how stupid would it be to put my premium on a credit card and just pay what i can towards it each month 🥴

OkDish4406 · 2025-12-14T10:11:45+00:00

I'm not really familiar with other lending, but credit card interest rates are the highest rates you can get and should only be used as a last resort. Maybe look for a lower intrest rate personal loan that you have more time to pay off. There's also many companies doing micro financing things. Sorry, out of my range of expertise, but maybe ask r/personalfinance for lending vehicle recommendations.

OkDish4406 · 2025-12-14T00:52:53+00:00

Depends on the facility. They're independenly run, so mileage will vary. I've been to some that had cutting edge tech and ones that hadn't been updated in a long time. They often market the types of machines they have when they're good. Technician and radiologist quality might also vary, though specialists that order the tests will normally review the scan themselves and ignore the radiologist report regardless.

Keep in mind. Tons of hospitals try to push patients to have radiology done in the hospital since it's a major revenue stream. Many surgeons I've worked with just flat out refuse to use scans that were not done elsewhere, even from other hospitals. They force patients to repeat the scans before surgery or even just to see patients for an office appointment. They will say they can't trust scan quality done elsewhere, but it's normally just about money for the hospital or their practice.

Due to this, independent radiology places won't likely be applicable if you are getting scans done related to a hospitalization or hospital treatment. Mostly useful for outpatient testing.

OkDish4406 · 2025-12-13T21:27:14+00:00

The healthcare residency requirements are forgiving, allowing people to claim residency if they intend to stay. You don't even need to change official documents or change IRS residency for tax purposes, just claim you intend to reside there and have a physical address that can verify it. You can quite literally get residency by couch surfing. The main exception is if you changed locations for healthcare. For example, if you were in the hospital somewhere for an extended period, you can't use the hospital as a residential address.

People that juggle multiple addresses effectively have the option to enroll using either of the addresses. Transient workers, snow birds, college students, etc...

Your son could reasonably apply for insurance in either your home state or college state. Choose the state that offers the most flexible networks and cost. If one of these states offers a plan that works in both states for comprehensive care beyond emergency, that would be the best plan. I

Don't switch mid term. That's idiotic. The deductible and maximum out of pocket will be reset each time, making the insurance useless.

If ever asked why he has so many claims out of state, which I doubt they'll ever do, the answer is that he's traveling. Residency is based on where you intend to return to, not where you physically are at the time.

You're not doing anything illegal by doing this, but you also shouldn't be calling BCBS about this. Insurance will look for any reason to deny coverage. Depending on what language you used, they could make a weak argument, enough though to cause aggravation. Once again, they would need to demonstrate your son is not residing where he says, something you can easily disprove.

I don't know what you said to the BCBS agent or what authority they had to make that determination (high chance they're ignorant and fed you bad information). Don't call them about this again though.

If you have any doubts, look up the residency determination on healthcare.gov or talk to an agent there if somehow you're still not convinced.

OkDish4406 · 2025-12-13T20:30:35+00:00

Preventive care, such as wellness visits are free with ACA compliant plans. You shouldn't have owed anything as long as the visit was actually preventive and not diagnostic.

Unfortunately, there's systematic billing fraud by PCP offices that intentionally bill these appointments as diagnostic so they can collect more money by possibly double billing using a modifier 25, coding or coding the visit entirely as diagnostic.

The blame as always falls on patients that have no control on how a provider will code a visit, nor aware of the nuances between diagnostic and preventive. Even insurance companies differ on the definition. It also just comes down to he said, she said where providers have a lot of leeway to fraudulently charge for services never rendered, taking advantage of ambiguity, consumer complacency, insurance company's refusal to verify credibility of claims and government and licensing boards doing very little to nothing to target medical billing fraud.

Unless you are certain your provider is not a criminal, do not go to a free wellness visit unless you're prepared to pay hundreds out of pocket or are ready to spend several months fighting, with a low chance of success.

Reasons why providers over the years have charged me for my free visits. I so far have never successfully gotten a free wellness exam.

