Health insurance out of state?

[M_O_Connor]

What a timely thread, and so important! COTH, are you listening? This would be a great topic for an article…equestrians are a very mobile population, prone to neglect their own health issues in the best of times (who has time to go to a doctor?), and very few have access to group coverage.

Our immediate family is split between three states; I reside in VA (where we file taxes), my husband’s seasonal business is in NY, and he works the entire WEF season in FL, along with traveling to many other states throughout the year for horse shows.

We have one daughter in school in VA, another , under 26, who is in the second year of filing her own taxes, and she resides in NY. Theoretically she should be allowed to remain on our policy, but this year we are told that’s not possible because of her independent tax status. I thought the ACA specified that if an u26 child didn’t have access to insurance through a job, that parents could keep them on their policy, but I guess those who actually execute the law didn’t read it.

Where and how to purchase coverage for us all is insanity. Apparently the ACA assumes that people live and work within a single county in a single state, drawing paychecks on a weekly basis that never vary in amount.

Our big medical bills for the past year include one ER visit in FL–do not assume that all is hunky-dory just because you go to the ER (even if, in advance, you call the insurance company to find out if you are doing what they want you to–because we sure did!)

We received a $26K THOUSAND (<—yes that’s THREE zeros after the 26) dollar hospital bill, ONLY for the hospital charges before being deluged with additional physician, and radiology bills. I had to fight tooth and nail, fending off collections (still in the process of doing that) while holding the insurance company responsible for what they are supposed to cover under the terms of our policy (which, btw, most people last year never got to see in advance or sometimes ever, because they weren’t available–I still haven’t seen ours, but did assume that it covered what they were legally obligated to cover according to the ACA).

The solution that has been suggested to us is to all purchase separate individual policies. So my husband should get a FL policy when he’s in FL, and a NY one for the rest of the year. I should get a VA policy, daughter in school thankfully can get hers through school, and daughter in NY should get a NY policy. Really? 4 and 5 policies a year to cover 4 people in the same family?

Where is that public option? Where are the PPO’s (none are available on the individual exchanges)? And how is one family supposed to cope with purchasing 4 or 5 separate policies when the subsidies are based on “household income?” but the premiums are priced individually?

This would have a far greater impact on the equestrian industry if the workers were for the most part legal! I’m all for free trade and free travel (really–I don’t think there should be artificial borders telling people where they can and can’t live and work) but hiring practices currently leave a lot to be desired in the horse business, and it has a chilling effect on workers’ rights.

[equisusan]

[QUOTE=M. O’Connor;7894521]
What a timely thread, and so important! COTH, are you listening? This would be a great topic for an article…equestrians are a very mobile population, prone to neglect their own health issues in the best of times (who has time to go to a doctor?), and very few have access to group coverage.

Our immediate family is split between three states; I reside in VA (where we file taxes), my husband’s seasonal business is in NY, and he works the entire WEF season in FL, along with traveling to many other states throughout the year for horse shows.

We have one daughter in school in VA, another , under 26, who is in the second year of filing her own taxes, and she resides in NY. Theoretically she should be allowed to remain on our policy, but this year we are told that’s not possible because of her independent tax status. I thought the ACA specified that if an u26 child didn’t have access to insurance through a job, that parents could keep them on their policy, but I guess those who actually execute the law didn’t read it.

Where and how to purchase coverage for us all is insanity. Apparently the ACA assumes that people live and work within a single county in a single state, drawing paychecks on a weekly basis that never vary in amount.

Our big medical bills for the past year include one ER visit in FL–do not assume that all is hunky-dory just because you go to the ER (even if, in advance, you call the insurance company to find out if you are doing what they want you to–because we sure did!)

We received a $26K THOUSAND (<—yes that’s THREE zeros after the 26) dollar hospital bill, ONLY for the hospital charges before being deluged with additional physician, and radiology bills. I had to fight tooth and nail, fending off collections (still in the process of doing that) while holding the insurance company responsible for what they are supposed to cover under the terms of our policy (which, btw, most people last year never got to see in advance or sometimes ever, because they weren’t available–I still haven’t seen ours, but did assume that it covered what they were legally obligated to cover according to the ACA).

