Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

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opus360
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Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

My family has heath insurance via getcoverednj, the ACA for residents of NJ. We have the Horizon Blue Cross Blue Shields of NJ Omnia Bronze. This past summer while on vacation outside of NJ, my kid got sick. We went to an urgent care center first, then urgent care center suggested we go to hospital ER, which we did. Both urgent care and hospital were in-network of the national network of Blue Shields.

To my surprised, the insurance we have does not coverage us outside of New Jersey, except for emergency care. So, I asked the customer service, what happens if after visiting ER, we get admitted to the hospital. She said that is when it will get reviewed on a case by case basis. She said only the Omia Gold, which the premium is $2,000 more per month, has out of state coverage. I am just thinking, they want you to visit ER rather than urgent care. It doesn't seem to make sense. (Urgent care wait was 3 hours vs 1 hour at the ER in this instance.)

Anyway, especially for those in NJ with Horizon Blue Cross, what is your experience? Do you buy insurance if you just going on vacation within the US? I understand we might need to get medical insurance travelling internationally. Is there an insurance via Getcoverednj that coverages out-of-state doctors with reasonable premium over the in-state only coverage?
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by BarbBrooklyn »

I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
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opus360
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
I sure hope your view is the insurance view too.

So, I am looking at the claims now. The ER visit for doctor bill was paid by insurance. ER claim for covid-19 testing is still pending. The urgent care visit wasn't covered, due to out of state, so I am on the hook for $200.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Watty »

BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
+1

At some point when you are well enough you may need to be transferred to an in network hospital for further treatment.

It is little different than if you were at home and in a car accident and an ambulance took you out of network hospital.

I have different insurance and while I have not used it they also have an 800 number and internet video telemedicine where some things can be handled remotely even when you are out of state.

When I am out of state I can also call and get the name of a nearby urgent care center. I am not sure if that is just for convenience or if they will direct you to an urgent care center that they have agreements with.

I have not been following the details but there are new federal laws going into effect in January to help eliminate surprise billing/balance billing by out of state emergency services. Some states already had laws like this.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by tibbitts »

I don't have experience with NJ but have a similar insurance plan in a different state. I think you just have to hope for the best when your situation is reviewed. I don't think having admission defined as "emergency" is going to be a big problem. I do think handling the out-of-network situation might be, unless there is some inter-BCBS cooperation that comes in to play, which used to happen with BCBS PPOs, but I don't know what will happen now. I think even if you have travel insurance you're still going to run into the "reasonable and customary" charge issue, where there might not be universal agreement on that.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by tibbitts »

opus360 wrote: Sat Sep 18, 2021 8:13 am
BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
I sure hope your view is the insurance view too.

So, I am looking at the claims now. The ER visit for doctor bill was paid by insurance. ER claim for covid-19 testing is still pending. The urgent care visit wasn't covered, due to out of state, so I am on the hook for $200.
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

tibbitts wrote: Sat Sep 18, 2021 8:35 am
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
Thanks for sharing your experience. The sequence for us was 1) phone call with family pediatrician who suggested to go to urgent care, 2) urgent care who suggested to go to ER, and 3) then finally ER.

Both urgent care and hospital were part of the national network of blue cross blue shield, amend just out-of-state for us. From my call with Horizon Blue Cross, the customer service rep said only ER is coverage, not urgent care. Her reasoning is if it is true emergency, then you won't go to urgent care. Maybe I should call back to explain that this is just really one incident, not separate.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by AnEngineer »

tibbitts wrote: Sat Sep 18, 2021 8:35 am
opus360 wrote: Sat Sep 18, 2021 8:13 am
BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
I sure hope your view is the insurance view too.

So, I am looking at the claims now. The ER visit for doctor bill was paid by insurance. ER claim for covid-19 testing is still pending. The urgent care visit wasn't covered, due to out of state, so I am on the hook for $200.
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
I believe ACA requires ER visits to be covered in network.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by bsteiner »

It’s a problem for NJ residents. People in the NJ suburbs of NYC often go to doctors in NYC. But they’re not in the network for the NJ Affordable Care Act plans on the NJ exchange. At least that was what someone I know found when looking for a plan on the exchange. And I don’t think people in NJ can buy NY Affordable Care Act plans on the NY exchange.

