Out of Network coverage no longer available

[Patrese415]

What is the name of your state? North Carolina

Many policies offered during this ACA Open Enrollment have completely dropped Out of Network coverage from their policies.

What happens if I'm traveling to a different state to see my grandchildren and have an accident, a heart attack, or need other emergency services. It's not clear how these would be handled. Do I need to purchase Travel Insurance to visit them?

 

[adjusterjack]

Many policies offered during this ACA Open Enrollment have completely dropped Out of Network coverage from their policies.

What happens if I'm traveling to a different state to see my grandchildren and have an accident, a heart attack, or need other emergency services. It's not clear how these would be handled.

I'm guessing that whatever plan you have now, has a 100+ page booklet somewhere in which emergency treatment is addressed. You're just going to have to read it or call the company.

If you get that information over the phone, make sure you ask where to see it in the plan booklet.

Otherwise, you'll just have to buy a plan that covers out-of-network emergencies.

Do I need to purchase Travel Insurance to visit them?

That's up to you.

Just make sure you read the policy before you buy it so that you know what you are getting.

Many of those policies (like extended car warranties) have more holes than Swiss Cheese.

 

[cbg]

FYI, the HMO model of health insurance plans does not and has never offered out of network coverage outside of emergency care. If it has an out of network option, it's not an HMO.

POS and PPO plans should all have an out of network option; HMO's do not; High Deductible plans might or might not depending on what model they are following. You can expect any plan with an OON option to cost more than one which does not.

 

[Patrese415]

FYI, the HMO model of health insurance plans does not and has never offered out of network coverage outside of emergency care. If it has an out of network option, it's not an HMO.

POS and PPO plans should all have an out of network option; HMO's do not; High Deductible plans might or might not depending on what model they are following. You can expect any plan with an OON option to cost more than one which does not.

FYI - The plans being offered on the ACA for 2023 DO NOT have out of network coverage unless you pick a plan that's $2500.00 a month for 1 person. This year I was paying $234.00 a month for one. Same plan for 2023 went up $71.00 with no OON coverage. Viewed all the plans available POS and PPO, no OON coverage.

 

[doucar]

Emergency coverage is available on most hmo plans when you are out of the service area of your plan. Do what AJ suggested review your plan booklet to make sure you have emergency coverage nationwide.

 

[cbg]

The majority of plans offered through the exchange, at least in my state, are High Deductible plans which can but do not routinely offer OON coverage.

If you are looking at plans that purport to be PPO or POS plans and which do not offer OON coverage then you are reading something wrong. BY DEFINITION those plan models offer OON coverage. Just as an HMO is not an HMO if there IS OON coverage, a PPO or a POS is not a PPO or a POS plan if it does not. I do this for a living, chum.

As doucar said, most if not all HMO's offer emergency coverage out of network. They will be less expensive.

 

[adjusterjack]

This year I was paying $234.00 a month for one. Same plan for 2023 went up $71.00

$300 per month for a medicare supplement for 2023 is in the ballpark.

I know reading those plan booklets can be daunting.

In mine the word "emergency" appears 89 times.

The phrase "out-of-network" appears 129 times.

You really have to read the plan booklet carefully and make notes to be able to piece together all the references.

 

[Patrese415]

The majority of plans offered through the exchange, at least in my state, are High Deductible plans which can but do not routinely offer OON coverage.

If you are looking at plans that purport to be PPO or POS plans and which do not offer OON coverage then you are reading something wrong. BY DEFINITION those plan models offer OON coverage. Just as an HMO is not an HMO if there IS OON coverage, a PPO or a POS is not a PPO or a POS plan if it does not. I do this for a living, chum.

As doucar said, most if not all HMO's offer emergency coverage out of network. They will be less expensive.

Thank you for your thoughts. Upon further review, the 3 plans available now are EPO, HMO, and PPO. PPO plans are the only one's that include OON coverage and are the most expensive. POS plans are no longer available on the Marketplace. My previous POS plan with OON is no longer available and has been replaced with EPO a plan.

Without reading through a 100 page plan document, which I wouldn't get until after I purchased the product, how would an OON emergency be paid, in general? I've never not had OON coverage, nor have I ever used OON coverage. We lost our Group Benefits last year and are wading through all of this confusion. Had supplement coverage for OON Max. OOP for this year.

 

[Patrese415]

$300 per month for a medicare supplement for 2023 is in the ballpark.

I know reading those plan booklets can be daunting.

In mine the word "emergency" appears 89 times.

The phrase "out-of-network" appears 129 times.

You really have to read the plan booklet carefully and make notes to be able to piece together all the references.

I'm not asking about Medicare Supplements. I'm researching coverage on the Healthcare.gov Marketplace, ACA coverage.

I get to go down the Medicare rabbit hole next month for enrollment next year.

 

[cbg]

Okay, now that we have established that I was right about HMO's and PPO's (I did not address EPO's) what legal question would you like answered?

 

[Patrese415]

After more digging and speaking to agents, I was made aware of the No Surprises Act of 2022. No one I spoke to knew anything about it. One agent just mentioned it in passing. Read links to the act and was able to pick out a better plan for less money.

 

[quincy]

For further information, below are links to CMS and DOL on the No Surprises Act:

https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act

https://www.cms.gov/nosurprises