Kay (not the front pager) asked a good question about out of area/out of network benefits:
What happens if you have an HMO or EPO and are injured/become ill while traveling? I have gone with the more expensive PPO for my employee coverage because my son lives in another state and we visit fairly often. I worry that something will happen while we are out-of-area and it will be as if we have no coverage. I really should contact the various insurers offered by my employer, but since you are here… How do HMOs and EPOs handle travelers?
There are two answers to this question. The first is the member/patient experience, and the second is the mechanics of the experience.
HMO/Point of Service/EPO won’t pay for routine out of network care. [Point of Service is very HMO-like without as much medical management built into it] For example,if you’re a diabetic, and there is an awesome endocrinologist that is out of network who you want to see for general management and care, you are SOL or at least cash out of pocket. In a PPO, the same out of network endocrinologist may see you and you’ll still be significantly cash out of pocket, but your insurance company will pay some of the listed fee.
Emergency care is different.
Primary medical insurance policies are required to pay for emergency medical care anywhere in the United States. It does not matter where an emergency room visit occurs. If you live in West Virginia and get in a cat accident in Missouri, you’ll get your emergency medical care covered.
Insurance companies will pay for the emergency care until you are either discharged from the emergency room or you are stable and safe enough to transfer to an in-network facility. For instance if you have a compound fracture of your right tibia, once you get the leg reset, a cast and crutches, you’re considered stabilized although you still need surgery. That surgery needs to occur back in your home region for it to be covered. If you have an aneurysm, the HMO/POS and EPO policies will cover the initial emergency treatment, any needed surgeries, and recovery time until you’re stable enough to get sent home. What constitutes “stable enough” to an insurance company compared to a patient or the patient’s spouse can often be a source of a nasty fight. Some companies will pay quickly, others will drag things out and make you fight for reimbursement.
Now how does this happen?
If you are insured through either a major national carrier (Wellspan, Aetna etc) or through a Blue, most likely there is an in network provider and hospital within a short distance. The big national carriers will have big national networks. That is their comparative advantage over other insurers, a seamless experience throughout the country. The local Blue will have a locally built and maintained network but there are cooperation and network sharing agreements among all of the Blues so if a Blue Cross of New Hampshire member travels to Michigan for a week, they can get in-network rates.
Smaller, regional carriers like Group Health in Washington or Harvard Pilgrim in Massachusetts or any of the other non-Blue, non-national plans use two techniques to insure national emergency coverage. There are several “repricer” and “rental network” companies that assemble regional or national networks of providers. A local insurance company will contract for access to portions of the rental regional or national network. For instance, Harvard Pilgrim in Massachusetts may contract with a rental network for access to hospitals west of the Hudson River and south of Hartford as anything north of Hartford and east of the Hudson can be covered by in-network hospitals. Group Health in Washington state may have an agreement to share a network with a California insurance company to share their California network and a seperate agreement for hospitals east of the Mississippi. So if a member goes to an out of area and out of network emergency room, the claim is submitted through a previously agreed upon pricing structure. From a claim perspective, it is quasi-in-network although the insurance comapny covering the member will almost always pay a higher than normal rate.
The second strategy for regional carriers comes into play when a member goes to a hospital that is not in any of the rental or repricer networks. At that point, the insurance company directly negoatiates on a one time basis an out of network fee with that hospital. If there are several claims in a reasonable short time frame, the negoatiation may lead to establishing an out of network contracted rate. For instance that rate going forward could be 75% of Usual and Customary or 47% of Chargemaster, or 250% of Medicare. That type of agreement reduces billable hours for the hospital and insurance company’s legal departments.
The Blues and the big national carriers also use these two strategies to provide out of area and out of network emergency coverage, but they tend to use them less often as their networks are bigger so the odds of a member going to an out of network hospital for emergency care are lower.
raven
Thanks for this!
ericblair
Deliberate? Freudian Slip? Who knows?
the antibob
The new exchange policies from Anthem Blue Cross in NH (only insurer on the exchange) have restricted the network to in state providers. Also, cut down the size of the in-state network by at least 60%. Nice for Anthem, having a monopoly. I spend a good deal of time out of state, and I’m having to set up an LLC with a friend, just to get access to the larger Anthem network.
maximiliano furtive, formerly known as dr. bloor
@the antibob: Apparently they don’t want to pay for Boston-based services anymore. Live free or die, etc., etc.
nhoj
As the son of ghc staff and lifetime member (er uh “consumer”), I will note ghc consumers are covered all over the country by Kaiser:
https://www1.ghc.org/html/public/health-plans/provider-networks
edit for grammar and link
Kay (not the front-pager)
Thanks, RM! I’m going to do a lot better job of researching our insurance options before this year’s open season. This information makes me much more comfortable about choosing one of the less expensive options.
Olivia
@ericblair:
I have had several cat accidents.
I spent several hours in the emergency room after one particularly nasty experience. I was reaching to grab a cat and lost my balance and fell down a flight of steps.
Richard Mayhew
@ericblair: Deliberate :)
Richard Mayhew
@the antibob: Anthem Exchange for New Hampshire will pay emegency room care if you get hit by a bus in Copley Square. They won’t pay for the follow-up surgery to fix your leg at Mass General. That surgery has to happen in Nashua or Manchester etc.