I suspect the same is true for people in the NJ suburbs of Philadelphia.
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opus360
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

bsteiner wrote: Sat Sep 18, 2021 9:16 am It’s a problem for NJ residents. People in the NJ suburbs of NYC often go to doctors in NYC. But they’re not in the network for the NJ Affordable Care Act plans on the NJ exchange. At least that was what someone I know found when looking for a plan on the exchange. And I don’t think people in NJ can buy NY Affordable Care Act plans on the NY exchange.

I suspect the same is true for people in the NJ suburbs of Philadelphia.
Did this change recently or in 2021 when the "getcoverednj" was instituted?

Back maybe three or four years ago, an insurance agent on youtube compared the Ameriheath coverage and compared it with Horizon BCBS of NJ. He said the lowest cost ACA marketplace insurance of AmeriHealth does not let you go out of state, whereas the Horizon does. At least for 2021, Horizon doesn't let you go out of state (except for Gold plan per Customer Service).
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by tibbitts »

AnEngineer wrote: Sat Sep 18, 2021 9:03 am
tibbitts wrote: Sat Sep 18, 2021 8:35 am
opus360 wrote: Sat Sep 18, 2021 8:13 am
BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
I sure hope your view is the insurance view too.

So, I am looking at the claims now. The ER visit for doctor bill was paid by insurance. ER claim for covid-19 testing is still pending. The urgent care visit wasn't covered, due to out of state, so I am on the hook for $200.
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
I believe ACA requires ER visits to be covered in network.
Interesting... I didn't know that. Is there an ER deductible or co-pay? I can envision a situation where insurance might drive typical urgent care traffic directly to an ER instead.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

tibbitts wrote: Sat Sep 18, 2021 9:41 am
AnEngineer wrote: Sat Sep 18, 2021 9:03 am
I believe ACA requires ER visits to be covered in network.
Interesting... I didn't know that. Is there an ER deductible or co-pay? I can envision a situation where insurance might drive typical urgent care traffic directly to an ER instead.
When I look at my policy (I assume this is for in-state coverage), there is a deductible on ER visit. But, when Horizon processed the ER doctor claim, deductible was not applied. (The ER covid-19 test is still in process, so I don't know yet if deductible will apply or not.) There must be some other out-of-state ER policy coverage that I am not familiar with.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by ncbill »

I pay $79 annually for Nationwide's Pro Deluxe plan...would get us both back to local, in-network hospitals.

https://travel.nationwide.com/plans/annual
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by vitaflo »

AnEngineer wrote: Sat Sep 18, 2021 9:03 am
tibbitts wrote: Sat Sep 18, 2021 8:35 am
opus360 wrote: Sat Sep 18, 2021 8:13 am
BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
I sure hope your view is the insurance view too.

So, I am looking at the claims now. The ER visit for doctor bill was paid by insurance. ER claim for covid-19 testing is still pending. The urgent care visit wasn't covered, due to out of state, so I am on the hook for $200.
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
I believe ACA requires ER visits to be covered in network.
Correct, out-of-network ER visits are covered as in-network under ACA. I know this because we had an ER visit 1500 miles from home a few years ago. It was covered as in-network.

However, note that the ER visit must be for emergency care. Going to an out-of-network ER for a sore throat will not be covered as in-network. Only emergency care will. You can't just go to any ER for anything and expect it to be covered as in-network.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by OnTrack2020 »

opus360 wrote: Sat Sep 18, 2021 8:57 am
tibbitts wrote: Sat Sep 18, 2021 8:35 am
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
Thanks for sharing your experience. The sequence for us was 1) phone call with family pediatrician who suggested to go to urgent care, 2) urgent care who suggested to go to ER, and 3) then finally ER.

Both urgent care and hospital were part of the national network of blue cross blue shield, amend just out-of-state for us. From my call with Horizon Blue Cross, the customer service rep said only ER is coverage, not urgent care. Her reasoning is if it is true emergency, then you won't go to urgent care. Maybe I should call back to explain that this is just really one incident, not separate.
I think you are out of luck as far as "one incident." You sought care at the Urgent Care and their recommendation was for you to go to the ER. Urgent Care will send you a bill--that's happened to us before with employer-based coverage. Then we were sent to ER and received a separate bill from them even though it was all tied to the same issue.

