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BCBS PPO out of state for a college kid
Old 12-20-2019, 04:00 PM   #1
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BCBS PPO out of state for a college kid

I have a daughter who is in college in Philadelphia which is out of state. I obtained BCBS PPO through ACA market place, I thought that among all the coverage, PPO covers the wide range of doctors and facilities in the network for out of the state.
In October, Daughter got sick and went to the emergency room, She ended up stay over night in the hospital with various tests, they didn't find anything and sent her home the day after.
In November, we got a letter from BCBS on request of her progress, it says the hospital is in the network.
In December, we got statement from BCBS said that we need to pay 21k for this event. the hospital is NOT in the network.
By the way, the policy coverage deductible is 2500/person maximum.

I spoke with ACA Agent, and was told that if you buy a coverage directly from BCBS, they will consider network out of state; but if you receive a subsidies through ACA, any out of state is considered out of network.

Anyone knows anything about this kind of things?
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Old 12-20-2019, 04:46 PM   #2
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I'd start thinking about talking to a lawyer. I bet they will pay when they get a lawyer type letter.
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Old 12-20-2019, 06:44 PM   #3
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It depends on what policy you have and the city and state you live in. I have BCBS PPO thru the ACA and my coverage is nationwide. When traveling I go to our BCBS website and enter the city and state. The site then pulls up in network hospitals and Drs.

My friend has BCBS PPO thru the ACA in Louisiana and she only has in network coverage in the state. No national coverage.

Call your BCBS carrier. If your health card has a small suitcase on it you have in network state coverage or national coverage.
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Old 12-20-2019, 06:49 PM   #4
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I had a talk with my ACA insurer because I really wanted to understand it. I have a HDHP that is HSA compatible. Like most ACA plans coverage out of your local area is is covered for medical emergencies only. My insurance card I have a section on the card that identifies this out of state PPO plan that has many more locations. But you only have coverage for medical emergencies. But you do (at least on my plan) have to use a facility/doctor from the extended plan. The rub is really how do you know it is an emergency. My insurance company note they use the diagnostic codes to determine if it was an emergency. If they deny it, you can appeal. In my case lets say I thought I was having a heart attack but the diagnosis was heart burn.They would likely deny the heart burn. They may however accept the need for me to go in since I have a pacemaker and there is more reasonable that I might really have been in need of emergency care.


No, nothing like large corporate insurance.
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Old 12-20-2019, 07:07 PM   #5
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Some (many) BC BS plans have reciprocal contractual arrangement. If you contact the hospital's billing office and speak with the team lead/supervisor and explain the situation, it may be as simple as how the registration staff coded the insurance at time of er admission .

Also, where insurance does not cover a visit, the hospital may extend self pay (cash) prices to the guarantor which are substantially lower than msrp ( charge master) prices.

Just my two cents.
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Old 12-20-2019, 07:43 PM   #6
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Quote:
Originally Posted by Eucerin View Post
I have a daughter who is in college in Philadelphia which is out of state. I obtained BCBS PPO through ACA market place, I thought that among all the coverage, PPO covers the wide range of doctors and facilities in the network for out of the state.
In October, Daughter got sick and went to the emergency room, She ended up stay over night in the hospital with various tests, they didn't find anything and sent her home the day after.
In November, we got a letter from BCBS on request of her progress, it says the hospital is in the network.
In December, we got statement from BCBS said that we need to pay 21k for this event. the hospital is NOT in the network.
By the way, the policy coverage deductible is 2500/person maximum.

I spoke with ACA Agent, and was told that if you buy a coverage directly from BCBS, they will consider network out of state; but if you receive a subsidies through ACA, any out of state is considered out of network.

Anyone knows anything about this kind of things?
I have ACA with Blue Shield PPO. My deductible and OOP are the same: $13,800.00. Does your plan show higher number? Does out of network service not count against OOP?
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Old 12-20-2019, 08:08 PM   #7
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I've never been a fan of PPO or HMO policies. Anthem BCBS sells online, and they often write insurance for companies with locations all over the U.S.