The solution that has been suggested to us is to all purchase separate individual policies. So my husband should get a FL policy when he’s in FL, and a NY one for the rest of the year. I should get a VA policy, daughter in school thankfully can get hers through school, and daughter in NY should get a NY policy. Really? 4 and 5 policies a year to cover 4 people in the same family?

Where is that public option? Where are the PPO’s (none are available on the individual exchanges)? And how is one family supposed to cope with purchasing 4 or 5 separate policies when the subsidies are based on “household income?” but the premiums are priced individually?

This would have a far greater impact on the equestrian industry if the workers were for the most part legal! I’m all for free trade and free travel (really–I don’t think there should be artificial borders telling people where they can and can’t live and work) but hiring practices currently leave a lot to be desired in the horse business, and it has a chilling effect on workers’ rights.[/QUOTE]

There are individual PPO plans from BCBS in Florida.

[rothmpp]

My experience in the last couple of weeks is that the reps from the insurance companies on the individual market have a challenge understanding the rules and regs of their own companies.

We became eligible on my husband’s employer’s plan as of November 1st. He was hired at the end of October and we could not get a straight answer until November 15th when we were eligible for coverage. When I contacted our private carrier (Health Plus), the rep checked for what seemed like forever about whether we could be cancelled retro to November 1st. Definitive answer I got was no. We could be cancelled as of the day I called, but no sooner. Imagine my surprise when I got all the cancellation paperwork in the mail yesterday stating we had been terminated per our request as of October 31st. That was a nice $500 refund surprise.

So, short answer long, while I would think that under a HMO you would not be able to seek non-emergency care outside your network, I would be pretty surprised if you were on the hook for a full bill for a emergent admission to the hospital. What I would offer as a caution is that you need to be really, really aware what your insurance company considers emergent. For example, for 99% of the adult population, poison ivy exposure not considered emergent. For me - I had a super intense reaction to poison ivy ten years ago, and now if it is near my face, or god forbid, my lungs - it is definitely an emergency. Two summers ago we were out of state visiting family and some brainiac decided to toss random vines on the bonfire. It took about two minutes of those burning to send me to the ER and a subsequent 24 hour admission. You don’t want to know how many months and statements I had to get from my reg doc and the docs there to get the insurance company to cover it.

[jody_jaffe]

Under an HMO, you are covered for emergency care in any state. How much or what percentage depends on your deductible and plan.

The rub comes with the word “stable.” (Small irony there:) Once you are deemed stable, your stay in the hospital is on your dime, if you are out of state.

At least that’s the way it’s been explained to me by three different insurance brokers (who, admittedly, could be wrong given all the confusion).

All that said, Rothmpp raises an important point…don’t expect it to be easy getting an insurance company to pay a claim, especially if it’s in a hazy area. They count on a certain number of people to give up. My advice would be: don’t.

[hype]

I have a chronic condition and have fought with insurance companies for years. I’m very well versed in dealing with insurance companies.

The key is what they determine as an emergency. If you are in a car wreck for instance and they send you to the er for follow up and it isn’t deemed an emergency guess who is left holding the bag?

I firmly believe that insurance companies have it in their business plans that they deny anything that could be considered borderline coverage. They count on a certain percentage of people giving up and just paying it. Eventually if you fight it they will pay but it’s very time consuming and frustrating.

My comments were not meant to be incendiary but rather what I have personally observed. While I do want to see everyone insured I’m not sure that the current laws take care of this.

I have personal friends (some horse professionals some just independent policy owners) seeing their premiums drastically increase and their benefits go down. They are questioning why they are paying $500/month for a family of five for insurance which had a $5000 deductible. Why not roll the dice and just keep your fingers crossed? This is exactly the type of attitude we can’t afford and make this program work. We need young and healthy people buying into this program.

So while some may think this is the answer to their prayers I haven’t found it to be this way. Our premiums with group insurance have increased, we have less doctors who accept our plan and our deductible has risen.

[Muggle_Mom]

OP, check out UnitedHealthcare. They just became an option for Virginia residents and they have a national provider network for their “Choice Plus” plans. Go to www.uhone.com to get a quote. Make sure you mark “choice plus” to get prices for the national provider network plans.

My DD is a groom and is always on the road. I checked out Wellington, Lexington and several other cities where DD works throughout the year. I was very pleased to find the major hospitals and a large number of physicians on their provider list in each area. UnitedHealthcare is the only option for Virginians seeking a national provider network. They are a bit higher than Anthem and the difference widens the older you are. It’s well worth the peace of mind to be insured for both emergencies and routine medical needs when your profession requires a lot of traveling.