We are currently on an ACA plan which has a limited coverage area (I think most of the plans do), but the plan does have emergency care when traveling out of state, as long as it's an actual emergency. We are going to seek out a medical travel plan in addition. I think I will look at the Nationwide Plan mentioned above.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Nyc10036 »

ncbill wrote: Sat Sep 18, 2021 12:40 pm I pay $79 annually for Nationwide's Pro Deluxe plan...would get us both back to local, in-network hospitals.

https://travel.nationwide.com/plans/annual
Just $79 per year?
That sounds too good to be true.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by fortunefavored »

Nyc10036 wrote: Sat Sep 18, 2021 7:03 pm
ncbill wrote: Sat Sep 18, 2021 12:40 pm I pay $79 annually for Nationwide's Pro Deluxe plan...would get us both back to local, in-network hospitals.

https://travel.nationwide.com/plans/annual
Just $79 per year?
That sounds too good to be true.
I expect it has a similarly narrow view of "emergency" and "must be admitted to a hospital for transport"

All of which are a pretty high bar. I would love to be wrong. Out of area coverage is one of the things that keeps me up at night moving from MegaCorp plan to ACA next year.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Nyc10036 »

opus360 wrote: Sat Sep 18, 2021 7:42 am My family has heath insurance via getcoverednj, the ACA for residents of NJ. We have the Horizon Blue Cross Blue Shields of NJ Omnia Bronze. This past summer while on vacation outside of NJ, my kid got sick. We went to an urgent care center first, then urgent care center suggested we go to hospital ER, which we did. Both urgent care and hospital were in-network of the national network of Blue Shields.

To my surprised, the insurance we have does not coverage us outside of New Jersey, except for emergency care. So, I asked the customer service, what happens if after visiting ER, we get admitted to the hospital. She said that is when it will get reviewed on a case by case basis. She said only the Omia Gold, which the premium is $2,000 more per month, has out of state coverage. I am just thinking, they want you to visit ER rather than urgent care. It doesn't seem to make sense. (Urgent care wait was 3 hours vs 1 hour at the ER in this instance.)

Anyway, especially for those in NJ with Horizon Blue Cross, what is your experience? Do you buy insurance if you just going on vacation within the US? I understand we might need to get medical insurance travelling internationally. Is there an insurance via Getcoverednj that coverages out-of-state doctors with reasonable premium over the in-state only coverage?
I have the Omnia Siliver.
This is Horizon BCBSNJ's webpage : https://www.horizonhealthnews.com/horiz ... vel-plans/

/
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by mkc »

opus360 wrote: Sat Sep 18, 2021 7:42 am Both urgent care and hospital were in-network of the national network of Blue Shields.
Which BCBSNJ network are you in? I don't believe there is a national network of Blue Shields, and there are multiple networks for each state's offering.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Nyc10036 »

mkc wrote: Sat Sep 18, 2021 8:41 pm
opus360 wrote: Sat Sep 18, 2021 7:42 am Both urgent care and hospital were in-network of the national network of Blue Shields.
Which BCBSNJ network are you in? I don't believe there is a national network of Blue Shields, and there are multiple networks for each state's offering.
That is BlueCard coverage.
My Omnia Silver HSA does not have it.
The ID card that has the BlueCard coverage would have an icon of a suitcase on the lower right corner.
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opus360
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

Nyc10036 wrote: Sun Sep 19, 2021 10:53 am
mkc wrote: Sat Sep 18, 2021 8:41 pm
opus360 wrote: Sat Sep 18, 2021 7:42 am Both urgent care and hospital were in-network of the national network of Blue Shields.
Which BCBSNJ network are you in? I don't believe there is a national network of Blue Shields, and there are multiple networks for each state's offering.
That is BlueCard coverage.
My Omnia Silver HSA does not have it.
The ID card that has the BlueCard coverage would have an icon of a suitcase on the lower right corner.
Nyc10036 ... thanks for the link. I was told only the Gold level ACA marketplace plan (getcoverednj) has the BlueCard. I am not sure if you can add that temporarily. But the GeoBlue (under the link you provided) has international coverage for $150 (better coverage) or $98/per person for up to 70 days of international trip within one year These are for my family given our ages. These are not far off the Nationwide rates of $79/per person provided by ncbill. The GeoBlue will cover non-emergency medical stuff. The BCBSNJ plan already provides coverage for emergency stuff - just go to hospital ER next time is the lesson for me.

mkc ... I am actually not sure what network of BCBSNJ I am in. My plan is Omnia if that helps.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

LilyFleur wrote: Sat Sep 18, 2021 6:50 pm I have a Blue Shield PPO bought on the California exchange, and I have a platinum plan. I am covered anywhere in the world. However, I pay $1760 a month for this privilege (and it is only me on my plan). (I have an expensive health condition, which is why I have a platinum plan. Being able to travel internationally and be covered just happens to come along with being able to cover my specialist care.)
That is a very expensive plan you got, but you got good reasons for using it.