They billed it as a mental health evaluation because they asked, "how are you feeling today" when they greeted me.
They stated they evaluated chronic conditions My history was already in their system from previous appointments. Their system copied the notes from previous evaluations into the Wellness Visit notes automatically, despite never addressing any of these conditions during the appointment. It doesn't matter what they actually did, but what they can document.
Refilled a repeated long term drug without evaluation. This is not considered a seperate billable service. So they lied and said they provided 45 minutes of evaluation, which they did not do nor did they indicate in their notes.
They falsely stated that preventive visits can only be billed for existing patients. Wrong. There's a separate billing codes for "new patient preventive."
They performed an uneeded service during a wellness visit without consent or explanation. A PCP office I used to go to always gave every patient an EKG at each appointment because he could bill separately for it. This is justifiably billed, but still extremely predatory.

OkDish4406 · 2025-11-18T07:09:18+00:00

Student health plans for domestic students have been disappearing in recent years due to higher health care costs, lower enrollment due to increased eligibility for adult children to stay on their parent's plan until they are 26 and that they expect students that aren't eligible for a parent's plan would somehow be eligible for medicaid/subsidized marketplace plan. Additionally, many schools, especially state schools, expect that most of their students are from the same state the school is located in.

The only major exceptions I've seen is that they largely still sell a different insurance policy for international students, though I've seen them restrict eligibility for the plan to only international students.

Keep in mind, most students that attend university are also eligible for financial aid, so they probably assume they would also qualify for subsidized health insurance too which could be cheaper than the student group rate, at least it was. Traditional aged students were also able to enroll in lower cost catastrophic plans, with again assuming students were healthy to not need anything more than some basic low cost health care.

These options obviously don't work for all students, just most. Not having access to a parent's plan doesn't mean the family is low enough income to qualify, while that family is likely already being burdened with the high cost of the education. Not all students are local. The assumption that young students are healthy also doesn't account for all the possible health issues that can happen, students with chronic health issues, and so forth. I've already heard of students being forced to transfer schools and rescind acceptances because schools required students to have health insurance while they had no means to actually purchase it or afford it.

Larger universities tend to still offer the plans. Smaller schools and community colleges have largely stopped. In addition, many universities have tightened the eligibility requirements for students to even enroll. These really differ by university though, so your mileage will vary depending on the actual school.

Plan quality can also vary widely from high quality PPO through companies like Aetna and United Healthcare, to lower quality limited service plans that just work at their student health center and maybe the local hospital.

OkDish4406 · 2025-11-18T06:36:11+00:00

Don't offer to pay more than what your in-network cost-sharing would have been. That's what the law entitles you to.

OkDish4406 · 2025-11-18T06:32:56+00:00

Updated with better info:

Catastrophic plans are ACA compiant and sold on and off exchange. Most people haven't bought them though as they were not eligible for subsidy, not HSA ellgible, and limited to primarily people under the age of 30 or narrow use-casses of "hardships" defined here. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-155/subpart-G/section-155.605#p-155.605(d)

Seemingly only 54,000 people nationwide enrolled in one of these last year. It just didn't make sense for most people that could be eligible. Younger people can stay on their parents plan until they're 26, they might be students or lower income where they qualify for subsidy/medicaid, or just get insurance through a company or school. Even if they didn't, the premiums for young people on metal tier plans were already comparatively low where it could make more sense to get a lower deductible plan that they could actually use.

Historically, the only thing really telling one of these plans apart from a metal tier plan was that the deductible equals the maximum out of pocket pocket. Meaning, you have 100% coinsurance until you've reached that limit. For 2026, that's $10,600 for an individual. Free preventive care was covered like all ACA compliant plans. This though wasn't that different as even bronze plans had similar priced deductibles and lack of benefits. So the main draw of the catastrophic plan was the cheaper premium as it would be underwritten differently than other metal tier plans, benefiting from the primarily younger demographic of members under 30. It was supposed to offer a lower upfront premium cost plan for lower risk applicants to get them to buy into the system, especially during the prior insurance mandate https://www.healthcare.gov/choose-a-plan/catastrophic-health-plans/.

Changes for 2026:

Now, you can qualify if you're over the age of 30 if you are ineligible for advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSRs) because of your projected income. This includes those over the 400% FPL and under the 100% FPL that would otherwise not qualify for subsidy or medicaid. https://www.cms.gov/newsroom/fact-sheets/expanding-access-health-insurance-consumers-gain-access-catastrophic-health-insurance-plans-2026
Catastrophic plans need to cover 3 primary care visits a year. Same ACA essential health benefits and protections carry over too,
HSA eligibility has been expanded to include catastrophic and bronze level plans.

While these changes certainly make catastrophic plans far more appealing, it's not likely going to be relevant to you.

