Question about ACA in-network coverage

[Popsicletoes]

Hello everyone,

I was playing around with different scenarios on Healthcare.gov website to see what choices I have for insurance companies. I noticed that the majority of choices in FL where I live had limited in-network choices for doctors, specialists, etc. Some of them were limited to the county where I live, so if I travel to another county or another state, and I need to see a doctor, I will pay out of network costs. That's an eye opener since I'm used to great country-wide in-network coverage from my employer's insurance.

Is this the same where you live?

Is the same in-network limitation applies to Medicare too?

For those of you who love to travel and use ACA, do you just bite the bullet and pay out of network costs as needed?

Thanks!

 

[Rianne]

Our ACA healthcare in Illinois will pay in-network if you go to the ER. If you're admitted it becomes out of network. Our deductible is approx. $7000/per adult. After that 100% covered. Our monthly premium is $8.95. This is keeping MAGI below $75K. Honestly, I believe this is a better deal than medicare.

 

[djsander]

Our ACA plans in our area are all hmo and restricted to the surrounding counties as near as I can tell unless an emergency. For Medicare it depends on what you get. Traditional with a supplement is good anywhere that Medicare is accepted. The advantage plans have a very wide range depending on what you plan you choose and they can be only local to a nationwide network. There are numerous threads on Medicare. My wife went with traditional Medicare with a plan G and it meets her needs. I’m on ACA for a few more years. It’s a lot different than employer provided health care. We had good coverage with low deductibles. I would rather be retired than working.

 

[PaunchyPirate]

This varies WIDELY around the country. And it can change every year.

This year I have a nice Blue Cross/Blue Shield PPO plan with wide in-network coverage in my part my state PLUS it offers BC/BS BlueCard coverage nationwide, which allows me to get in-network pricing nationwide from most other BC/BS companies - some restrictions apply. Plus, I have out-of-network coverage with higher deductibles/out-of-pockets.

Last year, all I had was an HMO with a different hospital/insurance company that only covered me at their own providers in my part of the state. No out of network coverage.

Every year, I have to research to see what's new and pick the best solution for me.

YES, coverage when I travel within the US is a huge concern for me. I try to protect myself as best I can with insurance, but the bottom line, I may only be covered for Emergency situations in some situations. All ACA plans are required to cover true emergency treatment at in-network pricing.

 

[MRG]

It's market specific. When I was in the KC area we freely went across state lines to see doctors, thats a unique market. Moved to SWCO I needed surgery, I could go 80 from home across state lines, no coverage. Instead I was told to travel a day each way for surgery and multiple follow-ups. No thanks.

Are you are looking at silver plans? Some lower cost plans have extremely limited networks in my experience. Truly YMMV.

Travel is limited to emergencies under any ACA plan I've seen. Medicare depends on your coverage. My understanding is supplements allow you to see any doctor that accepts Medicare and some Advantage plans have limited networks. I'm sure there's more to it.

 

[ShokWaveRider]

Ours here in 32092 is very good. Lots of specialists. Florida Blue is basically the biggest in Florida and does have pretty good assistance all over the state. DW has had the same Silver (PPO) plan for the last 4/5 years with no issues. If you go with a HMO it is a crap shoot.

 

[orchid55]

We live in the Atlanta suburbs and the ACA coverage is limited to narrow network HMOs much as the original poster described - basically county wide coverage only, leaving you on your own if you venture outside of a narrow area.

We just held our breath for the six years that we had those policies when we travelled. We were lucky and didn't need to see any doctors on any of our road trips.

We have original Medicare with Part G and used it this weekend in Tennessee for an urgent care visit and a CT scan. I am anticipating only paying the Part B deductible of $233. With any of our ACA plans we would have been on the hook for the entire huge bill. It would have been out of network and would not have counted toward the massive deductible. Some of the bronze ACA plans this year have a $8700 deductible.

 

[conversationalphrase]

We supplement ACA with 6 month travel insurance policies from World Nomads.