To all:

We travelled many times per year over the last 10 years, but never had to see a doctor on a trip until now. Is travel insurance worth it given say it cost $100/person for 70 days of coverage (essentially for non-emergency items, as emergency items are covered by current health plan)?
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Northern Flicker »

AnEngineer wrote: Sat Sep 18, 2021 9:03 am
tibbitts wrote: Sat Sep 18, 2021 8:35 am
opus360 wrote: Sat Sep 18, 2021 8:13 am
BarbBrooklyn wrote: Sat Sep 18, 2021 8:07 am I think you are defining "emergency care" too narrowly. It doesn't mean just ER care; it means medical care that addresses an emergency (not elective) situation.

If you have a heart attack on vacation and go to the ER and are admitted and treated, that's still "emergency care".
I sure hope your view is the insurance view too.

So, I am looking at the claims now. The ER visit for doctor bill was paid by insurance. ER claim for covid-19 testing is still pending. The urgent care visit wasn't covered, due to out of state, so I am on the hook for $200.
One problem I experienced in this situation was having services from both providers lumped into a single incident with the insurer. Despite appeals I could never get the insurer to see my similar out-of-state situation as one incident, which would have made a different in how much insurance would have covered. I'm not understanding how you got the ER visit covered, seemingly as in-network, unless there was some of the inter-BCBS cooperation going on like I mentioned. Obviously neither facility was in-state so I don't understand why you'd say urgent care wasn't covered because it was out-of-state but the hospital wasn't.
I believe ACA requires ER visits to be covered in network.
It does, but there are two issues. 1) the insurance company can say what the standard in-network cost is, but the out-of-network ER is not bound to a contract with the insurance company, and will still charge full freight. ER docs and surgeons and specialists on call often refuse to be in any insurance networks, which they can do while still getting business because patients have no choice. The insurer is required to cover their service in-network, but may choose to do so at in-network levels.

If the hospital or providers bill for the out-of-network excess, it is called balance billing. NJ has had a state law disallowing balance billing for some number of years, and there now is a Federal law disallowing it. I suspect it is not yet a seamless process for the patient to eliminate balance bills, however.

The other issue is the boundary of emergency care. If you go to an ER and are admitted to the hospital from the ER, there is a question of when care stops being emergency care. You may need to be transferred to an in-network hospital when medically feasible, but don't assume the hospital will manage this for you proactively. You or a family member should contact the insurer. This is not what a patient should be worrying about when dealing with a life threatening emergency, but there you are.
Last edited by Northern Flicker on Sun Sep 19, 2021 1:44 pm, edited 4 times in total.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by fortunefavored »

Northern Flicker wrote: Sun Sep 19, 2021 11:45 am
If the hospital or providers bill for the out- of-network excess, it is called balance billing. NJ has had a state law disallowing balance billing for some number of years, and there now is a Federal law disallowing it. I suspect it is not yet a seamless process for the patient to eliminate balance bills, however.
JFYI, the federal anti-balance billing law does not go into effect until January 2022.

Current state laws also do not apply to self-funded plans (most corporate provided insurance is self-funded, even if it is not obvious to the employee.)
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by MrsBDG »

In my west coast state, the Blue insurance plans only cover ED out of state, I have not gone beyond ED to check into admissions, but do know that some other companies cover urgent care so we have avoided the Blue plans, as I want the UC option when traveling. It is rather counter-intuitive that the Blue Card network exists, or used to, and yet they no longer allow that shared coverage between states for most plans. It seems like people would be healthier overall, so lower overall expenses, if they could deal with minor issues when OOS.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by livesoft »

opus360 wrote: Sat Sep 18, 2021 8:13 am ..., due to out of state, so I am on the hook for $200.
Are you sure that even if you were in NJ that you would not be on the hook for $200?