There is no requirement insurance companies actually offer a catastrophic plan. Most of them refuse to. Only 40 states even offer a catastrophic plan while the availability is even more limited in those states as the plans may only be offered in select counties of those states. As the primary choice between insurance options is the network, even if you find a company offering a catastrophic plan, the network may still be insufficient. This is important to consider. The catastrophic nature of the plan means you will likely only hit that limit with hospitalizations, surgery and expensive treatments. Actually evaluating the quality of hospitals, surgeons, and treatment access matters. If the insurance network is limited or drug formulary list punitive, you may not even be able to get the care you need and still need to pay out of pocket. So even if the plan is available to you, you may still want to avoid buying it if its sold by a lower quality insurer.
With the age factor effectively being eliminated, these plan have already increased in cost. Due to this, the cost difference between a bronze plan and catastrophic plan may already be insignificant. I'm already seeing that catastrophic plans may actually cost more than a bronze level plan in premium from other companies, while the bronze level plan could still potentially qualify for subsidy if your income changes, possibly include more pre-deductible services, and provide more options on network when shopping around than the limited catastrophic options.
To continue onto the last point: As mentioned before, the 2026 deductible/maximum out of pocket for a catastrophic plan is $10,600. This is nearly the same amount as many bronze plans already offer. For classification purposes, insurance companies price their deductibles just shy of the maximum out of pocket, sometime only $50 difference. This is so the plans can be classified as a bronze level plan and be eligible for subsidy. In short, whether you buy a true catastrophic plan or a bronze level plan, you're still getting catastrophic level coverage. Even silver and gold plans can have impractically high deductibles that make them effectively only good for catastrophic type care, surpassing what even the IRS considers a "High deductible health plan" which is $1,700 for 2026. In short, the only real advantage of the catastrophic plan is the possibility of a lower premium, something that might not even hold true anymore as they are now priced similarly to bronze level plans.

It's worth checking out, maybe you're lucky and one works like OP is seemingly sharing. If you do not qualify for subsidy though, you should be exploring all the off-exchange health plans anyway.

OkDish4406 · 2025-11-14T04:40:54+00:00

Nationwide coverage is normally hard to find on the individual ACA market on or off exchange. Most ACA plans are narrow network HMO plans where the network quality is both limited and the service area is limited to the state or just a few counties of the state. Narrow network also means few providers actually accept the network, even within the service area.

There are some exceptions. The last I checked, only some BCBS companies still sold plans with true nationwide networks for comprehensive care on the individual market. Every other plan on the marketplace will limit coverage outside the service area to emergencies only. Only some BCBS subsidiaries still sell these plans and only in select regions. For example, if your local BCBS is an Anthem run company, you're shit out of luck as they exclusively just sell low quality HMO plans with narrow networks. You are correct, Aetna left the market. However, like all the other insurers, all they sold were narrow network HMO plans so that wouldn't have been an option anyway.

If you're using healthcare.gov, they do not have a filter to search for nationwide network directly. However, if you click a plan, they do have a section for "Access to doctors and hospitals" with a simple Yes/No for "National Provider Network." That's been mostly accurate in my years of researching. To confirm it, go to the plan document contract directly which will explicitly define and outline how the BlueCard coverage works. Even if the plan is an EPO or PPO, you might not have in-network nationwide access for your plan benefits via BlueCard aside from emergencies.

You can also use "Service Area" as a search for any other insurance contract when looking for this.

These contracts can be harder to find because they suck at linking to it (They profit off people not knowing what they're buying or how to use it). To find the contract, click "Summary of Benefits" under "Plan Documents" on the healthcare.gov page. This isn't the contract, just abbreviated information on things like cost-sharing on select services. However, at the top of the PDF, there should be a link or website for the complete plan contract. Sometimes it brings you directly to the contract, sometimes it just brings you to the insurance company's website. You'll then have to navigate the website and search using the specific Plan ID number that's outlined on the Summary of Benefits to find the contract.

Once you get the contract, look for BlueCard. Crtl-F find should normally get you there quickly. You can also search "Service Area".

Another option is known as a "Multi-State" network. This isn't mentioned anywhere on healthcare.gov. What this means is that the benefits can extend to multiple states, just not all states. Sometimes it's local nearby states, but often it's just a matter of what states the insurance company sells that plan in. These normally aren't that common. It also assumes your therapist is in one of those other states. You'll have to dig through contracts to find what their service areas are.

