Private insurance with coverage out of network

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mak1277
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Private insurance with coverage out of network

Post by mak1277 »

As I finally do some detailed pre-retirement planning, I am struggling to find insurance that covers out of network services. My family has a very specific need that (currently) is only available from providers who are not part of any healthcare network. My (admittedly limited) research on ACA plans has not turned up any plans (even platinum) that cover out of network providers.

I am very curious about other options that people have found for this type of thing.

Appreciate any insights.
mhalley
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Re: Private insurance with coverage out of network

Post by mhalley »

Maybe call the provider and ask them what insurance they accept.
Topic Author
mak1277
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Re: Private insurance with coverage out of network

Post by mak1277 »

mhalley wrote: Wed Jan 13, 2021 11:53 am Maybe call the provider and ask them what insurance they accept.
They don't accept insurance at all. We have to pay out of pocket and then submit a claim to my insurance through work. It's covered under my current plan, but I can't find an ACA plan that pays for out of network services.
mhalley
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Re: Private insurance with coverage out of network

Post by mhalley »

Ahh, that’s tough. ACA plans are designed to be cheap, and one of the best ways to do that is by having a narrow network. My understanding is that ACA plans might pay an out of network provider in an emergency, but your situation does not count as one. The only thing I can think of is compare your total healthcare costs with an ACA plan plus paying out of pocket vs the cost of a non ACA plan. You probably need to get an insurance broker to help you find a plan.
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MP123
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Re: Private insurance with coverage out of network

Post by MP123 »

Are there any PPO ACA plans where you live? Those would be the most likely to cover out-of-network. HMO and EPO plans won't except for emergencies.

Many ACA insurers have dropped PPO plans, but in some areas they're still available.
Topic Author
mak1277
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Re: Private insurance with coverage out of network

Post by mak1277 »

MP123 wrote: Wed Jan 13, 2021 1:06 pm Are there any PPO ACA plans where you live? Those would be the most likely to cover out-of-network. HMO and EPO plans won't except for emergencies.

Many ACA insurers have dropped PPO plans, but in some areas they're still available.
I haven't seen any, but I also haven't looked at all of the available plans. I was starting with Platinum and Gold and working my way down.
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MP123
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Re: Private insurance with coverage out of network

Post by MP123 »

mak1277 wrote: Wed Jan 13, 2021 1:07 pm
MP123 wrote: Wed Jan 13, 2021 1:06 pm Are there any PPO ACA plans where you live? Those would be the most likely to cover out-of-network. HMO and EPO plans won't except for emergencies.

Many ACA insurers have dropped PPO plans, but in some areas they're still available.
I haven't seen any, but I also haven't looked at all of the available plans. I was starting with Platinum and Gold and working my way down.
Metal level (sliver, gold, etc) just determines the premium/deductible mix, the plan details should be the same within each plan.

In many of the state exchanges you can select plan types like EPO or PPO to filter by. It's often shown in the plan name too, like "BlueCross PPO".
HomeStretch
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Re: Private insurance with coverage out of network

Post by HomeStretch »

Your ACA plan may also have to treat an out-of-network specialist as if they were in-network if the plan does not have any such specialist in-network. You might have to go through the claim appeals process after first being denied. For planning purposes, consider calling your state insurance commission office or the ACA assistance people to discuss the situation to see what they recommend.
toofache32
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Re: Private insurance with coverage out of network

Post by toofache32 »

I am an OON physician and have seen this progress slowly over the past decade. Out-of-network benefits have basically disappeared. First they raised the OON deductibles to $8,000+, then $12,000, then later to $20,000 to make it essentially non-existent although still there on paper. Now they are simply not including OON benefits in policies. Boil the frog slowly. It's an easy way for insurance companies to avoid additional losses. And yes, claims paid are considered losses to the insurance companies.
Last edited by toofache32 on Thu Jan 14, 2021 10:03 am, edited 1 time in total.
Topic Author
mak1277
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Re: Private insurance with coverage out of network

Post by mak1277 »

This is a depressing conversation, and may force me to continue working far longer than I want to.

Excluding ACA plans, what private insurance options exist?
mkc
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Re: Private insurance with coverage out of network

Post by mkc »

mak1277 wrote: Thu Jan 14, 2021 8:09 am This is a depressing conversation, and may force me to continue working far longer than I want to.

Excluding ACA plans, what private insurance options exist?
It depends on your state and zip code if there are any options. Some insurance companies have left the off-exchange market in many states, making ACA the only option.
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MP123
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Re: Private insurance with coverage out of network

Post by MP123 »

mak1277 wrote: Thu Jan 14, 2021 8:09 am This is a depressing conversation, and may force me to continue working far longer than I want to.

Excluding ACA plans, what private insurance options exist?
I don't usually recommend health sharing ministries, they aren't a substitute for insurance IMO, but in this case maybe they might reimburse for the OON providers, and could be used in addition to a regular ACA plan. You'd have to investigate closely, buyer beware. Most non-ACA plans will exclude coverage for pre-existing conditions.

I'll add that ACA plans vary widely in different states, counties, and even zip codes. So the situation in one area may not be yours.
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