I cannot think of a single time where some kind of emergency care or visit didn't cost at least $200 no matter what kind of insurance we have had over the decades.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by beyou »

Not unique to NJ. I am in NY and ACA plans in my county only cover local in-network doctors.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Zetorman »

Our state offers EPO plans that have national provider networks. Per my target EPO plan for 2023, the brochure says that 98% of the hospitals in the US are in-network. I will confirm this information with the insurance co before I buy and/or travel out of state.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

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[How to deal with] Out of Network Expenses With ACA [Bronze] Plans

Post by bdaniel58 »

[Thread merged into here --admin LadyGeek]

Hi,

I retired on Sep 10 at age 62. We planned this for years and knew we wanted to manage our MAGI to get subsidies for ACA health insurance. I had looked at premiums and tax credits. We knew we wanted to get a Bronze plan which will be basically paid for with the credits. We don't have any serious health issues. We just want catastrophic coverage.

I made one minor mistake. I did not fully understand out-of-network expenses. I think I thought the max-out-of-pocket would handle that. It does not.

We travel a lot and need insurance out of our normal living area. Apparently all plans have to cover emergency care as an in-network-expense but it appears that does not cover something like a hospital stay after handling the emergency.

Fortunately for us we live in NC and out of 20 Bronze plans, three of them are POS plans and have a national network of providers. All three are BCBS of NC. A sales agent told me that in an emergency I could get care at any ER and when stable I would be transported to a provider in their network. I checked a couple of cities in the USA at random and they had hospitals in their network.

So I think we will be ok.

But what the heck? For those of you that leave your cave and actually travel outside your local area, what do you do for health insurance?
This seems crazy.

Thanks,
Bobby
curmudgeon
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Re: Beware Out of Network Expenses With ACA Plans

Post by curmudgeon »

I don't know that this is unique to ACA plans. We travel quite a bit, and I don't fret about it. The emergency coverage is all I really care about when travelling; if it's something serious and transportation is an option, I'd expect and want to be back home for any extended treatment.

Where it could be more of a challenge is in the snowbird case. If you have (or develop) medical conditions that need ongoing treatment, having a medical network on both ends could be important, and that could be a challenge with many ACA (or HMO/PPO) plans.

When you go on Medicare, there is a similar issue around travel outside of the US; no coverage with basic Medicare, and the supplements/advantage plans seem to all have a $50K lifetime overseas coverage limit.

Travel insurance can fill the gap in many cases.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by LadyGeek »

I merged bdaniel58's thread into a similar discussion. The combined thread is in the Personal Finance (Not Investing) forum (insurance).
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FireAway
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by FireAway »

I was on vacation once, and got a bad cut over my ankle that required stitches. I drove to the nearest medical facility that could deal with this - a 90-minute drive, each way - and a doctor stitched me up. Insurance refused to cover it, since it was out of network and wasn't 'emergency care', as the billing code wasn't an 'emergency' code. I asked the doctor why an emergency code wasn't used, and he said since his facility isn't licensed as an "ER", or something like that, he can't use the emergency billing codes.

So despite this being an emergency, and despite getting exactly the same treatment as I would have gotten at an ER, insurance refused to cover a single penny of it because of a technical issue regarding a number on a piece of paper. So, I would be very careful about expecting most out-of-network services to covered as emergency care, even if they are.
talzara
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Re: Beware Out of Network Expenses With ACA Plans

Post by talzara »

curmudgeon wrote: Thu Sep 23, 2021 1:25 pm Where it could be more of a challenge is in the snowbird case. If you have (or develop) medical conditions that need ongoing treatment, having a medical network on both ends could be important, and that could be a challenge with many ACA (or HMO/PPO) plans.
Blue Cross may be an option for snowbirds in certain states.

Blue Cross ACA plans sometimes include Away From Home Care, even when they do not provide out-of-state coverage. If you're staying at least 90 consecutive days in a sister Blue Cross company's territory, then you can get a guest membership with the local Blue Cross. The guest membership will not be the best Blue Cross plan, but at least you'll have local health insurance.

To set up the reciprocal membership, both companies need to offer AFHC. Blue Cross plans in snowbird states usually do. Two of the three Blue Cross companies in Florida offer AFHC, including the biggest one, Florida Blue.
marcopolo
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by marcopolo »

This is all very state and even county specific as to what plans are offered, and the coverage they provide our of area.
I don't think it possible to generalize what various insurers do. Even with the same carrier, the network limitations can change drastically by geographic region.