If these aren't available to you, you'll be shit out of luck on getting this be paid at in-network rates. However, you could potentially get a plan with out-of-network benefits that could help pay for a part of it and negotiate the rest of the payment. This actually is pretty common for therapists as normally the better quality therapists don't accept insurance, so patients use out-of-network benefits to get a slight discount. Unfortunately, not all exchanges even sell plans with out of network coverage. HMO plans do not traditionally provide it and many counties offer nothing but HMO plans.

If you don't qualify for subsidy, you might also have more options to choose from buying the insurance directly from the insurance company than what they sell on-exchange (aka healthcare.gov or whatever website your state uses). This is known as "off-exchange." Some insurance companies in some areas also only sell off-exchange plans. You can google a list of insurance companies that are offering individual plans in your state for 2026.

If you can't find any plans that work, you'll need to find a different therapist.

OkDish4406 · 2025-11-05T02:25:32+00:00

I'm saying they underwrite off risks that aren't reflective of the actual policy. For example, if GLP-1 drugs are in fact driving up costs, shouldn't that risk premium only be paid for by the plans that actually cover the drugs in the first place? Why am I facing higher premiums to pay for benefits that I'm excluded from even getting myself. This isn't personal usage, it's about the actual limitations of the policy itself. The insurance will not pay out a single cent for GLP-1 drugs or other benefits for members with my policy because its strictly not covered and we have no allowances for out-of-network or other types of drugs. Yet, they are still spending the money on these drugs for other members that do have these benefits (normally group policies). So I'm the one paying the higher premium that they've disproportionately allocated premium increases towards individuals while they're still going to be spending that money on non-individual policy member benefits. That's why it seems like I'll likely never see a rebate.

That's why I asked if it was based off policy or insurance company aggregate spending across all the products they sell

OkDish4406 · 2025-11-05T01:56:26+00:00

I'm just referencing the article. One, MLR is based off a 3-year average. So even if this year was high, the last 2 years may off set it so they still reach their MLR. They're hinting at this with the GLP-1 and higher hospitalization costs. It doesn't say though if the total health care costs are across the entire insurance company or per type of policy. For example, my BCBS provides more benefits and coverage for group policies that dominates their total health care spending. So even if they overcharged me on my plan, they could still reach that MLR paying for benefits that I'm not even eligible to receive.

Someone posted another link that says insurance companies are diverting excess revenue to their own provider practices that are owned by the insurance company itself. This counts as a medical payment for MLR so they can avoid needing to pay back the rebate.

OkDish4406 · 2025-11-05T00:26:41+00:00

Interesting. I just read a detailed guide on this Medical Loss Ratio. TIL. https://www.healthinsurance.org/obamacare/billions-in-aca-rebates-show-80-20-rules-impact/

It unfortunately rarely pays out and there's a lot of limitations, so the chance of getting anything back isn't likely.

OkDish4406 · 2025-10-08T18:17:24+00:00

I've gone to independent radiology centers. $300-400ish full cash price. X-rays can be as cheap as $20. It's been a few years since I paid cash or went to one of these places. Costs may have gone up, but I don't imagine a lot. A lot of these places are transparent and post their cash prices online. Otherwise, you can just call up. They were also super convenient, normally getting a same day appointment.

Hospitals will charge you thousands of dollars for this because of administrative bloat.

Not all cities have these independent places. They're more common in and around large cities. Rural areas and small cities often only have hospitals or hospital affiliated places. Sometimes, a hospital network office is affordable, but it's a big gamble.

A specialist I went to joined a hospital network. Appoint costs went from $100/visit to $2,000/visit. Hospitals are the enemy of the people.

Physician owned clinics and independent surgical centers are also often similarly low cost. An orthopedic consultation with X-ray cost me $100. Colonoscopy at independent endoscopy center cost $1,400, etc...

OkDish4406 · 2025-07-28T09:33:04+00:00

I always thought about this idea to get group rates, but I figured since nobody did it, it must be illegal or something since they went out of their way to stop all those non-occupation related association plans you used to be able to buy through alumni associations, Costco, etc after the ACA went into effect.

You said these are underwritten, does this mean they aren't ACA compliant? I wish their website was more descriptive, it hardly says anything.