Redshift
Can you tell me anything about Medicaid portability across state lines? I have a friend on Medicaid who lives near the state line in WV, and since it’s WV, most of the facilities closest to her are in Maryland or Virginia. Is she out of luck, or does Medicaid deal with out-of-state providers?
Seems like there would be a lot of people in that situation in the Mid-Atlantic/Northeast.
Violet
@Richard Mayhew: Just guessing, but they also wouldn’t pay for someone to visit that top notch Endocrinologist or Dermatologist or Psychiatrist in Boston either, right?
PurpleGirl
@Richard Mayhew: With the number of cat (and dog) people who either write for this blog or read and comment here, that was a good move and must have made a lot of people smile. (I know I did.)
Lee
> and get in a cat accident in Missouri
You probably should not make fun of John like that :)
Keith
It has always struck me as significant contrast that the GOP stomps their feet in favor of selling health insurance across state lines – yet nary a whisper from them about making sure care is available throughout the entire land at a uniform rate. The same as you would pay at home.
Which is odd, when you consider just how mobile our society is.
beth
Thanks as always for the good information. With a kid who is going off to college soon I wondered about health insurance. She can stay on my husband’s work policy until 26 now but I wondered about her having coverage at school. I guess she could do regular yearly healthcare visits here at home but for other things what I’m taking from your article is that we should see if the insurer has a network of doctors/hospitals where she winds up going to school? Do colleges still offer medical insurance plans for their students?
the antibob
@Richard Mayhew: Yes, I understand that.
I was referring to your paragraph stating that “big national carriers will have big national networks”. Yes they do, but they can also limit individual access to restricted local sub-networks, depending on the policy. And yes, this comes into play after the emergency room visit and stabilization.
RaflW
My old insurer canceled my old plan (and boy, was I mad at Obama. OK, not really at all). I changed policies and insurers under ACA Jan. 1 (not on exchange, but thanks to the lovely guaranteed issue).
Old Ins Co. offered a replacement plan, but the out-of-network coverage was crap and the network when traveling was crap. I snowboard every winter in several western states.
Going with the Blues means that if I’m unlucky or stupid and end up with a compound fracture, I can probably avoid the “ready for discharge and travel” fight since there will be an in-network provider pretty much wherever I ride.
It was a tweet by a MN journalist that got me to look at networks for companies like Health Partners of Minnesota when I was shopping. OK, they’d cover emergency care away from home but that’s it. I’m sometimes also gone for 2+ weeks at a time. I don’t rush to the Dr. when I have a cold, but non-emergency things do happen!
Richard Mayhew
@beth: Speak with your broker or HR rep first. If your daughter has any possible need for regular care while at college (ob/gyn for instance), out of network/out of area coverage comes into play. And if you are on an EPO/HMO/POS, that won’t be routinely covered. Emergency care is covered, usual care is not. So speak with someone knowledgable about your actual policy with your probable needs in mind.
Richard Mayhew
@Violet: Highly unlikely. Consult with the network, and if there is a documented medical need that can only be addressed at Mass General, there is a decent chance it will be paid as if it is in-network as a one-off exception.
scuffletuffle
@ericblair: Surely that would have been in West Virginia!
Richard Mayhew
@Redshift: It depends. I know my state has multiple Medicaid Managed Care Organizations (my company included) that have providers over the state line because there are decent size cities just over state lines that act as mini-medical hubs, while the in-state areas near the state lines are the definition of in the middle of nowhere with no docs. So sending people 8 miles over the state line instead of 35 miles to the closest in-state hospital is a no-brainer.
RaflW
@the antibob: Oh, this too. I looked at an on-exchange plan from the MN Blue and it had a much smaller network. I went to the MN Blue’s web site and bought the most expensive plan to have basically an open-access network.
Now, most expensive was still about $100/mo less than my old non-Blue plan. That had been a pretty good individual plan with a local co. But it had ratcheted up to over $400/mo after about 13 years on that plan. I’ll note that the replacement plan I didn’t accept from Local Co. was also cheaper – about $80/mo less, but with higher deductibles/out of pocket limits than the Blue.
As has been said a number of times by Richard, we’ll see how the renewals go – I’m braced for prices rising once the ACA hubub settles down, and our Blue figures out the actual risk pool that enroled.
David in NY
I remember a decade ago having to figure out whether my kid in college in Boston would be covered by my plan at work in New York. Turned out, yes (Oxford in NY had become part of United health, all over). Handy when one day he started vomiting blood all over a classroom building (rupture of esophagus-stomach joint) and had to be rushed to hospital. But immediate emergency treatment and hospitalization until it was clear bleeding had stopped might well have been covered anyway, maybe.
Except for the ambulance. I got a bill for $1500 for a five-block trip to the hospital, insurance saying they weren’t paying. I called insurance, said, “Who are you kidding, he was bleeding to death, you work the price out.” Woman on phone said, “Let me talk to my supervisor,” and three minutes later, “Nevermind.” Everything may not be negotiable, but lots of stuff is.