I pay $353 a month for my 32 year old daughter's BCBS conventional health insurance plan (including dental) with terms and deductibles much better than the ACA.

Most colleges have health insurance programs for their students available. Have you checked into them?
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Old 12-20-2019, 09:50 PM   #8
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In general most ACA policies only cover in-state. Out-of-state is only covered if it is an emergency or urgent care situation. Depending on the circumstances you could try arguing that it was an emergency situation.

Also, many ACA policies have a reasonable deductible but it is an in-network deductible. Out-of-network deductibles are often very much larger. Similar for OOP maximums.

+1 to Bamaman's suggestion to check into the student health insurance plan at your daughter's school. My son is at an out-of-state university and is using the SHIP plan for now. He may investigate getting an ACA policy in the state where he is going to school. If that idea is workable, it may be cheaper than SHIP.
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Old 12-21-2019, 05:04 AM   #9
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Originally Posted by Eucerin View Post
I spoke with ACA Agent, and was told that if you buy a coverage directly from BCBS, they will consider network out of state; but if you receive a subsidies through ACA, any out of state is considered out of network.

Anyone knows anything about this kind of things?
If the insurance plan is ACA compliant, this part is definitely not correct. Emergency room treatment is covered regardless of whether you are in or out of network. This is an ACA mandate. Buying direct or through the marketplace makes absolutely no difference.

Insurers can offer policies with larger or more restricted networks, and they can limit which policies are offered on the marketplace. Your policy network defines how broad the coverage is, and how you bought the policy makes absolutely no difference.
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Old 12-21-2019, 12:48 PM   #10
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Originally Posted by SecondCor521 View Post
In general most ACA policies only cover in-state. Out-of-state is only covered if it is an emergency or urgent care situation. Depending on the circumstances you could try arguing that it was an emergency situation.

Also, many ACA policies have a reasonable deductible but it is an in-network deductible. Out-of-network deductibles are often very much larger. Similar for OOP maximums.

+1 to Bamaman's suggestion to check into the student health insurance plan at your daughter's school. My son is at an out-of-state university and is using the SHIP plan for now. He may investigate getting an ACA policy in the state where he is going to school. If that idea is workable, it may be cheaper than SHIP.
SecondCor521 - you know me from another thread, you know all my problems now. I am an early retiree, when these things happening that always make me wondering if I should go back to work.

I did research on the difference between PPO, HMO and POS, and decided on PPO as it covers wide range of doctors and facilities. PPO cost more but thought its worth it as Daughter is out of state. Never knew that ACA doesn't cover out of state.

Daughter school health insurance 500/month=6k/year.

Question - can a college kid apply for ACA in another state?

To answer other questions -
my currently premium 311/month = 3732/year.
In-state d/a 1k/person; 2k/family; out of pocket Max 2500/person; 5k/family
Out of state d/a 8600/person; 17,200/family; out of pocket Max 15800/person; 31,600/family
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Old 12-21-2019, 01:42 PM   #11
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My BS PPO sent be a letter a coupke years back saying that they don't cover out of state any more.

I'm afraid in your case it's possible that since there was nothing wrong with her they might use that as a reason not to consider it an emergency. Awful situation to be in.
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Old 12-21-2019, 02:02 PM   #12
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Wow, those are some expensive college health plans!

My out-of-state kid's university health plan through United Healthcare (full year, August-August) is under $150/month for a gold-level (ACA equivalent) plan & even the physicians we use here are in-network.

Best of all it is paid for by his scholarship which covers all tuition/fees.
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Old 12-21-2019, 06:45 PM   #13
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Quote:
Originally Posted by Eucerin View Post
SecondCor521 - you know me from another thread, you know all my problems now. I am an early retiree, when these things happening that always make me wondering if I should go back to work.

I did research on the difference between PPO, HMO and POS, and decided on PPO as it covers wide range of doctors and facilities. PPO cost more but thought its worth it as Daughter is out of state. Never knew that ACA doesn't cover out of state.

Daughter school health insurance 500/month=6k/year.

Question - can a college kid apply for ACA in another state?

