<p>My post might not have been clear – I mean that Anthem seems to have a much higher out-of-pocket for out-of-network than Blue Shield, which has a max of $9350. </p>
<p>The BS documentation says max OOP for in-network is $6350, out-of-network is $9350. I called BS today to ask whether the $9350 (for individuals) - $12,700 / $18,700 (family). I wanted to clarify whether those are cumulative or blended – that is, $9350/$18700 the maximum total, or do those numbers get added together (total: $15,700/$31,400). The BS agent I talked to was going to send me some additional documentation - but that’s the attachment that didn’t come through properly in the email. Either way, Anthem’s figure is higher, but obviously it is less of a difference if it is $33K vs. $31.4K as opposed to $33K vs. $18.7K. </p>
<p>I had already tried to get a handle on whether the ACA puts restrictions on out-of-network maximums but have had no luck on the legal research front.</p>
<p>My experience with talking to agents hasn’t been good. Most of them are clueless. I hate it when they think they are certain about something, but on further questioning, it is apparent they really don’t know what they’re talking about. In fact, most times they are guessing.</p>
<p>GP, I agree that you can’t really rely on the info you get on the phone and the agents really don’t know about more complicated questions, but they may be able to provide more written documentation if you ask. I mean, one way or another I’ll be able to get a full copy of my policy fairly soon. If Anthem publishes a more extensive network by early December, then I might still switch – but otherwise I’ll go with BS for 2014. I can always change for 2015-- presumably by that point the networks will be more settled.</p>
<p>“My experience with talking to agents hasn’t been good. Most of them are clueless. I hate it when they think they are certain about something, but on further questioning, it is apparent they don’t really know what they’re talking about. In fact, most times they are guessing.”</p>
<p>Yes, but the worst is when they tell you something with complete certainty, and you believe it, because they’re so firm. And they’re dead wrong…</p>
<p>I read this thread everyday. Both of our kids will be buying individual plans. Both have ONE doctor that they need on the plan. So far, the info is not conclusive. The whole thing is nauseating. Luckily neither of them is under the January 1 wire. I think we are just going to wait until more issues get resolved. </p>
<p>In both cases, I think they will get silver PPO plans…which are offered in both states (Arizona and CT). Just have to clarify the providers.</p>
<p>Cardinal Fang - just saw your questions. I’m no expert in the all-payer system but the commission tells each hospital what they can charge and the same charges are for everyone. Some hospitals can charge more than others but there is no wild disparity as there is in your hypothetical. Snooty Hospital would simply not be able to charge those rates. Whether you’re medicaid, medicare, private pay or private insurance, you are billed the same thing. Maryland is the only state in the nation to have received a waiver from Medicare to do this. Other states are looking into it now. Here is an article that describes some of the components. It is price fixing at its finest and has worked well. We have never suffered from many of the problems described on this thread and others. </p>
<p>I thought I would provide some context why I break out in a cold sweat at the thought of calling a BS/Anthem agent. One of the times I changed plans, I tried to get the agent to send me the plan document, which is a 40-page document delineating and explaining all the terms and conditions of the policy. I am sure Calmom has read a few of them. </p>
<p>Well, the agent said she couldn’t send it to me until I purchased the plan, and I responded with why would I do that until I read the fine print. We went around in circles until I was elevated two levels above her, where I finally found a semi-rational person who understood the absurdity of this company policy. I wasted two hours of my time and some brain cells from the aggravation…and I don’t have a lot to begin with.</p>
<p>Indeed, Wolverine. It is important to learn as much as you can in any contract before signing on dotted line. </p>
<p>Talking to an agent on phone would be the least effective way of signing up for these plans. Too easy to choose wrong or think you are getting something else than you think.</p>
<p>Goldenpooch - that’s an old story and none of that happened. They moan and groan about every requested hike. They ask for more than they know they’ll get. They received a hike in June.
Believe me - Maryland’s hospitals are the envy of the rest of the country. I can’t think of any better place to be if I’m either in a major accident or become ill.</p>
<p>Just thinking out loud, I was wondering what we are going to find in the second year (2015) of the law. Of course, most of this thread entails what’s happening in the individual market, but we all know that is a small percentage of the overall market. </p>
<p>The group market, encompassing small and large business plans, have been relatively quiescent compared to the individual market. I have a hunch the landscape is going to change dramatically for this part of the market in 2015. Almost all small and large business plans are now being renewed without any of the changes we are seeing in the individual market. Of course, in the large market, the group mandate has been delayed for a year, but, not well-known, in the small business market there is a quirk in the law which allows small businesses to change their renewal date before the end of year, so they, too, can defer complying with ACA rules until 2015.</p>
<p>This means that group plan members should expect many of the same issues people are experiencing in the individual market. Small businesses will be incentivized to drop their plans if they experience the cost increases we are seeing in the individual market. Large employers will have the group mandate, which forces them to offer affordable plans (employees can’t pay more than 9.5% of their salary for the lowest cost plan) and higher premiums for the various benefit mandates and compliance with the myriad of ACA rules and regulations. Conceivably, many employers will be incented to downgrade to plans with the limited networks we are seeing in the individual market and to ones with higher deductibles and co-payments.</p>
<p>So the disruption and displacement of plans, we are currently experiencing in the individual market, could reach a crescendo in 2015. I think we are embarking on a very interesting journey, of which we are at the very beginning.</p>