We’re so relieved to find this option!

[RugBug]

[QUOTE=hype;7895315]

I have personal friends (some horse professionals some just independent policy owners) seeing their premiums drastically increase and their benefits go down. They are questioning why they are paying $500/month for a family of five for insurance which had a $5000 deductible. Why not roll the dice and just keep your fingers crossed?[/QUOTE]

Do you have any idea what a group plan for a family costs? Try $1200/month with. $4000 deductible. Zero deductible plan is over $1600/month for a famil.

[jody_jaffe]

"$500/month for a family of five for insurance which had a $5000 deductible. "

Ha, that’s cheap. Mine went from $330 to $680 for ONE PERSON, with a higher deductible and a big step down to an HMO. And I have no pre-existing conditions, though supposedly that’s no longer a factor. Age, however, is.

Mugglemom: United Healthone’s plans are $100 more than the others – at least here in SWVa, and not offered through the ACA marketplace. Ie, Their policy for me is $800 a month with $5k deductible. Not really much of an option for me.

[Darkwave]

[QUOTE=Muggle Mom;7895596]
OP, check out UnitedHealthcare. They just became an option for Virginia residents and they have a national provider network for their “Choice Plus” plans. Go to www.uhone.com to get a quote. Make sure you mark “choice plus” to get prices for the national provider network plans.[/QUOTE]

I will caution that United Healthcare ain’t great. I have them as my insurer through work, and I’ve had some struggles. For example, when I saw an out of network podiatrist (allowed under my plan), they refused to grant permission for an MRI he ordered until I had a second in network physician sign off on it.

As another example, I usually end up submitting claims myself - seems like more and more doctors won’t submit to United Healthcare, which they described to me as “really bad to deal with.” So I submit myself - I make sure that the documents I submit include all required information and also write up a cover letter listing everything I’ve submitted, and spelling out all their required data (diagnosis, date of service, location of service, etc). Despite this, they ALWAYS find a reason to deny on the first submission. Most recently, they claimed that my policy was cancelled (news to me - I’m still paying for it each month out of my paycheck).

If United Healthcare is your only option, then I guess that’s better than nothing. But they are pretty bad.

[Punkie]

You could carry an accident policy like US Able Life! It only covers one accident per year, but they will absolutely cover an out-of-network hospitalization in the case of an emergency even if your policy doesn’t. As other said, it is likely that a hospitalization as a result of an emergency will be covered out-of-state, but there may be a sizeable deductible or co-pay to go with it. An accident policy would help to cover some of those costs.

[juststartingout]

I carry the number one rated plan in the country through my employment. It is. PPO plan and provides for out of network care and out of state care. It still takes me an average of 9 months to collect for my out of pocket payments and multiple calls for out of state care. Without a single payer option, we are all at the mercy of carriers who are motivated to deny claims for as long and as much as possible

[poltroon]

[QUOTE=hype;7895315]
They are questioning why they are paying $500/month for a family of five for insurance which had a $5000 deductible. [/QUOTE]

It’s a good question to ask… it is expensive. But it is helpful to know that the average health insurance policy for a family is on order $16,000 a year in 2014.

Alas, even the simplest accident or health situation can cost many thousands of dollars without it. Just to walk in an ER these days is $3-4k if all you do is sit in a bed for a couple of hours.

(One reference: http://kff.org/health-costs/report/2014-employer-health-benefits-survey/ )

[DMK]

“what is an ER” is a bit more well defined under ACA (this part goes back to 2010) - the "prudent layperson standard:

How are emergency services defined?The standard is whether a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. The requirement is limited to emergency services that are provided in an emergency department of a hospital and stabilization services.