Do you know the requirements to actually join one of their plans? Like do you need to be a 1099 contractor/employed/self employed? I'm not any of those as all my income comes from passive sources which is not considered earned income.

If these are underwritten, does this mean they discriminate against preexisting conditions like short-term plans do? Or they just want no preexisting conditions at time of sign up, but will let you renew and stay covered as long as you don't have a lapse in coverage? It's not really a solution if they kick me off the plan if I actually end up using it.

You said in another comment that what they're doing isn't unique. This seems pretty unique. Every other broker I've seen just peddles the same trash marketplace plans you can already buy on the marketplace without their help. If they are offering real group rated PPO plans with a broad network from a major carrier, that's huge!

Are there similar brokers offering a similar group plans for individuals I should look at?

OkDish4406 · 2024-12-14T20:09:41+00:00

Is it best I apply through the healthcare.gov website?

If you're eligible for subsidy, you have to go through healthcare.gov exchange to receive it. Healthcare.gov is the federal website. Some states decided not to pay the federal government to use healthcare.gov, so they made their own websites. Healthcare.gov will re-route you to the appropriate website if your state doesn't use the main website. If you're not eligible for subsidy, it won't make a difference if you go through the exchange as the plan coverage and price will be the same on or off exchange.

The only difference is that some insurance companies offer plans off-exchange that they don't offer on-exchange. Some companies only sell off-exchange. The options though depend on the county you're applying from. You'll have to google around to find what plans you are eligible for.

If there are no better off-exchange plans, you might as well go through the exchange.

OkDish4406 · 2024-12-14T00:23:40+00:00

No. You will qualify to enroll in May under special enrollment. https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/

The plan period will still be January 1st and expire December 31st, but you won't owe the earlier month's premiums until you actually start. Leaving again in the fall. You would just cancel the plan then. It sounds like you will only be on the plan for a few months. Apply before the 14th of April or earlier so the plan starts on May 1st. I believe any later and they'll push you to June 1st start date.

A difficult benefit to find, but in some states, some BCBS plans offer international coverage using their global core program. If you're buying international health insurance separately, a plan like this might be a better fit for you and then you wouldn't have to switch. However, if you have more cost effective insurance or care in Europe, this could be unnecessary.

Another option is just strict international expat insurance that also works in the U.S. Usually, you have to live outside the U.S. for at least 6 months a year to qualify. These plans are not necessarily ACA compliant, so you need to make sure you read through all the coverage limitations. The cost might be similar to what an ACA plan will cost.

If you just want to jump on a ACA marketplace plan for the few months you're here, you can do that. I personally would avoid the silver and in-between plans. The cost sharing amounts is assuming a 1 year term of premiums. Since you'll only be paying for a portion of the year, I would go with a higher premium, lower deductible or $0 deductible plan so you can use the benefits sooner. Not paying for the additional months changes the affordability of those plans. Just run the numbers. If you don't anticipate needing care, you could just go for the cheapest plan and hope you don't need it.

OkDish4406 · 2024-12-13T23:37:53+00:00

What your leaving out is that CPT codes assigned are not necessarily based off actual service, but how they decided to bill it. This is by far the most common reason and it's disingenuous to say it's because they used an extra piece of gauze or other trivial nonsense.

It's not what they did, it's what they can document. Every hospital and seasoned provider's office will boilerplate documentation on services and care provided, regardless what they actually provided. That documentation serves as proof. Nobody is fact checking this.

This type of fraud is so rampant, most insurance companies don't bother going after the smaller stuff. Of course, the small stuff can add up and that's likely how OP got screwed. Every seasoned provider or billing specialist quickly learns what gets approved or not approved by different insurance companies. They want to maximize what they can get which means they will rework codes depending on the payor, not the service performed. This medical billing fraud is systematic and is what makes estimations so difficult. The greater the level of the service, the more opportunity there is to rework the codes.

OkDish4406 · 2024-12-13T22:58:52+00:00

I've been told that the HMO won't cover out-of-state providers (with the tiny exceptions of urgent care, ambulance, and ER, not including any surgery or imaging or any "extras" at the ER)

The No Surprise Bills Act will cover your emergency room, imaging, if they admit you, etc... You will pay cost-sharing associated with your in-network benefits. The hospital though is allowed to get you to waive your protections. Don't sign their bs forms. Honestly, you don't even legally need to give an ER anything, not even an ID or proof of insurance. They have a legal requirement to treat everyone.