 

[BuysToys]

Our TX ACA plan was an HMO as the only available option. We had very limited coverage areas and would pay 100% OOP for any service not in our provider list. Fortunately we had all our doctors in network and could work around all the other required services.



We're currently on Medicare Advantage plans. We have the same limitations on coverage (none if not in the provider network) but a much larger network to work with. We've been very happy with it so far.

 

[Aerides]

You're in FL, so if you go with a BCBS plan you'll at least have decent OON coverage when out of state. That's better than a lot of other states, where the plans don't even have that (out means out means zero).

We know each year we basically have two deductibles, IN and OUT, and hopefully don't need or use the OON side, but if we do, we know what it will cost.

 

[teej1985]

You're in FL, so if you go with a BCBS plan you'll at least have decent OON coverage when out of state. That's better than a lot of other states, where the plans don't even have that (out means out means zero).

We know each year we basically have two deductibles, IN and OUT, and hopefully don't need or use the OON side, but if we do, we know what it will cost.

BCBS doesn't necessarily mean you'll have decent OON out of state coverage:

https://californiahealthline.org/ne...te-coverage-give-some-californians-the-blues/

 

[Rianne]

Our ACA healthcare in Illinois will pay in-network if you go to the ER. If you're admitted it becomes out of network. Our deductible is approx. $7000/per adult. After that 100% covered. Our monthly premium is $8.95. This is keeping MAGI below $75K. Honestly, I believe this is a better deal than medicare.

I should qualify what I said here. We're not 65 yet, but will be this year. We're healthy and travel. If we got sick while traveling, our HC would cover the illness in the ER as in-network I'm basing my remark about medicare based on our health and what we've paid out over the last 10 years.

-Total premium for both of us (inclusive) for the year. $107
-We payout of our deductible the discounted amount offered, which is oftentimes similar to a co-pay for a doctor's visit.
-The estimate we were given for Medicare (Medigap + supplements) premium was approximately $7000/year for both of us.
-We have saved a boatload of $ over the past 10 years, partly because we're healthy, but partly because if I did have to pay the full deductible for an illness, it would still be less than a year of medicare, because there would be other costs after the Medicare premium is paid.

All of the above is based on our personal situation. And we're in Champaign, Illinois. I realize it is absolutely different everywhere else.

 

[Popsicletoes]

Thanks everyone. Yes, I noticed the cheaper options offered the most limited coverage. Sigh..

 

[Pluperfect]

For those of you who love to travel and use ACA, do you just bite the bullet and pay out of network costs as needed?

The irony is that many under-65 fulltimer travelers choose to domicile in Florida specifically because Florida Blue offers PPO plans that provide in-network coverage throughout the country, via the Blue Card program.

The Florida Blue PPO plans also have out-of-network coverage, unlike a lot of PPO plans; it is subject to a separate deductible and out-of-pocket maximum. But note that this is not the same as in-network coverage outside the state. It's the in-network coverage outside the state that makes the Florida Blue PPO plans such a good choice for travelers.

I have looked at this from only the perspective of someone who domiciles in Florida but doesn't actually live there, and would therefore be getting routine medical care outside Florida. It's a very good solution for them.

But it may not be the same when getting routine care in Florida, since Florida Blue has its own networks there, and in fact has two networks: one is Florida Blue Options and one is Florida Blue Select. Florida Blue Select plans are offered in only certain Florida counties, and have a smaller network than Florida Blue Options plans, which are offered in all Florida counties.

If you have a Florida Blue Select plan, when you get healthcare in Florida you have to use providers who are in the (more limited) Florida Blue Select network. I'm pretty sure that the providers in the broader Florida Blue Options network wouldn't be in-network to you. (Otherwise, why would they bother having a more limited network in the first place?)

In contrast, I assume (but don't know) that someone with a Blue Cross plan from another state, whose plan includes access to the Blue Card program, would have in-network access to all Blue Cross providers in Florida.

