Need your guidance in selecting a medical insurance plan

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frotec
Posts: 22
Joined: Sat Mar 24, 2018 10:19 am

Need your guidance in selecting a medical insurance plan

Post by frotec » Sun Nov 04, 2018 1:17 pm

​Requesting some advise in selecting a suitable medical insurance plan for my nephew;

Background

1) He is 26 and just getting off his parent's plan. Birth date is Dec 31 so a Jan 1 start date is what would be targeted

2) He is going to college in Austin and will be a student for entire 2019

3) IMPORTANT NOTE: However He has two internships (three month each), one in CA and one is Seattle and will be out of Texas for the duration

4) Looking at plans on the Government Health care marketplace

5) No PPOs are offered and only HMOs are offered and looking a BCBS HMO

6) Comparing two plans and need your guidance please on which makes more sense

PLAN A BCBS Bronze
Premium 307 pm
Deductible 7900
Out of Pocket MAx 7900

Copayments / Coinsurance
Emergency room care: No Charge After Deductible
Generic drugs: No Charge After Deductible
Primary doctor: No Charge After Deductible
Specialist doctor: No Charge After Deductible

PLAN B BCBS Gold HMO
Premium 420
Deductible 350
Out of pocket MAx 7900

Copayments / Coinsurance
Emergency room care: $950 Copay with deductible/40% Coinsurance after deductible
Generic drugs: No Charge
Primary doctor: $30/40% Coinsurance after deductible
Specialist doctor: 40% Coinsurance after deductible

MY QUESTIONS (two of them):

Question 1: I am reasonable clear on what needs to be done while he is in Austin. But when he is say in CA and has a medical emergency that requires months of medical care from specialists etc (accident etc.. sort of worst care situation).. MAIN QUESTION: Will my max out of pocket be $7900 no matter what out of network doctors attend to him ??

Question 2: I assume that when he is in CA and needs some medical care (something that is a minor emergency that may need one night of observation etc)

One plan talks of a 950 copay for emergency care and other talks of no charge after deductible is met.

What would he end up paying in each case..??

Thanks in advance for your guidance

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Watty
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Re: Need your guidance in selecting a medical insurance plan

Post by Watty » Sun Nov 04, 2018 2:21 pm

frotec wrote:
Sun Nov 04, 2018 1:17 pm
Question 1: I am reasonable clear on what needs to be done while he is in Austin. But when he is say in CA and has a medical emergency that requires months of medical care from specialists etc (accident etc.. sort of worst care situation).. MAIN QUESTION: Will my max out of pocket be $7900 no matter what out of network doctors attend to him ??

Question 2: I assume that when he is in CA and needs some medical care (something that is a minor emergency that may need one night of observation etc)
I am in a similar situation with my health insurance which is an HMO and I travel a lot. I am not a healthcare guru but my understanding is;

1) The out of network emergency care is likely only until he is stable enough to be moved to an in network facility so he is unlikely to spend months in a hospital there. Some urgent care may also be covered but you should call first since it may only be covered at certain urgent care centers.

2) A big question is how much they will pay. If they will only pay what they consider a reasonable and customary charge for the services then that can be a problem. If they do not have a negotiated price with the hospital then the hospital can charge whatever they want. There are all sorts of issues with "balance billing"(Google this) that can vary with state laws. I have Kaiser which is a huge HMO and my impression is that they are pretty good at covering out of network emergency care as if it was in network but I don't know if all HMOs are like that.

It would be best to call the insurance companies and ask about how it would work with the specific plans. It was before ACA but when I had BCBS health insurance through work it was a PPO plan, before I went on a trip to Europe I called them to ask how that would work for emergency care and it turned that even in Europe they have some hospitals and doctors in major cities that would be considered to be in-network for emergency care only.

It would also be good to ask about him being out of Austin for a total of six months.
frotec wrote:
Sun Nov 04, 2018 1:17 pm
He is 26 and just getting off his parent's plan.
One other option to look at would be to see if he could use COBRA for that plan. It might have better coverage in California and Washington and it might have better terms.

His school might also offer student health insurance that would work better for him.

frotec
Posts: 22
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Re: Need your guidance in selecting a medical insurance plan

Post by frotec » Sun Nov 04, 2018 3:01 pm

Thanks for your response. Did check that his school does not offer student insurance nor is COBRA an option. The balance Billing concept is bothersome. The insurance is BCBS which is a large company but still !!

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MP123
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Re: Need your guidance in selecting a medical insurance plan

Post by MP123 » Sun Nov 04, 2018 7:57 pm

Nationwide PPO plans are hard to find in the individual market in many states.

You might call BCBS and ask them. I also have Kaiser and agree with Watty's summary above. Kaiser lets it's members go to Kaiser facilities in any of their service areas which includes WA and CA but not TX. So Kaiser might be a good choice to cover his time away at least.

Moving to a new location is a qualifying life event for ACA insurance which means that you can enroll in a new plan outside of open enrollment. Obviously getting a new policy for a 3 month move might be more trouble than it's worth but that could be an option.

frotec
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Re: Need your guidance in selecting a medical insurance plan

Post by frotec » Sun Nov 04, 2018 9:27 pm

Thanks MP123 for your input. From your response it seems Kaiser does not have a provision for coverage in Texas. His original policy is through Kaiser as he lived in CA before coming for his studies to Austin. The impression given to his parents was that emergency coverage would be provided in Texas not sure how though. Wonder if they misunderstood.

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MP123
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Re: Need your guidance in selecting a medical insurance plan

Post by MP123 » Mon Nov 05, 2018 7:44 pm

frotec wrote:
Sun Nov 04, 2018 9:27 pm
Thanks MP123 for your input. From your response it seems Kaiser does not have a provision for coverage in Texas. His original policy is through Kaiser as he lived in CA before coming for his studies to Austin. The impression given to his parents was that emergency coverage would be provided in Texas not sure how though. Wonder if they misunderstood.
To clarify I don't think Kaiser would provide regular doctor visits and that sort of thing in TX as they would in both WA and CA at their facilities. I do think they would pay for emergency care though even though it's not through their network.

Not sure of the details on how that would work out but it's an ACA requirement.

frotec
Posts: 22
Joined: Sat Mar 24, 2018 10:19 am

Re: Need your guidance in selecting a medical insurance plan

Post by frotec » Tue Nov 06, 2018 2:40 pm

Thanks MP123 for the clarification. It is along the lines of what i thought would be the process

carolynb2
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Re: Need your guidance in selecting a medical insurance plan

Post by carolynb2 » Thu Nov 08, 2018 11:40 am

Following up on the qualifying event comment - if he moves to a state for his internship that expanded medicaid he may well qualify for that while he lives there. Doctor visits and meds $3/each, hospitalization $10/day in most states (if not identical then similarly low).

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