Health insurance out of state?

[jody_jaffe]

This isn’t as off-topic as it seems. For those who compete out of state, I’m wondering what other riders will be doing now that Anthem no longer covers hospitalization outside of the state in which the policy was issued. It seems unbelievable that this is the policy, but I was told that repeatedly by an Anthem representative. He said he faces the same problem in California as I do in Virginia, that if he travels to say Las Vegas, he would have to pay for a hospital stay in case of an accident.

Please, let’s not let this turn into a political discussion. I’m looking for suggestions and alternatives.

I was thinking of going to Aiken this winter for a few weeks and while I don’t plan to get hurt, if I do, I don’t want to lose my farm from a hospital stay.

thanks!
ps… if anyone has information that I’m wrong on this, I’d love to hear it. But i was assured by the Anthem person as well as the representative from the Affordable Health Care office that this is true.

[IPEsq]

Anthem does the Blue Cross/Blue Shield policies, right? Is this a new (as in this year) change? I had a policy through them up until this year, and I was always covered out of state, but I did have to be sure I had a policy that didn’t have restrictions on providers (with an HMO type plan I would have probably been out of pocket a lot). I had that kind of policy because I was a student and always moving around. Didn’t really think about the risk of things like weekend travel at the time.

[jody_jaffe]

This is new. The Anthem person told me that all new Anthem policies exclude hospital coverage out of state. I think the situation is different if you get your insurance through your work and it is a group plan.

[Trixie]

According to their website:

http://www.anthem.com/wps/portal/ahpagent?content_path=shared/noapplication/f3/s1/t0/pw_a034778.htm&state=oh&label=Coverage%20While%20Traveling

And this:

http://www.anthem.com/wps/portal/ahpmember?content_path=member/oh/f5/s4/t0/pw_006945.htm&label=Travel%20Coverage

You may have more trouble if your care provider doesn’t accept Anthem. Maybe try to get clarification in writing?

[RugBug]

You will have emergency care… but you may not have follow up care.

[jody_jaffe]

The way I understand it, and I will clarify again tomorrow with another Anthem representative to make sure the first Anthem representative was correct in telling me that all new Anthem policies for individuals exclude out of state hospitalization, is that emergency care is covered out of state, at a percentage depending on your plan.

But hospitalization is not. That means should you be involved in a bad accident which requires hospitalization following emergency care, it comes out of your pocket completely.

So I am wondering what my fellow Cothers do who compete out of state and carry individual health insurance (as opposed to having group insurance from work which usually covers out of state hospitalization). Because, not to be gloom and doom, but if you were badly injured while out of state, you could wind up owing the hospital hundreds of thousands of dollars.

[poltroon]

That is extremely curious.

I can imagine it not covering, for example, you electing to visit the Mayo Clinic for your specialized surgery. I already know there are and always have been issues going for a regular appointment outside your service area (which btw is pretty silly, because it’s a reason people go to the ER unnecessarily).

But I really can’t imagine that if you are brought into the ER and admitted to the hospital from the ER that you wouldn’t be covered. My experience has been that hospitals are pretty much always in-network (there have been problems with the doctors that treat you, especially anesthesiologists, not being in network though).

Next question: you’re at the ER out of state. To what extent does the policy pay for transport?

It’s worth considering that admission to the hospital directly from the ER isn’t as common as you might think. For most things they patch you up and send you home. Even if you break bones, if orthopedic surgery is needed, very often you’ll be sent home with a referral. That’s probably your most likely and annoying case… you break a leg in one state, they patch you in the ER but don’t admit you, now for your “follow up” you need orthopedic surgery monday… and maybe you have to travel home for it to be covered. That would potentially suck.

Certainly there are people whose job it is to create and build weird loopholes of denialness, and it’s possible this is one of those situations. Health insurance does have regulation at the state level as well so your state insurance laws have something to say about this. You might also contact your state insurance commissioner and see what they have to say.

I’m interested to hear more about this.

[jody_jaffe]

Here is how it works. If you purchase insurance through the Marketplace, Anthem only offers HMOs which do NOT cover out of state hospitalization. This is true for every state in the country. The reason to go through the Marketplace is if you are eligible for federal subsidies.

But if you go through Anthem outside of the Marketplace, they offer coverage called POS which will cover out of state hospitalization at (at least) double the rates you have been paying-- with no federal subsidies. A friend of mine is now paying triple her rate from last year.

[TheJenners]

This does not seem like good coverage for an athlete or someone who travels a lot. Average Joe? Probably ok.

[PoohLP]

This may or may not help.