To answer other questions -
my currently premium 311/month = 3732/year.
In-state d/a 1k/person; 2k/family; out of pocket Max 2500/person; 5k/family
Out of state d/a 8600/person; 17,200/family; out of pocket Max 15800/person; 31,600/family
Looks like your daughter's ER cost falls in this bucket?

My daughter is filing tax on her own, so independent, and she buys her own ACA Silver policy. Can you call the state exchange (if there is one) where your daughter's school resides? Find out what qualifies for young adult to purchase their own ACA policy in that state. May need to be independent and file own tax return.
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Old 12-21-2019, 08:53 PM   #14
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Quote:
Originally Posted by Eucerin View Post
SecondCor521 - you know me from another thread, you know all my problems now. I am an early retiree, when these things happening that always make me wondering if I should go back to work.

I did research on the difference between PPO, HMO and POS, and decided on PPO as it covers wide range of doctors and facilities. PPO cost more but thought its worth it as Daughter is out of state. Never knew that ACA doesn't cover out of state.

Daughter school health insurance 500/month=6k/year.

Question - can a college kid apply for ACA in another state?

To answer other questions -
my currently premium 311/month = 3732/year.
In-state d/a 1k/person; 2k/family; out of pocket Max 2500/person; 5k/family
Out of state d/a 8600/person; 17,200/family; out of pocket Max 15800/person; 31,600/family
Bolding mine.

My understanding when I asked the question here myself before is that yes, your daughter could get her own ACA plan in the state where she goes to college.

Her college may have requirements regarding what health coverage your daughter has. Check with them first to see if her being on an ACA plan would be acceptable.

Her student health insurance plan offered by her college may be more expensive but may be less hassle.

As an aside, I don't think you need to go back to work. I think you just need to research things more up front.

Quote:
Originally Posted by fh2000 View Post
Looks like your daughter's ER cost falls in this bucket?

My daughter is filing tax on her own, so independent, and she buys her own ACA Silver policy. Can you call the state exchange (if there is one) where your daughter's school resides? Find out what qualifies for young adult to purchase their own ACA policy in that state. May need to be independent and file own tax return.
Bolding mine again. Neither are necessary.

First question is whether kid qualifies as a dependent. In OP's case, it sounds like OP is paying for college, so the kid is probably a dependent. But OP should check the IRS flowcharts to determine whether kid is a dependent.

If kid is a dependent, then her tax family is the parent(s) plus any other dependents of those parent(s). If kid is independent, then kid is her own tax family (well, plus any kids she has, but OP's daughter probably doesn't have kids).

Next question is whether the tax family's income is within ACA range. If so, kid can get an ACA policy in PA.

If kid is a dependent and there are two ACA policies involved, then the information from both ACA policies is put on the parents' tax return and netted out accordingly. If kid is independent, then everyone reports their ACA policies on their own tax returns.
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Old 12-22-2019, 05:38 PM   #15
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Quote:
Originally Posted by Eucerin View Post
I have a daughter who is in college in Philadelphia which is out of state. I obtained BCBS PPO through ACA market place, I thought that among all the coverage, PPO covers the wide range of doctors and facilities in the network for out of the state.
In October, Daughter got sick and went to the emergency room, She ended up stay over night in the hospital with various tests, they didn't find anything and sent her home the day after.
In November, we got a letter from BCBS on request of her progress, it says the hospital is in the network.
In December, we got statement from BCBS said that we need to pay 21k for this event. the hospital is NOT in the network.
By the way, the policy coverage deductible is 2500/person maximum.

I spoke with ACA Agent, and was told that if you buy a coverage directly from BCBS, they will consider network out of state; but if you receive a subsidies through ACA, any out of state is considered out of network.

Anyone knows anything about this kind of things?
Doesn't matter if the same plan is sold through the insurance company or via heathcare.gov. The same plan number will have the exact same benefits both instate and out of state.