This means it is not always the medical definition of an emergency (meaning what would a trained professional do) but rather a “prudent layperson”. In other words, drug seeking behavior in the absence of an actual medical condition or going in for a flu shot can reliably be considered imprudent uses of your local ER.

see healthcare.gov for important details

https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/

https://www.healthcare.gov/health-care-law-protections/doctor-choice-emergency-room-access/

https://www.aetna.com/health-reform-connection/questions-answers/emergency-room-services.html

If you are admitted to an out-of-network facility, be it within the service area or outside the state, you may be potentially at risk for what is called balance billing (explained in that last link). However every insurer has different rules on how it is handled. Surprisingly enough, you are probably most likely to be balance billed if you are in a PPO vs. an HMO. That’s just the nature of the beast. In general, my experience has been that while it is an emergency and/or emergency related admission, the insurer is going to work with the hospital to not get the patient in the middle. Please note this is not true of all insurers, and there certainly are plenty of hospitals/certain independent physicians that treat this as an opportunity to engage in some fairly impressive billing practices, well above any going rate for similar services. It’s an unpleasant situation for all involved.

Which is why it is in your best interest to get back in a participating facility as soon as you can. And as soon as you are stable, an insurer is probably going to recommend that. Recommend it, arrange it, possibly even cover it in full since it is to both your advantages that you be back in a network facility (although chances are if you have been in the hospital with such a potentially long term admission, you have already met your out of pocket and all covered care is at a 100%).

If you DO have an HMO and you do travel a lot, you may want to sign up for a policy that covers minute clinics or even teledoc (both of these are available to people not covered under such policies for very reasonable fees). Teledoc most definitely does not care where you call from and Minute Clinics (or similar types of clinics) are also probably available as covered wherever one is available (good question to ask your insurer). Additionally, if you have a good relationship with a PCP (and if you do not, there isn’t much excuse), they will often help you with prescriptions, etc. when you are out of town. But the doctor patient relationship has to be there.

So there are cost effective alternatives for out of town care with an HMO. It may make sense to look at the cost of the PPO and an HMO, see if the difference justifies you setting aside a discretionary fund for those non-emergent moments and potentially pocket the difference if you do not use it. But it also requires you being smart about your health and your finances. This is relatively new territory for most people. They are rather used to employers being very big paternalistic about health insurance. But even for those who continue to be covered under plan sponsored coverage, may see a transition to a private exchange experience where employees have a bucket of money (provided by the employer) in which to shop. And they will be required to shop smartly if they want to maximize their finances.

[IPEsq]

[QUOTE=Darkwave;7896331]
I will caution that United Healthcare ain’t great. I have them as my insurer through work, and I’ve had some struggles. For example, when I saw an out of network podiatrist (allowed under my plan), they refused to grant permission for an MRI he ordered until I had a second in network physician sign off on it.

As another example, I usually end up submitting claims myself - seems like more and more doctors won’t submit to United Healthcare, which they described to me as “really bad to deal with.” So I submit myself - I make sure that the documents I submit include all required information and also write up a cover letter listing everything I’ve submitted, and spelling out all their required data (diagnosis, date of service, location of service, etc). Despite this, they ALWAYS find a reason to deny on the first submission. Most recently, they claimed that my policy was cancelled (news to me - I’m still paying for it each month out of my paycheck).

If United Healthcare is your only option, then I guess that’s better than nothing. But they are pretty bad.[/QUOTE]

I have UHC through my work now too and I agree with this. Actually, for the non-preventive care type stuff that us horse people have to deal with from time to time (chiropractic, physical therapy, etc.), even the “in network” providers are often cheaper if I go with their out of pocket payment option rather than bill to UHC. While I got fewer annual visits under Anthem before ACA, I’d rather just pay my chiro $55 directly than my $60 in-network specialist visit copay and have to deal with paperwork. AND, even if I did pay the copay (say, to my PT whose out of pocket price is $65 vs. the $60 copay), NONE of the copay amounts for this go to my deductible. They all go to my out of pocket limit which is so high it would require some surgeries to hit. Not that my deductible is low.

This past year, with eye doctor visits, contact lens purchases, trips to the chiro, PT, and annual physical with bloodwork, the only thing that has gone towards my deductible is the $28 I paid to the lab for the bloodwork.