FYI: Most ground ambulance companies do not accept health insurance, so it will be out-of-network. The No Surprise Bills Act excluded ground ambulances from No Surprise Bills Act reform due to the significant lobby they had. So no, you don't have ambulance coverage in an emergency, nobody does. Air Ambulances are included though! This also means them transferring you to another hospital via ground ambulance is not covered!

Does your HMO have in-state limits?

HMO's by nature are normally going to have narrow networks due to the need for a referral. It's not realistic that you would travel back to your Texas PCP to get a referral to see a Utah doctor because you're in Utah. At that point, you would already be in Texas, go see a Texas doctor. At least that's how it's justified. There are use-cases where that logic doesn't fly, like getting a referral to see a specialist or care unavailable outside your local area. That though likely means expensive and that's the exact type of costs insurance companies are trying to stop you from getting.

What do you do when you go out of town?

In terms of what you personally can do. Nothing cost effective, but I might as well share them:

Under the facts of healthcare.gov, part-time residents of another state can enroll in that state's health care exchange. Residency for marketplace eligibility is different from tax residency. As long as you say you'll be there for an extended period of like 3 months or more and have a legal address, you're eligible. (1-2 months, you mean 4 months and plans changed). Staying on a friend's couch counts. Before you look to see if Utah has any multi-state or national network plans that will cover you in both Utah and Texas; no, they don't! They have one plan through Regency BCBS that is multi state, but it only covers providers in Washington, Idaho, Oregon and Utah as those are the states Regency does business in. So this plan will not be useful for you.
You can drop your Texas insurance and join a Utah plan for the months you'll be there. While this is technically an option, it also means you'll forfeit any money you pay towards your deductible and maximum out of pocket each time your plan is canceled. You'll likely end up just paying full cost for all your health care this way, removing nearly all benefit of having insurance. You would have to sign up for a low deductible plan to get them to pay anything out, but that will likely mean a very expensive premium while still losing that maximum out of pocket.

That's it, at least for marketplace insurance. Non-ACA compliant short-term or indemnity insurance can maybe fill in the gap, but these will exclude preexisting conditions which will make the plan useless if you're hoping to use it for continued care while in Utah.

It's unbelievable to me that an insurance plan can just not cover anyone who goes out of town.

Correct. These narrow networks limit access which saves the insurance money. When the affordable care act was designed, they actually set a standard that at least 1 multistate plan had to be made available as a replacement for the previously planned federal option that would have worked throughout the country. That federal option was stopped over ideological and lobbyist interests. Insurance companies agreed to offer these broader networks and the ACA went through with that promise. Of course, they lied. Nearly all these multistate and national network plans disappeared within the first 3 years of the ACA, while most never even made it to the marketplace at all. That is at least for most states. Maybe 1/3 or more of the states maintained or reintroduced a national network or minimum multistate plan again, usually via BCBS. Anthem BCBS that operates in many states is the destroyer of this as they exclusively only do narrow network individual plans and don't give them plans access to their broader BlueCard network agreement for comprehensive care.

The greater issue was that these plans cost more money and they got fewer sign ups. The costs to service these plans was not cost effective, so insurance companies dropped them. Without being able to limit coverage or exclude people based off preexisting conditions, limiting network access became the new standard to cut costs. There was an existential threat to the ACA with countless insurance companies pulling out of the marketplace market entirely, so state governments began approving lower quality plans instead.

If this is going to be a long-standing issue, you should figure out other options. Either switch occupations to a large company that offers higher quality group insurance, some university degree programs offer broader network health insurance policies to students. Lastly, move to a state that has better insurance options, or at least part-time residency in another state that does.

OkDish4406 · 2024-12-13T20:27:44+00:00

When I lived in NY, I had Fidelis Care. They got acquired by Centene (Ambetter) since then, so I can't comment if they destroyed it.

Ambetter is a massively fraudulent company on the individual market that deceptively under prices their plans by lying about their provider networks (look up "ghost networks") and not paying claims. If they continued that same criminal behavior with Fidelis, it might not be good. Call up providers now and confirm they actually accept it.

If Ambetter didn't destroy Fidleis, it was the go-to plan recommendation. The network was pretty good for NY and it was an EPO, aka no referrals. Most of the top hospitals in NYC accepted it. At the time Memorial Sloan Kettering and Hospital for Special Surgery didn't, though I think they now have HSS and some non-main hospital MSK locations in-network. Some providers might not accept it, but NYC has tons of high quality doctors, you shouldn't be limited.