When we were in PA none of the plans available in our area provided out of area coverage, not even in different part of the same state. We had to put our older son who was at an in-state school in PA on a separate insurance plan so he would have coverage near his school.

We have since moved to Hawaii, and our younger son goes to the same school in PA. The PPO plan we have in Hawaii is part of the BCBS BlueCard network and provides in-network coverage in the area of his school in PA, including the University Health System.

But, as has been mentioned above, not all BCBS plans provide that type of network access. It is all a crapshoot.
Once in a while you get shown the light, in the strangest of places if you look at it right.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by talzara »

opus360 wrote: Sat Sep 18, 2021 7:42 am To my surprised, the insurance we have does not coverage us outside of New Jersey, except for emergency care. So, I asked the customer service, what happens if after visiting ER, we get admitted to the hospital. She said that is when it will get reviewed on a case by case basis. She said only the Omia Gold, which the premium is $2,000 more per month, has out of state coverage. I am just thinking, they want you to visit ER rather than urgent care. It doesn't seem to make sense. (Urgent care wait was 3 hours vs 1 hour at the ER in this instance.)
The federal subsidy is determined by the Second Lowest Cost Silver Plan (SLCSP). That is why you only get out-of-state coverage with the Gold and Platinum plans.

In competitive states, insurance companies must reduce the price of their Silver plan so that subsidized policyholders have the smallest out-of-pocket premium. Out-of-area coverage (BlueCard) costs more because it encourages medical tourism, so it's not offered. Your insurer does not want you to visit the ER instead of the urgent care, but that's a side effect of offering only in-state coverage.
talzara
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by talzara »

marcopolo wrote: Thu Sep 23, 2021 3:39 pm We have since moved to Hawaii, and our younger son goes to the same school in PA. The PPO plan we have in Hawaii is part of the BCBS BlueCard network and provides in-network coverage in the area of his school in PA, including the University Health System.
Since your son is attending school for more than 90 days, he would qualify for the Away From Home Care program. He does not need BlueCard.

Of course, you may also be buying BlueCard for yourself. It is certainly more convenient to have BlueCard.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by marcopolo »

talzara wrote: Thu Sep 23, 2021 3:41 pm
opus360 wrote: Sat Sep 18, 2021 7:42 am To my surprised, the insurance we have does not coverage us outside of New Jersey, except for emergency care. So, I asked the customer service, what happens if after visiting ER, we get admitted to the hospital. She said that is when it will get reviewed on a case by case basis. She said only the Omia Gold, which the premium is $2,000 more per month, has out of state coverage. I am just thinking, they want you to visit ER rather than urgent care. It doesn't seem to make sense. (Urgent care wait was 3 hours vs 1 hour at the ER in this instance.)
The federal subsidy is determined by the Second Lowest Cost Silver Plan (SLCSP). That is why you only get out-of-state coverage with the Gold and Platinum plans.

In competitive states, insurance companies must reduce the price of their Silver plan so that subsidized policyholders have the smallest out-of-pocket premium. Out-of-area coverage (BlueCard) costs more because it encourages medical tourism, so it's not offered. Your insurer does not want you to visit the ER instead of the urgent care, but that's a side effect of offering only in-state coverage.
1) I think you have this backwards. If you want to minimize out of pocket premiums for subsidized policy holders, you would increase the price of the SLCSP, not reduce it. Look at what happened in Blue States when they pulled the "Silver Switcheroo" to accomplish just that.

2) I have heard of medical tourism to places like Malaysia, Singapore, Mexico, etc. I am not sure I have ever heard of anyone doing so to utilize their BlueCard benefits. Is that really a thing, widespread enough to make any difference?
Last edited by marcopolo on Thu Sep 23, 2021 3:52 pm, edited 1 time in total.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by marcopolo »

talzara wrote: Thu Sep 23, 2021 3:46 pm
marcopolo wrote: Thu Sep 23, 2021 3:39 pm We have since moved to Hawaii, and our younger son goes to the same school in PA. The PPO plan we have in Hawaii is part of the BCBS BlueCard network and provides in-network coverage in the area of his school in PA, including the University Health System.
Since your son is attending school for more than 90 days, he would qualify for the Away From Home Care program. He does not need BlueCard.

