<p>Yeah, Busdriver. I think this is a california thing, but since most of this thread is about california? who knows. Here in NC, there are limited network plans at all levels, but there are also unlimited plans. </p>
<p>so, you absolutely get to choose. And this is all from the same insurer. So, it’s not like they sign up with BCBS and take all the BCBS insurance. Some BCBS is everyone and some is more limited. I’m not sure how that is determined, but it keeps the costs lower for some.</p>
<p>As I understand it, in an EPO, an exclusive provider organization, there is NO out of network insurance coverage. </p>
<p>See my post about my acquaintance needing a liver transplant. If he were in an EPO, he’d have to pay for the entire thing himself if he went out of state. And since the waiting list is shorter in other states, the choice is either wait for a liver and possibly die or go to another state and pay for it yourself.</p>
That would be illegal. The ACA requires that emergency care always be covered, and if it could be shown that a particular treatment is necessary but only available from a specific doctor or location, then I believe the law would als require that the insurance cover it – or at least pay its set rates for such coverage.</p>
<p>Poetgrl, TatinG’s characterization of an EPO is mistaken. ALL plans MUST cover out-of-network services in an emergency, and I think that would also cover necessary, life-saving treatment such as a liver transplant. If you will die without a liver transplant and there are no livers in California but you can get one in South Dakota, in a sense that is an “emergency.” </p>
<p>An EPO is more akin to an HMO, but without the requirement that you get a referral from a primary care physician before seeing a specialist. EPO’s do not let you go out of network for routine or regular followup care.</p>
<p>I’m wondering about the liver transplant case. It’s not as if no liver transplants are done in California; it’s just that TatinG’s friend wants to jump ahead of other Californians waiting for livers, and the people in the other state, by going out of state. The supply of livers is, sadly, smaller than the number of people who need them. Why should a California insurance company pay so that TatinG’s friend can jump the queue?</p>
<p>Flossy, the exchange is for insurance companies, not hospitals or doctors. There is no such thing as a hospital opting in or out. The hospital can choose which insurances to accept, subject to limitations imposed by some state laws. That is what has happened in California: the UC Medical hospitals have decided not to accept the new Blue Shield plans.</p>
<p>CF, I really don’t know, because that also brings in a lot of technicalities about transplant procedures. It’s not just a matter of a queue, there would also have to be a tissue match. I don’t know enough about how transplants are handled to know what the real story might be with TatinG’s friend. (Probably more than we have been told, because it does sound rather odd – I thought the transplant lists were handled with a national database, and that the procedure was to transport the organ from one facility to the other, not the patient.)</p>
<p>My only point is that if (a) there is an accepted, medical procedure that is imminently necessary; and (b) it is likely that the patient will die or suffer serious bodily harm without the procedure, and (c) that procedure is not available at an in-network facility – then the insurance can be used to pay for that procedure, even if out-of-network. There will be some procedural hurdles and the out-of-network facility is not bound to accept the insurance payments as payment in full – but the point is that the patient can seek payment from their own insurer.</p>
<p>I wouldn’t expect my insurance company to pay for it. My going to another state for the liver would mean that someone else, someone who would have lived, would die because of me. I don’t see why my insurance company ought to fund that.</p>
<p>EPOs do allow for out of network care for emergencies. I wouldn’t want to bet that less waiting time for a transplant would be considered an emergency. I would not want an EPO.</p>
<p>The issue of how liver transplants are allocated came up in the context of Steve Jobs’ controversial liver transplant in Tennessee. Here’s an article about how liver transplant lists work. Short answer: it’s complicated.</p>
<p>Most insurance companies like BC/BS, Anthem, UHC, etc., have Centers For Excellence where you can go to get treatment for extremely serious conditions, so I would think if you have an EPO but needed very specialized treatment you can go to one of the CofE designated hospitals. </p>
<p>So, if for example, you have an Athem EPO you could go to one of their Centers for Excellence. </p>
<p>CF, by that reasoning you would refuse any transplant if there were other people also in line.</p>
<p>To my mind, health insurance is for when catastrophes happen, like the gall bladder cancer case in the WSJ or the need for a transplant. If the exchanges are trying to save money by limiting treatment for those conditions in order to cover minor things, that’s nuts.</p>
<p>Just read the past two pages. I think with an EPO you can have covered service out-of-state or out-of-country as long as the provider is within the network. If you go out of network then I think only out-of-area emergency care is covered.</p>
<p>EPOs would discourage those with pre-existing conditions from signing up. If you had something serious, would you sign up in a small network where, like the woman in the WSJ article you could no longer see your specialist ?</p>