facility using nonmedical or nonemergency transportation but the patient opts to stay at the out-of-network facility; a receiving in-network facility must be within a reasonable travel distance.

A patient simply cannot give consent when they are far away from any in-network providers and unable to use nonmedical transportation. The same is true if an individual faces unreasonable travel burdens (such as being unable to afford transport or not well enough to take public transit). These limitations prevent them from giving consent. When a patient cannot consent, the NSA’s protections continue to apply to post-stabilization services and the patient cannot be balance billed.

Reference: https://www.healthaffairs.org/do/10.1377/forefront.20210706.903518/full/

 

[GTFan]

Are we thinking that this would largely prevent the previous fears of having a major health incident while in the USA but not near your network? Say you are traveling in Florida but live on the west coast and you break a leg.

Before this law, they could balance bill you for the care I think?

This was not allowed under the ACA, I think, because emergencies are covered as in-network.

My wife broke her leg in DC in 2015 (while on vacation) and we had Humana ACA then. They covered everything as in-network, even the OON surgeon's fee. Total bill paid by insurance was something like $57k for a 3-day stay and all we paid was $6500 deductible.

 

[Chuckanut]

AMA is standing with the doctors and services that have surprise billing as a business model. Unfortunate but not unexpected.

This makes me want to become and automobile mechanic. Every time a M.D. or medical center administrator brings his car in for service, I'll use the same logic on him. " Dr. Achenbach, here's your bill for the new water pump $853. $240 to install the pump, $125 for the pump, and the rest is for the guy who tested and restored your coolant to the proper water/coolant ratio. He's an independent coolant specialist with a certificate from the Joplin Tech Academy. Not one of my regular shop staff."

 

[subwayhamster]

This will be my first year with an ACA plan and am a bit confused about the changes resulting from the law, specifically the part about post-stabilization services. I was under the impression that before this law went into effect, if you were vacationing in another State and happen to end up as an inpatient in the hospital after receiving care in their ER, you would be responsible in full for the inpatient part of the bill. From my reading of the Health Affairs article quoted earlier, it seems that now (from my point of view as an ACA plan recipient) that same inpatient stay is covered in-network if you cannot feasibly return to your State for in-network care (I'm choosing to ignore the 'impoverished' part of that rule). Is this your understanding as well? Am I right in thinking that I will not need to buy travel insurance for the medical coverage each time I vacation domestically in the US? (I'm not concerned about minor costs like urgent care clinic visits, just the cost for inpatient stays following ER care.) The new law sounds pretty good and very timely (at least to me in my first year of ACA). Thanks for your input!

 

[Fermion]

Sounds pretty good, you can't be billed if you are not able to be stabilized enough to use non emergency transportation.

So if you can't fly, you can't be billed.