Of course, you may also be buying BlueCard for yourself. It is certainly more convenient to have BlueCard.
We don't pay anything extra for BlueCard, it is part of our PPO benefits.
Once in a while you get shown the light, in the strangest of places if you look at it right.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by mkc »

talzara wrote: Thu Sep 23, 2021 3:41 pm
The federal subsidy is determined by the Second Lowest Cost Silver Plan (SLCSP). That is why you only get out-of-state coverage with the Gold and Platinum plans.
Neither out of network nor out of state is covered on any of our domicile county's ACA plans (which are BCBS). Nor is Blue Card. So don't automatically assume you have it with higher metal level plans.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by fortunefavored »

mkc wrote: Thu Sep 23, 2021 4:34 pm
talzara wrote: Thu Sep 23, 2021 3:41 pm
The federal subsidy is determined by the Second Lowest Cost Silver Plan (SLCSP). That is why you only get out-of-state coverage with the Gold and Platinum plans.
Neither out of network nor out of state is covered on any of our domicile county's ACA plans (which are BCBS). Nor is Blue Card. So don't automatically assume you have it with higher metal level plans.
BlueCard was removed in my area's BCBS plans some time between 2019 and 2021. The plans just get worse every year, so you have to stay on top of changes. Even if they were "good" at one time, they gradually peel things off.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by fortunefavored »

marcopolo wrote: Thu Sep 23, 2021 3:49 pm2) I have heard of medical tourism to places like Malaysia, Singapore, Mexico, etc. I am not sure I have ever heard of anyone doing so to utilize their BlueCard benefits. Is that really a thing, widespread enough to make any difference?
I assume what they mean by this is to stop you going to the Mayo clinic for care instead of Mediocre Local Hospital. I would certainly not want cancer treatment at my local hospital, I'd rather go to a research hospital 70 miles away.. but it is not covered as "in-network" with my area's current ACA plans.
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opus360
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by opus360 »

fortunefavored wrote: Thu Sep 23, 2021 5:26 pm BlueCard was removed in my area's BCBS plans some time between 2019 and 2021. The plans just get worse every year, so you have to stay on top of changes. Even if they were "good" at one time, they gradually peel things off.
Maybe 5 or 6 years ago, we did go out of state for a treatment and it was covered. Also, maybe 3 or 4 years ago, I saw on youtube, which compared the Ameriheath coverage and Horizon BCBS of NJ. It said the lowest cost ACA marketplace insurance of AmeriHealth does not let you go out of state, whereas the Horizon does. Now, what you wrote then explains my puzzle why out-of-state wasn't covered this year. Thanks.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by talzara »

marcopolo wrote: Thu Sep 23, 2021 3:49 pm
talzara wrote: Thu Sep 23, 2021 3:41 pm In competitive states, insurance companies must reduce the price of their Silver plan so that subsidized policyholders have the smallest out-of-pocket premium. Out-of-area coverage (BlueCard) costs more because it encourages medical tourism, so it's not offered. Your insurer does not want you to visit the ER instead of the urgent care, but that's a side effect of offering only in-state coverage.
1) I think you have this backwards. If you want to minimize out of pocket premiums for subsidized policy holders, you would increase the price of the SLCSP, not reduce it. Look at what happened in Blue States when they pulled the "Silver Switcheroo" to accomplish just that.
Silver loading and silver switcheroo only work because of state action. When a state forces all insurers to load CSR on the silver plans, then it could push up the prices for all on-exchange Silver plans and also push up the federal subsidy. Insurers couldn't compete to reduce the loading because it was required by the state.

However, the states do not require all Silver plans to offer nationwide coverage. It only takes one defector to remove nationwide coverage from the federal subsidy, because one insurance company can offer two Silver plans.

There's actually an insurer that used to play the spoiler as its marketing strategy. It would spam the exchange with two low-cost Silver plans with very narrow networks, trying to make the higher-cost plan the SLCSP. The other insurers responded exactly as the game theory would predict. They created their own low-cost narrow-network Silver plans to compete for the SLCSP spot.
marcopolo wrote: Thu Sep 23, 2021 3:49 pm 2) I have heard of medical tourism to places like Malaysia, Singapore, Mexico, etc. I am not sure I have ever heard of anyone doing so to utilize their BlueCard benefits. Is that really a thing, widespread enough to make any difference?
Even $20 is a lot when you're competing to be the SLCSP.