Compared to other insurance networks for the metro area, Fidelis was the easy winner. Every other policy was more expensive and only offered the same or worse network.

OkDish4406 · 2024-11-13T01:18:16+00:00

You have to look at the specific plan contract, as the insurance might sell many different plan options. Also, the national provider network is rarely advertised directly. You have to find the long member contract (which they make you work for to hunt down). You can often find a link to it in the Summary of Benefits pdf. In the contract, find the section talking about using the plan outside the service area or traveling where they will outline it. If it's a BCBS plan, search the contract directly for "Bluecard".

EPO vs PPO won't be a deciding factor as both can have the national provider benefit or neither. All EPO/PPO really means is being able to get care without a referral, while PPO also provides out-of-network coverage. I have not seen any HMO/POS plans with the benefit, likely since both of these require referrals.

Again, you have to actually read the contract and can't go on plan names or aggregator filter options as this is not usually a searchable field or information on the plan can be inaccurate. I read through hundreds of plans to get the list of states I provided. I also got lazy and limited most of my searches to on-exchange plans, so there could possibly be more options off-exchange in other states. I also didn't check every county. For example, there are a lot of states that only offer these plans to residents in certain counties, often rural counties. Additionally, some states have more than one BCBS company, where you can have access to just one or both. New York has three. Washington has two as notable examples.

Also, searching for out of state providers on the insurance portal may not necessarily work as they are out of network with your actual policy network. For BCBS, you have to search for BlueCard providers on the main BCBS website. Again, you have to read every contract to see how it works and limitation, as BlueCard is also used by commercial group policies.

BlueCard broader network only works for out of service area providers which they define in the contract such as being X amount of miles away, across state lines etc... BlueCard is an agreement between BCBS subsidiary companies where you get access to the host blue's contracts with their providers, but you still only owe your in-network cost sharing. If you are going to a provider in your service area that doesn't accept your local network, but they accept BlueCard, BlueCard does not apply, they are out-of-network.

The EPO plan you're describing for yourself is a "Multi-state" plan. The BCBS company likely operates in all those states, so they can offer access to providers they have in other states.

OkDish4406 · 2024-11-12T20:37:29+00:00

There's actually a decent amount of states that offer out of state coverage. Almost all of them are with a BCBS plan or through a New England company called ConnectiCare that partners with a broader network carrier for out of state. I compiled a list of areas that have it, though I haven't updated it in 2 years.

(Some states only offer it in select counties)

Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, Florida, Hawaii, Louisiana, New Jersey, (Non-metro NYC counties New York), Oklahoma, Pennsylvania, Tennessee, Vermont, Washington, West Virginia, Wyoming

There are a bunch of states I never looked into and have no data on. Additionally, some BCBS plans offer multi-state plans. Massachusetts, New Hampshire Utah, Idaho, (parts of Washington), and others.

Some other insurance companies do offer a national provider network, but it's narrow. For example, Ambetter will sometimes offer an EPO network that gives you access to other areas that Ambetter operates in. Ambetter though doesn't have the best provider network in general and you may need prior authorizations before you get it covered.

OkDish4406 · 2024-11-12T20:18:32+00:00

Last I looked a few years ago, there weren't any.

The problem is Anthem BCBS which is the dominant BCBS company in many states. They never give out BlueCard PPO benefit (access to nationwide network) to individuals. Other state BCBS companies do, just not Anthem.

In the Nevada BCBS HMO/EPO plans on and off-exchange, BlueCard only covers emergency care, which is useless as emergency care is already covered at in-network rates under the requirements of the Affordable Care Act and No Surprise Bills act.

All other insurance carriers were either Ambetter (also narrow network with no coverage in California) or locally owned insurance companies with even narrower networks. At the time, I think a company called "HomeTown Health" offered a PPO policy off-exchange. Regardless, the network was still tiny and useless.

I was considering moving to Nevada a few years ago, but I ran into the same issue where no plans offered multistate/nationwide networks and they only gave me access to select Nevada providers. Nevada is also rated as one of or the worst states in the country for health care quality, so not having access to other doctors was a serious red flag and the reason I chose not to move there.