I am in an HMO. Now, it is group insurance and it isn’t Anthem, but the HMO has links to BCBS for emergency medical needs outside Florida. My mom is on the exact same policy. She recently suffered a kidney stone while out of the state and had to go to the emergency room. They admitted her to the hospital on Saturday and recommended surgery because she had a blockage, but the surgery could not be done until Monday. She had to stay in the hospital until Monday because the pain required IV pain killers. For the actual surgery, they had to contact her home HMO to receive approval to do the surgery our of network. The case has to be made that the patient cannot reasonably be moved. In her drug addled state, she was worried they would say no and she’d have to fly home in severe pain for surgery. Luckily, there was no problem. My mom was told that because she was admitted through the emergency room, everything was covered as if she were in her home coverage area. Not sure if she had to pay an out of network premium, but if she did, it was minimal (by healthcare cost standards).

[poltroon]

I have sent some of this on to a friend of mine who has expertise in this area.

[RugBug]

It is usually handled the way it was for PoohLP’s mother. You are considered emergent until you are stable enough to be moved.

[OveroHunter]

From what I have read and been told, your plan will work similarly to PoohLP’s mother’s plan. Emergency services are covered and if your entire stay is deemed an emergency then it will be covered according to your plan.

It is hard to figure out what may or may not be deemed an emergency though. That’s the risk you take I guess when buying on the exchange for an individual plan

[IPEsq]

[QUOTE=jody jaffe;7888573]
Here is how it works. If you purchase insurance through the Marketplace, Anthem only offers HMOs which do NOT cover out of state hospitalization. This is true for every state in the country. The reason to go through the Marketplace is if you are eligible for federal subsidies.

But if you go through Anthem outside of the Marketplace, they offer coverage called POS which will cover out of state hospitalization at (at least) double the rates you have been paying-- with no federal subsidies. A friend of mine is now paying triple her rate from last year.[/QUOTE]

My understanding from having PPO and POS plans with Anthem in the past, albeit pre-Marketplace, is that your out of state provider needs to submit the claim to their local Anthem office, in order to be viewed as still “in network” benefits. So, say your home state is GA and you are horse showing and injured in FL, the FL hospital DOES NOT submit your claim to Anthem/BCBS of GA but submits to the Florida Anthem affiliate who processes the claim. It eventually gets forwarded on to the GA affiliate who ultimately pays the provider.

The reason I know this is because I had some imaging done at a hospital out of state. The imaging was pre-approved by BCBS GA (my then home policy), but someone screwed up somewhere between the new state’s Anthem office and the hospital, because the the new state’s Anthem office denied my claim and never forwarded it on to GA. This created a headache, because I couldn’t talk to anyone on the phone at Anthem-new state, because my policy wasn’t with them, and people in GA were clueless because they had no information on the claim other than the pre-auth. It was eventually worked out in my case (thankfully because MRIs aren’t cheap!), but that is how I learned about all the finagling that the “in network” providers have to do when dealing with out of state policies.

Where I think you can get into trouble post-ACA implementation is in this whole tiered system of preferred providers that the insurance companies have. This is also true if you have a group plan. If your provider isn’t on the highest tier, then the costs to see that provider can be significantly higher. And I think many providers are confused about these varying degrees of being “in network”. In an emergency situation, it is even harder to try to find out these details.

Anyway, long story short is that I think that if your provider bills their local office of your insurance company you will be covered but they should not submit the claim directly to your home state. This is very important, say, if you happen to be unconscious and the hospital treats you and asks (or doesn’t) about insurance details later. The sooner you can get your insurance info to the administrators, the better. You definitely don’t want to have to submit claims to your home office after the fact–this is where I think you won’t be covered.

As an aside, I try to always wear my RoadID while riding. I have an interactive one which would allow the hospital to access my insurance info even if I don’t have my card with me. Now, if you are unconscious, they may or may not notice/care/be competent to do this. I was in an accident on my bike and had to take an ambo ride to the ER. I had my RoadID, which I had to give to the guy who took my info. Luckily, I was alert and lucid, because no one noticed it until I mentioned it. Also, the guy was clueless about how to access my info: “We can’t get on that website from our system”. “Ok, so did you try calling the number?” “I thought that was your emergency contacts number”. “No, my emergency contact number is not a 1-888 number”. (The RoadID provides some basic info and then says to call the number or go to the website for more info and provide my ID’s PIN). Still, better than nothing, as they eventually got my insurance info.

I do agree that it is not highly likely for you to be admitted to the hospital following a trip to the ER if you have a broken bone or similar. However, we participate in a sport that has a risk of head injury, and if the ER docs think you need to stay a while in order to be cleared for that reason, then you are staying.

[DMK]

[QUOTE=jody jaffe;7888573]
Here is how it works. If you purchase insurance through the Marketplace, Anthem only offers HMOs which do NOT cover out of state hospitalization. This is true for every state in the country. The reason to go through the Marketplace is if you are eligible for federal subsidies.

But if you go through Anthem outside of the Marketplace, they offer coverage called POS which will cover out of state hospitalization at (at least) double the rates you have been paying-- with no federal subsidies. A friend of mine is now paying triple her rate from last year.[/QUOTE]

bolded is mine.