I've seen insurers spam the exchange with two Silver plans that were only $5 apart.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by talzara »

fortunefavored wrote: Thu Sep 23, 2021 5:29 pm
marcopolo wrote: Thu Sep 23, 2021 3:49 pm2) I have heard of medical tourism to places like Malaysia, Singapore, Mexico, etc. I am not sure I have ever heard of anyone doing so to utilize their BlueCard benefits. Is that really a thing, widespread enough to make any difference?
I assume what they mean by this is to stop you going to the Mayo clinic for care instead of Mediocre Local Hospital. I would certainly not want cancer treatment at my local hospital, I'd rather go to a research hospital 70 miles away.. but it is not covered as "in-network" with my area's current ACA plans.
That is exactly what I meant.

It could even be medical commuting instead of medical tourism. The OP is in New Jersey. Horizon Blue Cross can't afford to allow its members to see doctors in New York City, at least not on the Silver plan. On the Gold plan, it's not competing for the subsidized members, so anything goes. Anyone who buys a Gold plan should be able to afford the BlueCard.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Alaska_Skeeter »

How do folks that have a summer or winter home get covered out of state?

For example, we have a home in Alaska and Blue Cross Gold 1500 plan
that covers us in AK and WA.
But we are wintering for 4 months in MT/VA and
the Blue Cross Gold 1500 plan only covers emergencies
outside of AK/WA.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by tibbitts »

Alaska_Skeeter wrote: Fri Nov 12, 2021 8:26 am How do folks that have a summer or winter home get covered out of state?

For example, we have a home in Alaska and Blue Cross Gold 1500 plan
that covers us in AK and WA.
But we are wintering for 4 months in MT/VA and
the Blue Cross Gold 1500 plan only covers emergencies
outside of AK/WA.
For me the answer is I don't have coverage outside of my state, and yes it's annoying and potentially costly. Back before the pandemic ended travel (although that's becoming a distant memory so somewhat foggy), I would buy insurance that included medical for short trips, but had no solution for longer out-of-state stays. I'm not aware of insurance that pays for "evacuation" for purely in-network purposes.
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by talzara »

Alaska_Skeeter wrote: Fri Nov 12, 2021 8:26 am How do folks that have a summer or winter home get covered out of state?

For example, we have a home in Alaska and Blue Cross Gold 1500 plan
that covers us in AK and WA.
But we are wintering for 4 months in MT/VA and
the Blue Cross Gold 1500 plan only covers emergencies
outside of AK/WA.
As I already explained in this thread, Blue Cross Away From Home Care is a good solution for seasonal residents. They buy a plan from their own Blue Cross and get a guest membership with another Blue Cross. They can carry the same plan year-round and have coverage for non-emergency care in both places.

Unfortunately, neither Alaska nor Washington participates in AFHC. It looks like Premera just opted out for both of its territories.

Blue Cross of Montana participates in AFHC, but you can't use it in Alaska, so that doesn't help you.

Can you qualify to buy plans on-exchange for 4/8 months? If so, then you could just switch plans twice a year.
Alaska_Skeeter
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by Alaska_Skeeter »

The problem is we qualify for ACA subsidized using the AK threshold of 89k gross income,
but not the lower threshold in MT.
At least we can drive to Spokane in 3 hours, but I was wondering how those thousands of
folks that winter in one state and summer in another state deal with the problem.

Also how does Blue Cross determine "emergency care" for coverage out of state.
For example, a broken finger visit to urgent care not covered,
the same broken finger visit to the ER covered?
fortunefavored
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Re: Health insurance coverage limited to in-state. What do you do for out-of-state coverage?

Post by fortunefavored »

Alaska_Skeeter wrote: Sat Nov 13, 2021 8:33 am The problem is we qualify for ACA subsidized using the AK threshold of 89k gross income,
but not the lower threshold in MT.
At least we can drive to Spokane in 3 hours, but I was wondering how those thousands of
folks that winter in one state and summer in another state deal with the problem.

Also how does Blue Cross determine "emergency care" for coverage out of state.
For example, a broken finger visit to urgent care not covered,
the same broken finger visit to the ER covered?
There's the rub.. if they deem it non-emergency (but you went to an ER) - it won't be covered. There is basically no answer for "regular" or "non-emergency but urgent" care when you are away from your home base. The best you can do is sock away an extra $5000 or so for out of pocket costs and identify urgent care/doctors in your remote location in advance.

There is no solution until medicare or we get universal health care.
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