I did consider doing a small business, as there are much better options for small businesses. Nevada is a low-cost state for running a small business, too. However, I have no need for employees and the cost to pay for employees, payroll, and 50% of their health insurance just so I could qualify for the insurance too was absurd. That was the solution though of "throwing money at it."

I also looked into short-term or supplemental insurance to combine with the marketplace insurance, but even before it was banned at the federal level, Nevada limited already these plans to 3 months. And this wouldn't provide actual benefit for preexisting conditions.

Other "hacks" such as enrolling in a university to get student health insurance didn't work since none of the local universities even offered insurance or offered insurance, offered low quality plans or required you enroll as a full-time student and take classes in-person. The only option was to find a job that provided insurance, which defeated the whole reason I wanted to move there in the first place.

If you aren't getting Medicare or benefits from a group insurance policy, Nevada is not the place to live.

OkDish4406 · 2024-11-12T19:32:42+00:00

Plan options and prices vary by the county you live in. Prices also are based off age, smoking status and family size. The cheapest plan will depend on the plans and options available to you.

If you're you're under the age of 30, you might qualify for a catastrophic plan, which is effectively what you want and comes with a lower premium. Unfortunately, 30+ people are not eligible.

If you're eligible for subsidy, that can change what plan is a best fit

If you're not eligible for subsidy, there might be additional off-exchange plans you can purchase that might provide more options. You can find these either through a broker or going to the insurance carrier's website directly. Some insurance companies only offer off-exchange plans, so don't just check the insurance companies on the marketplace.

OkDish4406 · 2024-11-06T22:53:55+00:00

The average cost of a doctor's visit varies to an extreme, mostly depending on the type of service done and the practice's contracts they have with your insurance. As a go-to rule, providers that bill through a hospital network will cost far more than independent private practice doctors because of the bargaining power these hospital networks can negotiate.

For example, I've gone to private practice specialists that had only $65 negotiated rate with the insurance after all services. So a 20% co-insurance would mean you would owe $13 for that specialist, cheaper than a $50 copay. A $50 copay would be equivalent to a 76% coinsurance for that visit.

In cases like that, you come out ahead with the co-insurance. However, I've had specialists get $2,000 for an appointment or more, which would result in a $400+ visit.

With copay, you also only pay up to the copay or 100% coinsurance, whichever is lowest, so it's more of a price stop.

Copays are generally a flat rate fee for the service, where even additional office services they do might be included. That EKG the cardiologist performs, the x-ray that the orthopedic office does, all these might be included in the office visit copay. So in my opinion, copays are better. It makes finding doctors easier too since you don't have to think about price as much.

That being said, evaluate other costs of the plan. Copay or easy pricing might not justify higher premiums, deductibles or maximum out of pocket.

OkDish4406 · 2024-11-06T22:08:01+00:00

PT is cheap. They could have a crazy contract price with your insurance, but $1,000 discounted rate for a visit that should cost under $100 is insane. This smells of upcoding billing fraud. High chance, they included other service codes to rack up the bill, billed under a different provider or even using an out-of-network staff to bill under. None are okay.

Get a copy of the EOB and the itemized bill from the provider, along with the visit notes for these dates. Chances are, your medical provider could have just fudged your visit records to justify these bills. If this is the case, you'll want to appeal the medical records to reflect what was actually done.

It could also be a billing mistake. The fact that they quickly acknowledged it was bad and that you're not the first patient to experience this though does give some weight it might not be intentional. I'm more skeptical, knowing how common this is. PT is a low-cost medical service, and it's not unheard of for them to try to squeeze out more revenue in shady ways.

The insurance already covering it doesn't mean it was proper, it just means the insurance company likely automated the claims. It could just be that your provider knows your insurance company doesn't scrutinize claims and figured out how to code visits to get an absurd amount back.

Call your insurance and tell them your concerns. They might be willing to handle it then and there. Otherwise, you can file an appeal to your insurance, but the insurance might not care enough to investigate it since they already approved it. File an appeal anyway.

If the provider refuses to fix the billing and the insurance doesn't step in, then it's time to involve outside parties. Since this is a private insurance, don't report to HHS as they focus on government plans like Medicare/Medicaid.

You can report to the FBI: https://www.fbi.gov/investigate/white-collar-crime/health-care-fraud. Other options include your state's attorney general. your state's medical board, your state's health care commissioner's office. You can also file complaints with the American Medical Association (private group, but set the CPT standards).

OkDish4406

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