<p>If your plan is a PPO and you think you go to an in-network facility, you could still be charged out-of-network fees in a tricky way.</p>
<p>The in-network facility may outsource some of your care to another out-of-network group on the ground (excuse?) that it is “more cost effective” for them to do so, thus some procedures are done out-of-network. They may not even tell you this explicitly in advance. In my book, they are borderline “crooks” who try to extract as much money from the patients when they are not able to extract enough money from the insurance company. The hospital are fully aware that it is much easier for them to take advantage of the individual patient than the big, bad insurance company which is in a sense their long-term business partener with the same business goal: try to maximize the profits for the share holders at the expense of individual patients.</p>
<p>After I posted (#191), it occurred to me that since I live in MA I should know this. The state’s Commonwealth Care has 5 HMO’s, including some large ones like Fallon. CC is for people who don’t qualify for MassHealth, meaning they make more money. (It’s weird to phrase the meaning of “qualify” so it indicates poverty instead of wealth.) Above CC is Commonwealth Choice, meaning for people who make even more money. Below MassHealth is Health Safety Net, which is as the name suggests even lower cost or free care for the really poor. AND people generally can buy insurance through the Health Connector, which is the online exchange, and offers health insurance from additional companies in various forms. So I was wrong in my earlier post. </p>
<p>In other words, a lot of choices and layers of choices and types of coverage, etc. </p>
<p>Thing is: it has worked well. Nearly every child is covered. The state had a money shortfall because not enough people were opting out and paying the penalty. And they had to change the rules to keep people from running without insurance until they got sick.</p>
<p>I’ve gone through the websites more than once, particularly the Health Connector. Thing is, they certainly can be confusing but you make a choice. That’s a key point: unless you’re a person like me who analyzes all the details and gets mad when comparisons aren’t clear, you just make a choice and it will be fine because it’s insurance coverage with a specified minimum set of benefits. That, I repeat, is the real point: with a set basket of minimum benefits, you pick something. </p>
<p>BTW, the employer mandate was set at 11 fulltime equivalent employees - defined as the lower of 35 hours or qualification for benefits under the employer’s rules. The rest gets complicated, including compliance reporting 4x a year, but note that there hasn’t been a shift in the Federal Reserve data in the composition of employment (meaning part-timers) and also that MA’s economy is doing better than most, adding more jobs, etc. I mention this because from what I can see, MA’s law has been more onerous than the ACA will be - many of MA’s rules are changing with to match the ACA - and it hasn’t has had a noticeable negative effect.</p>
<p>I just got off the phone with a rep from Blue Shield of California, because my doctor’s name is not showing up on the network for the new plans on their web site. They told me that ALL of the doctors who were covered under the old plans are being automatically rolled into the new ACA plans unless the doctor takes action to cancel the contract with BS, but the process of rolling those names into the new web site database is not complete. </p>
<p>In other words, if you are a Blue Shield PPO right now and seeing an in-network private doctor, that doctor will still be in-network on the new plan. </p>
<p>I would not rely on what the phone agents say 100%, but I am sharing this mainly to let people know the current provider listings on the Blue Shield of California web site for the new ACA plans are incomplete. (I called to ask the question because I suspected as much, as this data only came on line within the last few days). The situation is probably similar with other insurance companies or PPO’s. </p>
<p>Obviously if you are changing from a PPO to an EPO or HMO then you would expect to see a more restricted network.</p>
<p>Wonder about changing providers? DS’s individual policy carrier is not participating in the exchanges. Our inclination is to stay with the current plan…which also includes dental…and pays 100% after the deductible of $3500 is met. Not sure the exchanges will offer the same coverage,with the same doctors, for the same price.</p>
<p>My friend got a letter from her family doctor saying he is no longer taking insurance. So he is no longer “in network” anywhere. That is a usual thing here in the NYC areas but a new development for her in the midwest. What that means is that a person has to submit the paper work for out of network reimbursement to go to such physicians. Whether the doctor is worth the additional cost and likely additional costs is up to each person. I have gone out of network on occaison when I felt that the expertise of the doctor was worth while. When I first moved here Memorial Sloan Kettering was not in network, and my son’s protocol was written by a pediatric oncologist there, and I paid the extra costs and went through the extra paper work for years so that he could get his follow up care there rather than just trying to coordinate with someone in network. It was a high priority that he have the best possible care in that area, so we paid for it out of pocket. </p>
<p>I had some issues a few years ago where I wanted an opinon from someone top rate and access to some programs that were out of network, and so I paid for that.<br>
[
I am curious to see how things are going to work tomorrow too, as I have a son who is going to be seeking health insurance 1/1 through ACA.</p>
<p>I have two friends whose PCPs have become concierge doctors. They were given the choice of signing up…and paying up front…or having their medical records transferred elsewhere.</p>
