Does anyone have thoughts/experience with going with a higher level EPO plan with no out of network benefits, vs a direct access plan that offers some out of network protection? This is a blue cross plan and the rep was explaining that you would have access to out of state doctors that participate in blue cross through the “blue card”. She also explained that for out of network, the insurance company will only pay up to the “reasonable and customary” cost of the visit or treatment (after the deductible and co-pay of course).
The reason to keep the DA plan is to have access to out of network doctors (get to go to the “best” if something serious happens), but this makes it sound like it might be unaffordable to do that even with the out of network coverage.
Any thoughts? The big practice group in this area is in network and I am trying to figure out what the coverage is out of the area (in the local big city and kid’s college city for example).
The decision for one person/family may be different than for others.
How many doctors/specialists/providers do you typically see in a year? What types of service do you anticipate you might need? Do you have an existing relationship with a given provider that you feel is worth continuing?
How long does it take to get an appointment for a regular checkup, annual physical, etc.
Does the network churn providers? Do they have adequate coverage of in-network providers?
Some folks prefer to simply go for the highest level of coverage, and don’t care less about which doctors are in. Some really think their own PCP is super important.
Thanks. Agree that is an individual decision. The main question at the moment is whether out of network coverage is a meaningful benefit if facing a very difficult diagnosis or if one will have to chose in-network because the amount the insurance will actually cover does not reduce the cost enough to make it a real option.
I have a BC/BS EPO with no out of network benefits. Our state only offered EPO plans this year. There is a good selection of network providers and it has been fine so far, but does make me a bit nervous.
If you know what U your kids will attend, you can ask the insurer if there are in network providers accepting new patients in the city were the U is located. Our family has a PPO policy. I’m only familiar with PPO and HMOs, not other types of plans.
As for out of network coverage and a difficult diagnosis, many (but not all) states have “Network Adequacy” requirements, so that if the network does not offer providers who treat a given condition / perform a given procedure, they have to cover an out-of-network provider at the same in-network level, for that condition.
This has made it easier for us to accept the “Narrow Network” provisions of our insurance.
If you have access to the full provider network for BCBS, you have a lot of options. For example, I had a medical issue this year where the specialist my primary care dr sent me to recommended some pretty significant surgery. I decided to get a 2nd opinion, and with BCBS was able to go to the state flagship university hospital for it. Guess what? No surgery actually needed. I have another medical condition that is going to require regular follow up for many years; I can go to the U for that, too.
My kid at college has also used the BCBS network for stuff like an orthopedic surgeon to evaluate her broken arm. All in network.
But I think some of the hybrids they offer now restrict your options in-state more, and give you full Bluecard network out of state.
Yes, the full BCBS network is quite large and has tons of providers participating, but you need it clarified in writing whether your policy provides access to said huge network or a much smaller one.
Yes, I admit that you MAY have to fight for the appropriate reimbursements and payments. Generally I’ve been able to get most of my requests paid with persistence and assertiveness. It helps if you have a lie out of pocket cap on your expenses and get names and contact info of helpful folks.
There is a good selection of network providers and it has been fine so far, but does make me a bit nervous.