Once upon a time a BCBS PPO plan did in most cases mean a nationwide network, but that was changed several years ago. Most BCBS PPO plans are only regional plans nowadays. There are a few states that still have nationwide networks with Florida being one of them, but most now are just regional plans, because there is really no way for an insurance company to control/contain their costs with such a large price difference in procedures around the country. When looking at a plan, always read the contract to make sure the plan includes the nationwide BlueCard program. The Summary of Benefits may not contain the info necessary to make such a determination.
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Old 12-23-2019, 06:29 AM   #16
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The rub is really how do you know it is an emergency. My insurance company note they use the diagnostic codes to determine if it was an emergency. If they deny it, you can appeal.
+1

File an appeal saying she thought it was a serious emergency. Anthem BCBS sometimes uses the final diagnosis. You can read more in the articles below. You want them to consider the initial diagnosis and any other factors that led her to use the ER. There is nothing wrong with the plan you chose. You just need to convince them it was a proper use of the ER.

https://www.npr.org/2018/05/23/61364...aces-criticism

https://www.nytimes.com/2018/05/19/u...avoidable.html

Quote:
Originally Posted by Eucerin View Post
In November, we got a letter from BCBS on request of her progress, it says the hospital is in the network.
In December, we got statement from BCBS said that we need to pay 21k for this event. the hospital is NOT in the network.
Like my plan, your particular BCBS plan is attached to the BlueCard national provider network for emergencies only. This means BlueCard providers do not balance bill covered emergency services. Once the plan determined the visit was not an emergency, the hospital was no longer in-network. The hospital will be back in-network when you win the appeal and the visit is deemed an emergency.

Quote:
BlueCard (Out Of Area): Urgent/Emergency Coverage Only

Emergency Care

Covered Services are subject to any in-Network Copayment, Deductible, and Coinsurance. An out-of-Network Provider can bill you for the difference between the Allowed Amount we pay and his or her actual charge.

Emergency Care Outside the State

If you get emergency care from a provider that has a provider agreement with the local Blue Cross and/or Blue Shield Licensee through the BlueCard® Program, your out-of-pocket expenses may be reduced. This is because those providers accept the allowable charge for a covered service as payment in full. When you receive covered emergency care from one of these providers, you're responsible only for any deductible, copays, or coinsurance required by this plan.
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Old 12-23-2019, 10:29 AM   #17
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+1

File an appeal saying she thought it was a serious emergency. Anthem BCBS sometimes uses the final diagnosis. You can read more in the articles below. You want them to consider the initial diagnosis and any other factors that led her to use the ER. There is nothing wrong with the plan you chose. You just need to convince them it was a proper use of the ER.

https://www.npr.org/2018/05/23/61364...aces-criticism

https://www.nytimes.com/2018/05/19/u...avoidable.html

Like my plan, your particular BCBS plan is attached to the BlueCard national provider network for emergencies only. This means BlueCard providers do not balance bill covered emergency services. Once the plan determined the visit was not an emergency, the hospital was no longer in-network. The hospital will be back in-network when you win the appeal and the visit is deemed an emergency.
Daughter was sent to emergency room by school doctor, twice actually. The first time was few days before this event, she was there for couple of hours then sent back; The second time was there because she lost balance (vertigo was diagnosed), she stayed in the hospital for further tests and sent home the following day.
The large bill was all for 2nd visit. The 1st visit wasn't mentioned.
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Old 12-27-2019, 12:05 PM   #18
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Every individual plan comes with a benefit grid (sometimes called Schedule of Benefits) and an Evidence of Coverage.

The former would show how out of network coverage is billed. That's at least a starting point. The latter is the bigger legal document which would detail your rights to an appeal, etc. I'd try to get those from your agent or the insurance company if you haven't already.

You could also check with the plan's provider search tool online (or call customer service) to see what docs and hospitals would be considered "in-network" near her in Philadelphia.

There are 4 or 5 major provider systems in Philly, so not all of them will likely participate, but I bet one of them does if it is in fact a Blues PPO plan she's on. That would be good knowledge for using her plan in the event something happens in the future.

Otherwise, I do agree with previous poster who said that emergency coverage should be billed at in-network rates, no matter where the patient went to the ER. If you're fighting the insurance company, I would start there. See here for some background info: https://www.healthcare.gov/using-mar...mergency-care/
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