<p>I have not read the entire thread, but I have a comment on having “a doctor”. After having three doctors in a row choose to leave for another practice or retire, I decided to look for a practice where they had solved that issue. I ended up with a teaching practice here in Portland that assigns you to a first-year intern who is under supervision by teaching staff. You stay with your intern until they leave the program (five or six years). My only choice was “man or woman”. Two years in, I am delighted to have two sets of eyes on my medical care, a practice that believes in cooperation, and to be part of teaching the next generation of doctors.</p>
<p>I was clearly negligent in letting my kids know how health care worked. I never really discussed it with them. We always had pretty good insurance, and so I’d whip out the old insurance card, and maybe pay a copay at some doctors. My kids thought that was the end of it. They had no idea that I got bills up unitl the deductible was paid for most things and them had to pay a portion of some costs that were not covered, often hefty amount when I did go out of network. </p>
<p>My one son who is living hand to mouth is going to have a tough time when it comes to health care costs, and I’ll probably have to subsidize for a while longer. He’s off of our coverage soon, and I think the ACA options will have better rates than what COBRA premiums are going to be. Either way, he needs to see what the true costs of his health care are. I’ve just paid them as they were incurred, thankfully, they have not been much, never surpassed the deductibles. But I did not do him any favors not sharing the bill info with him as he thought it was all free with insurance. </p>
<p>Frankly, I don’t know how low income individuals are going to be able to pay for care where there are the deductibles and copays. When the monthly income does not cover expenses as it is, how are such folks going to pay anything more? My son’s premiums will be his Christmas and birthday presents, but he will be responsible for copays and deductible costs is what I am hoping but if he doesn’t have the money…I don’t know how this will work out.</p>
<p>Yes, back when my daughter was in high school and went to our doctor for a birth control prescription, I don’t think she quite understood that I would be seeing the EOB and bill for that visit. ;)</p>
<p>The individuals on the lower end of the economic spectrum will qualify for Medicaid or qualify for plans that include substantial premium subsidies as well as subsidies for the copays.</p>
That would be enough to prompt me to change doctors. </p>
<p>Since you say that he is the “family doctor” I am assuming that he is not a specialist – I understand your decision to go with Memorial Sloan Ketterling when you needed an oncologist – I’d go out of network too if I had a serious disease and knew that there was a doctor or facility which clearly could offer a better quality of service. But not for routine care via a general practitioner.</p>
There is a dentist in my area who did the same thing - no insurance unless you submit it yourself, you pay the rates he charges, to him, or he doesn’t do the work. This means he serves an upper-middle class customer who can afford to pay a few grand out of pocket as needed but can’t shell out the monthly cash for a concierge practice.</p>
<p>I know him, he is a nice guy, but he will not get my business. Quite frankly, I just don’t think him worth it.</p>
<p>I’ve never had dental insurance so I haven’t paid much attention to what insurance the dentists take, but there is a huge difference with dentistry: I have found that if I call up a dentist and ask what they charge for specific procedures, they will give me a straightforward answer. They will also tell me right off the bat whether they will reduce the bill for payment up front.</p>
<p>So to me that is a very big difference. The dental marketplace is competitive, allowing those of us without insurance to shop around.</p>
<p>Yes, and no. This assumes BS is offering a PPO plan via the exchange. At last check, in my case, they are not - it is now an EPO plan and it does not cover all the same facilities or providers. It has specifically cut out the main provider in our county - who also happens to be the most expensive. Healthnet and Aetna offer PPO options - at a higher premium than BS.</p>
<p>I just called the 800 number for Covered California. The phone was answered on the first ring. (at 4:30pm, the day before launch). Very polite young and helpful young woman on the other end. My questions were answered: (1) I will be able to complete the entire application process online if I want, and (2) the web site will be able to accept applications by 8am tomorrow (Oct 1). </p>
<p>So I will let everyone here know how it goes. (My real question was whether the site would go active at midnight – I’d be very happy to get a head start on the process)</p>
<p>I go to an out of network dentist. I pay him upfront, his office submits my claim and my insurance company sends me a check a few weeks later for about 35% of the total bill. If he didn’t submit directly to the insurance company, I would just submit it myself. It’s not very difficult to submit a claim, so. </p>
<p>I really like my dentist so decided not to use an in network dentist even though it’s pretty much free - a very small ($20) once a year co-pay, but both H and my kid use in network dentists.</p>
<p>I think that dental care is different because you don’t have the potentially catastrophic costs on the high end. That is, even with high end dental costs, you are talking about thousands of dollars, not tens of thousands or hundreds of thousands. So it is something that we can budget for. </p>
<p>Additionally, the most expensive dentists are often those who specialize in cosmetic dentistry – something that the insurance probably won’t cover anyway. But of course there is a great demand for that – it’s a lucrative speciality for dentists, even if they can’t bill the insurance companies.</p>