None of this matters if you have a Florida Blue plan and you're never in Florida, because you're using the Blue Card coverage everywhere but Florida. I've wondered why I never see anything about issues with people who domicile in Florida and also snowbird there, for example, but I think it may be because most of them are on Medicare and aren't dealing with Florida Blue PPO plans and the two separate Florida networks they have.

If a person is going to be spending time in Florida and is getting a Florida Blue PPO plan, I'd suggest getting a Blue Options just to be sure not to run afoul of the more restrictive Blue Select network when getting routine care in Florida. Blue Select plans are cheaper than Blue Options plans, so they're attractive when shopping, but this issue with the two networks isn't very apparent to a person shopping plans.

And for the record, all the other ACA plans I ran across in Florida are either (1) HMOs, which have a limited local network and no out-of-network coverage, or (2) PPOs with just a local network and maybe not any out-of-network coverage, neither of which is a good option for someone who is traveling outside Florida.

 

[Boose]

Pluperfect, thanks for your explanation - I've been looking at the Florida Blue plans online. DH and I have been thinking about domiciling in TX or FL and being nomadic most of the year; the health insurance possibilities of FL have us leaning in that direction. Interestingly, there are no Blue Cross ACA plans in my current state.

 

[npage]

Old thread, new question I have wondered about. I had a situation under my partner's corporate plan whereby locally after three failed procedures on my heart I needed to find someone better. No one locally could help and I had to seek out the "best guy" in another state. It was all covered (BCBS PPO).

Knowing what I know now about my unique heart structure and situation if I needed work it is clear I need to go this guy or one of his proteges again in another state.

I've actually thought I would move if I had to, it's life or death. Do insurance companies have a system where you could make case to go out of network like this? Still have a few years on partners plan while she works to figure out.

 

[PaunchyPirate]

Old thread, new question I have wondered about. I had a situation under my partner's corporate plan whereby locally after three failed procedures on my heart I needed to find someone better. No one locally could help and I had to seek out the "best guy" in another state. It was all covered (BCBS PPO).

Knowing what I know now about my unique heart structure and situation if I needed work it is clear I need to go this guy or one of his proteges again in another state.

I've actually thought I would move if I had to, it's life or death. Do insurance companies have a system where you could make case to go out of network like this? Still have a few years on partners plan while she works to figure out.

I think you could try to get your insurance to cover the out of network charges but I think you would be fighting an uphill battle. I don’t believe they are under any obligation to do so.

However, there isn’t anything stopping you from moving to a location and insurance where the desired specialist was in network. Relocation to a new zip code is a legitimate way to qualify for a special enrollment period. You could go on your own policy at the new location. But you would need to establish that as your home.

 

[npage]

What a mess of a system. Sorry we know you could go to this guy who could save your life but too bad. Stay with a local guy while we waste money on the procedure and you die.

In hindsight they could have flown me to another state first class put me up in a Ritz Carlton and saved 3 failed procedures, 2 years and multiple six figures. From a pure greed perspective you would think insurance people would want this. And I am sure they have the data of the top people to see they have a higher success rate at all sorts of procedures.

 

[Montecfo]

I have started looking at options and it looks like it is all HMO or exclusive provider plans.

The HMO is Kaiser.

I guess I will need trip insurance for our travels.

 

[ImaCheesehead]

The irony is that many under-65 fulltimer travelers choose to domicile in Florida specifically because Florida Blue offers ……………

neither of which is a good option for someone who is traveling outside Florida.

Pluperfect, thank you for the EXCELLENT post above!! You put a lot of effort into it and it helped explain a lot of questions I had about Blue Options vs Blue Select. I am on COBRA til the end of the year and we just moved domicile to FL so that we will have access to out of state networks while we travel full time.

 

[Pluperfect]

Pluperfect, thank you for the EXCELLENT post above!! You put a lot of effort into it and it helped explain a lot of questions I had about Blue Options vs Blue Select.

