Interesting Obamacare Out-Of-Network question

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Two of the ways insurance companies have attempted to artificially lower the premiums for the lowest (Bronze) Obamacare plans have been:

1) Set the deductibles at max ($12,700 for in-network family, $36,000 for out-of-network family or some plans I've seen don't cover out-of-network at all)

2) Shrink the in-network doctor pool dramatically - something like 10% of the MDs and 30% of the facilities within your zipcode.

here's a screenshot of a bronze plan I was quoted double my current premium:

Here's the question:

What happens when you leave your zipcode and need healthcare ?

That's going to be by definition an out-of-network incident and, depending on your plan, you'll have to either meet a $36,000 deductible before insurance kicks in, or in some cases out-of-network isn't covered at all.

brilliant, eh? kinda like a voluntary house arrest, no?

What amazes me is with those kind of deductibles the premiums are so high.

As to your question being out-of-state doesn't mean out-of-network under private insurance but under The Unaffordable Health Care Act who knows.

don't confuse the presence with the past DD.

The new "networks" are sculpted so narrowly that even two MDs in the same building can be on different "networks".

There's no doubt that the government health care is all about making money for the bankers and controlling the population. Reducing mobility is certainly one method of control.

Originally Posted by UtahLefty

kinda like a voluntary house arrest, no?

Gotta restrict the movements of the masses don't ya know. Can't have 'em moving about the country freely.

Mike

Originally Posted by derby_dude

What amazes me is with those kind of deductibles the premiums are so high.

Many cannot afford those high deductibles. The government knows this and will own everything that person has at death.

The premiums should still be lower than they are for those kinds of deductibles. Under Medicare I have a $2,000 deductible and my premiums are affordable. They only thing I can think of is this is a money collection scheme for the bankers.

Instead of affordable healthcare it's unaffordable catastrophic coverage that doesn't cover much of anything or so it seems.

Are there any benefits covered for routine care that have a co-pay before you meet the deductible?

That's why I think one of it's primary function is to collect money for the bankers.

Lefty,

Please forgive the ignorance, but is that quote from a state plan? Assuming the national-level site is not operable?

Thanks - Bob

here is another thing that sucks, suppose you have a serious accident just before Thanksgiving and your bills roll into the next year.

You might not meet your deductible in either year, but pay more than your deductible allows in total for a single incident.

I hate the idea of a large deductible. I think $12K for a family is absurd, even for families that are making $40K a year.

Originally Posted by Akbob5

Lefty,

Please forgive the ignorance, but is that quote from a state plan? Assuming the national-level site is not operable?

Thanks - Bob

that quote is from the only exchange I could get a quote from -- the American Veterinary Medical Association's national (private) exchange.

the insurance company it's from is Assurant, and from what I can tell, they have a labyrinth of different contracted networks nationwide.

I was only able to ID an in-network MD in 3 of the 7 states I travel to and it'd be sheer luck if one was able to find once close enough to drive to on a phone app.

Originally Posted by derby_dude

What amazes me is with those kind of deductibles the premiums are so high.

Well, where do you think the money's coming from the cover the 30 million uninsured??? Remember the LIC said, 'we'll cover everybody AND your premiums will be reduced by $2500..'

LIES, LIES, and more LIES from this a-hole..

in the interests of full disclosure, here's the rest of the quote:

so those monthly premiums are for a family of 5, in a very healthy "community rating" community of vets.

whichever one of those you might choose, you're looking at $25,000 to $30,000 a year minimum in premiums + deductible for an in network incident. $40,000 to $50,000 if you had an out-of-network incident.

even if you hand no incident in a year, that's $12,000 to $25,000 in premiums. every year

who in their right mind would do that ??

cray cray!

I am not sure why health insurance companies get to stick it to you after you reach your deductible. If you wreck your car, and pay your deductible, the car insurance company picks up the rest of the tab. Why does health insurance make you pay your deductible and then only pick up 80% or so? They should have to pay 100%.

they really should have a deductible per incident, and then they pick up the rest

break your leg? pay $300 and we get the rest. Cost less than $300, then don't bother filing the claim.

That's how auto works, right?

Affordable Health Care Act what a Oxymoron . It will be Cheaper to go to the Vet for your Medical Care

Originally Posted by UtahLefty

in the interests of full disclosure, here's the rest of the quote:

so those monthly premiums are for a family of 5, in a very healthy "community rating" community of vets.

whichever one of those you might choose, you're looking at $25,000 to $30,000 a year minimum in premiums + deductible for an in network incident. $40,000 to $50,000 if you had an out-of-network incident.

even if you hand no incident in a year, that's $12,000 to $25,000 in premiums. every year

who in their right mind would do that ??

cray cray!

That somewhat answers my previous question but what is "Coins %" ?

I understand it's co-insurance but what does it mean and how does that apply?

they way that's worked in the past (and I see no reason it's changed) is as follows:

patient #1 incurs costs. Insured pays 100% until the $6,000 individual deductible is met.