This is emphatically NOT TRUE and not how HMOs (or other closed network products) work.

Voluntary or non-emergent hospitalization is not covered outside the network (the network may be state-wide or only portions of the state). EMERGENCY visits and emergency related admissions are covered, regardless of network affiliation. That is how closed networks have always operated and just in case they were not, they now have federal laws in place (since 2010) to ensure that they do.

So if you fall off your horse and go to hospital X and are subsequently admitted, regardless of whether that hospital is 5 miles or 5000 miles from your home, in the network or not in the network, it will be covered at the in network cost share.

You may have to transfer to a participating hospital at some point (presumably when you are stable), but it is not an issue of not having coverage.

Now if you are frequently out of the service area and may have non emergency expenses like doctor visits, urgent care visits, etc, and returning to the service area to get this care is difficult, then an HMO is probably not for you. But neither is a POS since the out of network deductible and coinsurance is so high as to make it a non-benefit. You are probably better off with a PPO that typically has a national network.

[RugBug]

[QUOTE=DMK;7889376]
bolded is mine.

This is emphatically NOT TRUE and not how HMOs (or other closed network products) work.

Voluntary or non-emergent hospitalization is not covered outside the network (the network may be state-wide or only portions of the state). EMERGENCY visits and emergency related admissions are covered, regardless of network affiliation. That is how closed networks have always operated and just in case they were not, they now have federal laws in place (since 2010) to ensure that they do.

So if you fall off your horse and go to hospital X and are subsequently admitted, regardless of whether that hospital is 5 miles or 5000 miles from your home, in the network or not in the network, it will be covered at the in network cost share.

You may have to transfer to a participating hospital at some point (presumably when you are stable), but it is not an issue of not having coverage.

Now if you are frequently out of the service area and may have non emergency expenses like doctor visits, urgent care visits, etc, and returning to the service area to get this care is difficult, then an HMO is probably not for you. But neither is a POS since the out of network deductible and coinsurance is so high as to make it a non-benefit. You are probably better off with a PPO that typically has a national network.[/QUOTE]

Thanks for weighing in DMK. Appreciate the knowledgeable perspective. I’m not familiar with the individual market but it just didn’t ring true to what I do know.

the interesting thing that IS going on, however, is whether on out of network hospital used in an emergency will waive the excess charges. when I was in NY recently, they had a news story about a very young woman taken to an ER due to a heart attack. Her insurance company paid at the in-network level, but the hospital would not write off the excess charges and she was responsible. This potentially could still be an issue for riders out of state.

[jody_jaffe]

DMK, I hope you are correct. This is not what the Anthem reps have told me. Or the reps from the Affordable CAre act office. I’ve had three Anthem reps tell me that under the HMO plan, which are the only plans available in Virginia in the Marketplace, hospital stays are not covered once you are released from the emergency room.

I realize they may be wrong, but this is what they have told me. I was also told by Anthem that they no longer offer PPO (at least in Va), but only offer POS, and that is NOT through the Marketplace since they don’t meet ACA guidelines.

[jody_jaffe]

I suspect no one has the absolute correct answer since everything is in a confused state. Here is the email I just got from my insurance broker who’s been in the insurance business many years:

“I have been on the phone with Anthem several times today and I am still receiving conflicting information regarding the Hospital Stay, with the “on exchange” plans; one Broker Service person says you will be covered for 50% and the other says not at all. They all concurred that the “Off Exchange”, POS plans will provide coverage. I have a meeting this evening, so I may have to get back with you in the morning with my recommendation. Sorry for the delay.”

If they can’t understand what’s going on, how can I?

[poltroon]

God how I hate health insurance. And health insurance companies.

I appreciate that you’re hashing this out here.

So we do have a couple of scenarios to work out.

1. You’re brought to the ER and admitted to the hospital from the ER.
2. A situation like a broken leg, where they see you in the ER, and refer you for surgery in a day or two. Does it matter if you’re able to travel home, and who decides if you can?

[jody_jaffe]

Poltroon,

The first thing to consider what type of insurance you have. If you have a group plan through work, you are most likely covered for everything, right now. That could change next year when the group plans must be compliant with the ACA, I was told by one of the brokers I spoke to today.

This new no-hospitalization scenario only refers to INDIVIDUAL plans that are being sold through the ACA Marketplace. According to all three Anthem reps I spoke to, Anthem is only offering HMO plans through the Marketplace. If you want a POS plan, you have to buy it through them at a much higher cost that you were paying.

So back to your scenario, good questions to which I don’t have the answer. I think it will be a matter of interpretation and lawsuits to determine what “stable” means. And even if that is the criteria, that could change as well.

One thing is for certain: it’s a mess. By the way, the CEO of Anthem made $17million in 2013 for nine months of work. So someone’s doing well with all this.