I hope I made it clear that my conclusions aren't based on anything Florida Blue told me. What I did was spend a lot of time inputting different data into the provider network interface to see if I could come up with a pattern for Blue Options vs. Blue Select, and I based my conclusions on the results of those searches.

I know someone who had a Blue Select plan and used it for a few doc-in-a-box visits outside Florida, and it worked fine. And that's the main thing people worry about--will it work other than in Florida (domicile state)? The answer is "yes," and I found no differences between Blue Select and Blue Options when it comes to using the Blue Card nationwide network. In fact, when you do a provider search on the Blue Card network, the website asks you the prefix of your plan, and I asked someone with Blue Options what his prefix was, and it was the same as Blue Select--VMA.

But I've never seen anyone dive into the differences between Blue Select and Blue Options, and I'd bet that most people don't even grok that there might be any differences. Even if you're diligent and do the "compare plans" thing, or go even further and look at "plan details" AND "summary of benefits and coverage," all you see is differences in deductibles and copays and coinsurance; I don't think there's any indication that Select and Choice have two different networks in Florida. And I can't remember how I managed to grok, myself, and investigate.

Anyway, that's why I suggest choosing Blue Options if someone is going to be spending time in Florida--I may not be sure how it works, but it's undisputed that Blue Select and Blue Options have different networks in Florida, and the Blue Options network is bigger.

If you do your own research when selecting a Florida Blue plan later this year, it would be great if you would report back here with what you find out--either new information, or confirming or rebutting what I came up with.

 

[ImaCheesehead]

I hope I made it clear that my conclusions aren't based on anything Florida Blue told me. What I did was spend a lot of time inputting different data into the provider network interface to see if I could come up with a pattern for Blue Options vs. Blue Select, and I based my conclusions on the results of those searches.

I know someone who had a Blue Select plan and used it for a few doc-in-a-box visits outside Florida, and it worked fine. And that's the main thing people worry about--will it work other than in Florida (domicile state)? The answer is "yes," and I found no differences between Blue Select and Blue Options when it comes to using the Blue Card nationwide network. In fact, when you do a provider search on the Blue Card network, the website asks you the prefix of your plan, and I asked someone with Blue Options what his prefix was, and it was the same as Blue Select--VMA.

But I've never seen anyone dive into the differences between Blue Select and Blue Options, and I'd bet that most people don't even grok that there might be any differences. Even if you're diligent and do the "compare plans" thing, or go even further and look at "plan details" AND "summary of benefits and coverage," all you see is differences in deductibles and copays and coinsurance; I don't think there's any indication that Select and Choice have two different networks in Florida. And I can't remember how I managed to grok, myself, and investigate.

Anyway, that's why I suggest choosing Blue Options if someone is going to be spending time in Florida--I may not be sure how it works, but it's undisputed that Blue Select and Blue Options have different networks in Florida, and the Blue Options network is bigger.

If you do your own research when selecting a Florida Blue plan later this year, it would be great if you would report back here with what you find out--either new information, or confirming or rebutting what I came up with.

Will try to remember to do so

 

[Pluperfect]

Do insurance companies have a system where you could make case to go out of network like this?

It varies by insurance company, but such a procedure exists. I found this summary (click on "read the full article):
https://www.fairhealthconsumer.org/...out-of-network-care-can-be-covered-in-network

In hindsight they could have flown me to another state first class put me up in a Ritz Carlton and saved 3 failed procedures, 2 years and multiple six figures.

I hate insurance companies as much as the next guy, but I doubt they're any happier with the result than you are.

And for the record, I'm now one month into Medicare and to anyone who chants "Medicare for all!!" I want to ask, "Do you know anything about Medicare?" What a swamp that is.

 

[npage]

Thanks for the information. It's all a mess for sure. There is so much room for improvement at all levels that should not be political and simply data driven. Won't hold my breath there.