With a 75/25 coinsurance percentage policy, the insured then pays 25% of costs from $6,000 to $12,000 and it's not until cost go over $12,000 that the policy pays 100%.

** keep in mind that with a family policy, it's entirely possible for you to have to pay 100% of $5,999 for patient #1 and $5,999 for patient #2 in any give year with the insurance company not having to pay out money at all.**

Coins is after you meet your deductible....

say deductible is $5000, then you start the coinsurance not to exceed out of pocket

Any accident coverage available? Generally most ins companies will pay (or at least offer it) 100% of accidents.

Quote

What amazes me is with those kind of deductibles the premiums are so high.

What did everybody expect when the insurance company has to sign
everybody up for the same price regardless of pre-existing conditions. It does not make sense to sign up an new patient that may be terminal ill from cancer, at the same price as a 20 year old that is in good health, but that is what the Government is forcing them to do. miles

Originally Posted by milespatton

Quote

What amazes me is with those kind of deductibles the premiums are so high.

What did everybody expect when the insurance company has to sign
everybody up for the same price regardless of pre-existing conditions. It does not make sense to sign up an new patient that may be terminal ill from cancer, at the same price as a 20 year old that is in good health, but that is what the Government is forcing them to do. miles

DITTOS.

Originally Posted by Stan V

Coins is after you meet your deductible....

say deductible is $5000, then you start the coinsurance not to exceed out of pocket

Any accident coverage available? Generally most ins companies will pay (or at least offer it) 100% of accidents.

^^^ That's a good question that I'd also like to know the answer to.

Quote

That's a good question that I'd also like to know the answer to.

Insurance companies are in business to make money and Obama and his helpers are trying to legislate that away so they will have the only insurance in town. Subsidized by the taxpayer. miles

Originally Posted by UtahLefty

in the interests of full disclosure, here's the rest of the quote:

so those monthly premiums are for a family of 5, in a very healthy "community rating" community of vets.

whichever one of those you might choose, you're looking at $25,000 to $30,000 a year minimum in premiums + deductible for an in network incident. $40,000 to $50,000 if you had an out-of-network incident.

even if you hand no incident in a year, that's $12,000 to $25,000 in premiums. every year

who in their right mind would do that ??

cray cray!

The IRS is going to have to hire another 16,000 employees just to rack up and collect the penalties of all the Americans who are gonna say "up yours democrats" and refuse to sign up. I see how the deficient is going to be paid off. kwg

Originally Posted by fish head

Originally Posted by Stan V

Coins is after you meet your deductible....

say deductible is $5000, then you start the coinsurance not to exceed out of pocket

Any accident coverage available? Generally most ins companies will pay (or at least offer it) 100% of accidents.

^^^ That's a good question that I'd also like to know the answer to.

under obamacare ? no.

however, it does appear you can still purchase accident insurance through your auto insurance company.

I did find this, however:

Originally Posted by .gov

Out-Of-Network Emergency Services
Q15: Public Health Service Act (PHS Act) section 2719A generally provides, among other things, that if a group health plan or health insurance coverage provides any benefits for emergency services in an emergency department of a hospital, the plan or issuer must cover emergency services without regard to whether a particular health care provider is an in-network provider with respect to the services, and generally cannot impose any copayment or coinsurance that is greater than what would be imposed if services were provided in network. At the same time, the statute does not require plans or issuers to cover amounts that out-of-network providers may "balance bill". Accordingly, the interim final regulations under section 2719A set forth minimum payment standards in paragraph (b)(3) to ensure that a plan or issuer does not pay an unreasonably low amount to an out-of-network emergency service provider who, in turn, could simply balance bill the patient.
Are the minimum payment standards in paragraph (b)(3) of the regulations intended to apply in circumstances where State law prohibits balance billing? (Similarly, what if a plan or issuer is contractually obligated to bear the cost of any amounts balance billed, so that the patient is held harmless from those costs?)
No. As stated in the preamble to the interim final regulations under section 2719A, the minimum payment standards set forth in paragraph (b)(3) of the regulations were developed to protect patients from being financially penalized for obtaining emergency services on an out-of-network basis. If a State law prohibits balance billing, plans and issuers are not required to satisfy the payment minimums set forth in the regulations. Similarly, if a plan or issuer is contractually responsible for any amounts balance billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimums. In both situations, however, patients must be provided with adequate and prominent notice of their lack of financial responsibility with respect to such amounts, to prevent inadvertent payment by the patient. Nonetheless, even if State law prohibits balance billing, or if the plan or issuer is contractually responsible for amounts balance billed, the plan or issuer may not impose any copayment or coinsurance requirement that is higher than the copayment or coinsurance requirement that would apply if the services were provided in network.

In short, it says plans cannot charge more for out-of-network ER services than they would charge for in-network ER services. (all co-pays and deductibles apply)

It does give them the ability to question whether it truly was an emergency though, and the option to deny payment for stubbed toes and sore throats.

What's also interesting is that it defers to state law on the question of "balance billing" --- where the hospital bills the patient the difference between what they charged you and what the insurance paid.