[Monarch]

I am not real happy about things with HI right now but not alot I can do about it. My husband & I are self employed we had crappy insurance at one point and changed providers new provider would not cover a hyster. that I needed. Basically it was considered a pre existing condition. I was able to get the surgery done (robotic) for under $15000 and that included the 2 surgeons, anesthesiologist, hospital with one night stay. That is what it cost me now this was not an emergency and had had time to shop around I will say most of the hospitals were not negotiable even though I had cash to pay. I will also say what was so frustrating to me was the price variances with no real explanation as to why what things cost. One example of what I am talking about was I had to have several MRI done the list price was $3100 I paid just under $400 this was their cash price if we had run it though my insurance even though they were not going to pay it would have cost me $700 needless to say we did not run it though insurance I also am assuming that they did not lose money when they did the MRI for the cash price.
Now this last year we had insurance that had a high deductible 5000 indiv 10000 family then 100% coverage at a cost of 379 a month for the 2 of us. No longer can get this coverage. What our insurance agent sent us that is close to what we had although coverage is a bit diff. now looking at 6000 ind. and 12500 family deductible the 100% coverage (supposedly) new price $890 a month.
Now i will not think that this is the worse change in plans and premiums out there but for us it would be more than double what we are paying.
Personally I think insurance should just cover accidents/emergencies and catastrophic not doctor visits and the like. It would not make it perfect but I think we would have a better idea of what things really cost.
Rant over
M

[hype]

[QUOTE=RugBug;7895777]
Do you have any idea what a group plan for a family costs? Try $1200/month with. $4000 deductible. Zero deductible plan is over $1600/month for a famil.[/QUOTE]

I’m passing on what my friend told me she was paying. She said that it was $500/month for a family of 5 with a $5000 deductible. I have no reason to think she was exaggerating or underestimating it.

This could be last year’s premium though. We are also in a state which does not have a state run health exchange which could influence the prices.

Another thought that the insurance agent brought up when I sat through the benefits meeting with my husband’s work.

Just because you are in an approved facility, it doesn’t mean that all of the providers in the said facility are approved. If you go to the ER (and this is her example not mine) and need a MRI and surgery, it might not all be covered in network. While the ER may be an approved facility, the radiologist who reads the MRI might not be in network, ditto with the surgeon and the anesthesiologist. Last surgery one of my family members had, we had I think four different charges on it. Facility, surgeon, anesthesia, professional nurse care. This was for a straightforward outpatient surgery.

We were billed over $26,000 for the surgery and then with insurance discount, I think it ended up around $10,000.

In the past if you were at an in network facility, everything was covered in network because it was understood that you didn’t get to choose your anesthesiologist or radiologist. Now, they can make you pay full boat for those services when in reality you have no choice in them especially in a surgical emergency.

I did ask prior to my daughter having surgery last year which groups were responsible for all of the extra care and determined if they were in network or not prior to the surgery. It was planned so I was able to do so but this is something new that has come up and I know people who have been hit with really large bills not understanding this new loop hole.

So while it might be a covered expense, if it isn’t covered in network, it costs you significantly more money out of pocket. I think on our current insurance in network deductible is $2500/person and out of network it is $5000 and the amount they count toward your out of network deductibel is not what you are actually paying or being billed, it is what they deem reasonable. HUGE difference there!

For instance, for one service we were billed $250 by the doctor. She was out of network. We paid $250. Insurance company said that $75 was what was reasonable and customary for that procedure so $75 was credited toward our $5000 deductible when in reality we paid $250. So out of network really doesn’t come into play until you are probably into it at least twice what they’ve listed.

Be informed and advocate for yourself. It can save you thousands.

[equisusan]

I found the only PPOs on the exchange in Florida are from Assurant which seems to be Aetna. I think I’m going to go for that. Any thoughts or advice?

[hype]

I would ALWAYS go for a PPO given a choice. From what I’ve seen, HMO’s are very limited in coverage and doctor choices.
\

[equisusan]

[QUOTE=hype;7898526]
I would ALWAYS go for a PPO given a choice. From what I’ve seen, HMO’s are very limited in coverage and doctor choices.
[/QUOTE]

Yes me too hype

[DMK]

[QUOTE=equisusan;7898446]
I found the only PPOs on the exchange in Florida are from Assurant which seems to be Aetna. I think I’m going to go for that. Any thoughts or advice?[/QUOTE]

Assurant =/= Aetna

Aetna is on the exchange in FL, but only in a few counties and is identified as “Aetna”. Coventry is now owned by Aetna and is still identified as Coventry, but is still called Coventry.

Regarding PPOs and HMOs, when it comes to the large national carriers such as UHC, Aetna, Wellpoint, CIGNA and so on, generally the HMO and PPO networks for group coverage are largely the same. When it comes to individual coverage, ther emay be differences. But for that matter, I would never assume the PPO individual plan has the same network as the PPO group plan.