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ACA - across states?
Old 11-24-2020, 05:02 AM   #1
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ACA - across states?

We live on the border of 2 states. We live in Michigan but all our doctors are in Ohio. Is ACA state by state? Can we live in Michigan and get insurance that will cover our Ohio doctors?
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Old 11-24-2020, 07:23 AM   #2
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We live on the border of 2 states. We live in Michigan but all our doctors are in Ohio. Is ACA state by state? Can we live in Michigan and get insurance that will cover our Ohio doctors?
Insurance purchased directly by an individual anywhere, via the ACA exchange or not, is going to be location-specific. You need to identify what zip code you live in, which determines your county, which determines your state. Insurance plans that are available to be sold to you are based on this location. The "in-network" providers will vary from company to company and even plan to plan in many cases. Many of the large companies that provide nationwide insurance via employers do not sell plans directly to individuals, let alone via the ACA exchange. But you have to check who sells insurance in your home zip code.

Now that does NOT necessarily mean you cannot use medical providers in another state under your coverage. But it could mean that. You need to fully understand what the plan you purchase covers. They may or may not include out-of-state providers.

So, if you've decided you want to purchase off the ACA exchange (which you must do if you wish to get an ACA subsidy), then you need to comb through the available plans and see what they will cover. You look up specific doctors to see if the plan covers them. You look up specific hospitals to see if the plan covers them.

If your plan is a PPO, then it probably has some coverage in other states, but it may be at higher out-of-network pricing.

I'm 10 miles from Ohio, living in PA. My ACA insurance plan has a list of about 50 hospitals that are in-network. Most of them are owned by one corporate hospital system. I don't believe any of them are across the border in OH, but I haven't actually looked that up since I have a PA one that is closer.

Edited to add: I just looked at the network supported by my plan. There are indeed a few hospitals across state borders that are included in my plan -- several Cleveland Clinic hospitals. But certainly not all hospitals, just a select few. I'd have to check individual doctors by name to know if they were in-network or not.
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Old 11-24-2020, 07:31 AM   #3
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I'm smack in the middle of my state so I don't know the answer. I do know that you can put in your doctors' names and see which, if any, plans cover those doctors. Give it a try.
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Old 11-24-2020, 08:12 AM   #4
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Depends. When I lived in KC state lines made zero difference. The entire area KCK and KCMO were the network, even 60+ miles outside of the metro.

Living in rural CO going 30 miles to NM is out of network. It's a crazy system.
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Old 11-24-2020, 08:49 AM   #5
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We live on the border of 2 states. We live in Michigan but all our doctors are in Ohio. Is ACA state by state? Can we live in Michigan and get insurance that will cover our Ohio doctors?
When you are shopping for ACA insurance, you'll want to look at what docs are in the network associated with the various plans that you are considering.

Just because you live in Michigan and buy insurance in Michigan there would likely be some Michigan docs that are not in-network, and some Ohio docs that are in-network. IOW, it depends on how the network is defined, not the state that you live in or buy insurance from.

When we had ACA insurance from Vermont we still had some in-network docs in neighboring New Hampshire which was only a 1/2 hour drive.
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Old 11-24-2020, 08:52 AM   #6
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You can look up the doctors covered as in-network on your plan.
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Old 11-24-2020, 08:54 AM   #7
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When you are shopping for ACA insurance, you'll want to look at what docs are in the network associated with the various plans that you are considering.

Just because you live in Michigan and buy insurance in Michigan there would likely be some Michigan docs that are not in-network, and some Ohio docs that are in-network. IOW, it depends on how the network is defined, not the state that you live in or buy insurance from.

When we had ACA insurance from Vermont we still had some in-network docs in neighboring New Hampshire which was only a 1/2 hour drive.
+1

It is a "business decision" on the part of the various health insurance companies and the "providers" who sign contracts with them to become in-network.

Your state and zip-code of residence will determine which plans are available to you, but the devil in the unregulated details is the in-network definitions which varies.

-gauss
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Old 11-24-2020, 09:05 AM   #8
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I want to mention one other thing. Sometimes providers make mistakes in filing these state-border cases. Be vigilant and check that they filed with the correct insurance company.

Here's my story. I worked for a doctor's billing office in the early 80s, in Illinois. We had a border with Indiana. Indiana BC/BS would cover our Illinois based services. However, we had some people in the office constantly forget this and just file with BCBS Illinois. BCBS Illinois would simply reject it. Some of these went to collections due to the incompetence of our office workers.

Fortunately, we had a wonderful, patient woman -- a saint on earth -- who would kindly remind the young whipper-snappers of this issue, and how to deal with it. She would even pull some of the cases out of collection (hard to do) and fix them by re-filing with Indiana BCBS. I know it made an impression in me, and also gave me an example of what excellence in your work is.
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Old 11-25-2020, 04:21 PM   #9
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It appears very limited. The only PPO available in my zip code is Blue Cross and they consider everything in Ohio as out of network.
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Old 11-25-2020, 04:47 PM   #10
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It appears very limited. The only PPO available in my zip code is Blue Cross and they consider everything in Ohio as out of network.
This is not at all surprising. Reason #414 why our country needs a healthcare overhaul. Congratulations on having access to a PPO.
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Old 11-25-2020, 04:56 PM   #11
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There was, at one time, “multi state” plans available in the Exchange. I don’t know if they are available anywhere, any more. They seem to have gone the way of the PPOs — almost never available any more, at least not where I have seen. Pretty much everything now is either EPO or HMO.
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Old 11-25-2020, 05:49 PM   #12
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Here's my story. I worked for a doctor's billing office in the early 80s, in Illinois. We had a border with Indiana.
I just checked a map......... We still have a border with Indiana! Hoosiers don't want to admit, but, yes, it's still there!
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Old 11-26-2020, 12:21 PM   #13
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I just checked a map......... We still have a border with Indiana! Hoosiers don't want to admit, but, yes, it's still there!
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Old 11-28-2020, 03:22 AM   #14
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This is not at all surprising. Reason #414 why our country needs a healthcare overhaul. Congratulations on having access to a PPO.
+1

Also I believe the local coverage limitations of the ACA insurance is something a lot of people that travel may not appreciate. In the plans available in our area you have essentially zero insurance coverage out of the local area. This necessitates a separate travel medical insurance policy.
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Old 11-28-2020, 05:22 AM   #15
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+1

Also I believe the local coverage limitations of the ACA insurance is something a lot of people that travel may not appreciate. In the plans available in our area you have essentially zero insurance coverage out of the local area. This necessitates a separate travel medical insurance policy.
There are no ACA local coverage limitations. The ACA does not limit or regulate the size, reach or breadth of insurer provide networks. This is the state insurance regulator working with insurance companies. Some state regulators are just more effective than others. The same network coverage issues also affects some employer provided insurance.


The ACA does require all policies to provide emergency coverage across the US.
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