@beth: Think this all worked for me because United Heath was a national carrier
Villago Delenda Est
@Richard Mayhew: And well done!
Villago Delenda Est
@scuffletuffle: Someone was invited to Joplin as a guest cat ass shaver, and, well, the thing you’d expect to happen happened.
David in NY
@beth: I believe my son’s college had an insurance plan as well, which I could have paid for but waived. Was moderately expensive (on top of outrageous educational costs). They made clear it was important to have coverage in their area (if kid breaks bone, s/he can still go to classes if getting follow-up care at school, but not is s/he’s got to go home) and made us swear we had local insurance before we could waive the charge for theirs.
raven
@Villago Delenda Est: is that a Nugent song?
Mnemosyne
@beth:
It also depends on how big the school is. A lot of schools will have clinics for routine care, so when I was an undergrad, I was able to get my pap smear, blood test, antibiotics, etc. at the school’s clinic. But that was 20 years ago, so I’m not sure how it works these days. A school with an enrollment of at least 10K will probably have some kind of on-campus clinic.
PhoenixRising
@Violet: No. Contrary to the expert’s advice, I’m gonna go out on the limb of actual field work in this area. They aren’t paying in-network fees, neither are you.
Ask if your preferred provider is on a contracted rate with your network, though.
/paid for rare cancer OOP to 20K out of network limit because there is no provider in network or in the region who will take the risks of treating eyeball malignancies once they are on the move. Do you know how many nerves are in the side of your face next to your lymph nodes? All of em. Malpractice policies frown on surgeons cutting outside their training, so they don’t.
Villago Delenda Est
@raven: The meter is right. Could be!
scuffletuffle
@Villago Delenda Est: Cat Ass Fever!
Violet
@Richard Mayhew: But if there’s a special doctor that you want to see–say you’ve exhausted your doctor options near you and this doctor is known for treating whatever your issue is–you’ll be paying out-of-network prices at least, right?
@David in NY:
Going forward is this going to be an advantage for larger insurance providers? That they can tap into a national network? Is it going to put pressure on smaller providers to show they have a relationship with other providers across state lines so when you go on that trip to New York City or San Francisco or to visit grandma in Omaha or whatever you’ll be covered if needed.
Villago Delenda Est
@scuffletuffle: Seeing as cat ass fever often directly leads to cat scratch fever, I think we’re on to something here.
Villago Delenda Est
@Violet: Just another signpost on the way to a universal network. You know, like every other industrialized country.
Violet
@Villago Delenda Est: I hope so, but our situation is different due to having states. It’s somewhat comparable to the EU, and all those countries have different systems, although they’re reciprocal, from what I understand.
wvng
Richard, a question. We live in WV, my daughter is in graduate school in California. When we got insurance through the WV exchange, we wanted to keep her on our policy (she is 25) but they said she needed to go on Medicaid because of her age and limited income. WV Medicaid said she should get California Medicaid. CA Medicaid is dragging its heals putting her on. And she will be done with school in a few months going we are not sure where next. We really want her to be insured, but don’t know how best to proceed. Any suggestions?
Richard Mayhew
@wvng: Unfortunately, I don’t know enough about the intricacies of Medicaid eligibility in those states to offer a good set of advice. Apply for both, get rejected, appeal. Remember, if something goes down between now and graduation day, she can be retroactively added if need be. Talk with a navigator or a broker as well about consequences of adding her to your Exchange plan as it could impact financial aid and tax situation.
JoyfulA
My parents, ages 89 and 92, along with my retired sisters, spent January and February in Florida this year.* They saw their regular providers before they left Pennsylvania, and they had no physical problems out of state.
Should I worry that when they take this trip in 2015 there might be out-of-state insurance problems? She’s a state retiree, and he’s a federal retiree; the last I checked, they’re cross-insured; his plan has better this, and her plan has better that. The federal retiree health insurance seems to stay pretty much the same, but the state plan gyrates. (One year she had Geisinger, which was a big failure for her location.)
*Yes, they did just happen to pick the coldest, snowiest winter ever to spend at Cocoa Beach for the first time. Not a flake of snow since they’re home.
Anna in PDX
@Richard Mayhew: Very, very clever, well done! I love these insurance posts, always learn a lot and they are even more fun to read with gentle, Cole-mocking humor.
Mnemosyne
@wvng:
She probably needs to be an official California resident before they’ll accept her on Medi-Cal — here’s some information from the state on how to do that. If she doesn’t think she’s going to stay in California after she graduates, I’m not sure it’s worth going through the process to get a few months of coverage. Can you get her a short-term catastrophic policy?
Richard Mayhew
@JoyfulA: Medicare has not been significantly altered by PPACA, so what has been working for them should still be working for them going forward.
There are numerous Medicare Advantage policies out there for snowbirds. Regular Medicare (Part A and B) work nationwide as well.
JaneE
There are no cat accidents. You only think it wasn’t deliberate.
Bill Arnold
@JaneE:
Mmm. Sufficiently advanced malice is indistinguishable from bad luck.
stinger
@Villago Delenda Est: Have Cat Ass Razor, Will Travel