November 2, 2016 8:44 am

During open enrollment time, you may be faced with a large variety of different health insurance plans to choose from. Our patients frequently ask us for advice on what the best insurance to ensure they will be able to access the best care. We have a simple answer: whenever possible, choose the plan that gives you a variety of choices.

An increasing number of plans force patients to choose from a narrow network of providers. This narrow list of providers often have sharply discounted fees; in exchange, they get a high volume of patients from the insurance company. These arrangements are almost always about economics, not patient care.

Choose a Plan That Lets you Choose

That’s why it is so important for people to choose plans that give them the ability to go to almost any doctor. Most plans feature a mix of In-Network providers and Out of Network coverage.
If you choose a physician or facility within the In Network option, it will often have reduced co-pays and smaller deductibles. By ensuring you have at least some Out of Network benefits, you will have the opportunity to choose the best doctor for your particular medical condition without having to worry about paying entirely out of pocket.

Making sure you have some Out of Network benefit is just the beginning, just like most things in life the devil is in the details! Here are some important questions to ask about any potential Out of Network benefits:

How much is the co-insurance?

Co-insurance is the percentage of the bill you will likely have to pay if you use an Out of Network provider. Co-insurance used to be an 80/20 split, with the employee picking up the 20%. Recently we have observed that out of network co-insurance rates of 60/40 or even 50/50 splits. While many surgery centers have financial assistance programs to help patients who may have the means to pay these high amounts, the lower the co-insurance share paid by the patient, the more options you will have.

What is the Out of Pocket Max?

Once you hit your out of pocket maximum, you no longer have to pay the co-insurance. So an annual out of pocket maximum of $5000 means that once you hit that number, your insurance will cover all costs going forward. We are seeing Out of Network Out of Pocket Maximums increase to $10,000 or even $15,000. These higher maximums could end up costing you dearly. Always make sure to ask if the surgery center or provider has a financial assistance policy that could offset these expenses.

How is the out of network physician reimbursed?

In the past, most plans reimbursed at a usual and customary rate — which meant the physician or surgery center would be getting a reimbursement at least based on the average charges for the area. Today, many plans are limiting out of network costs to a percentage of Medicare, typically ranging from 110% to 300%. This percentage is typically significantly less than the average “usual and customary” reimbursement.

These limited compensation plans pay physicians and facilities dramatically less than usual and customary. These plans often have names like MRC2, for maximum reimbursement charge, or MNRP, for Maximum Non-network reimbursement policy. Some providers will then bill the patient, for the difference between what they should be getting paid and what they receive under these limited reimbursement plans. The best Out of Network programs will not limit reimbursement beyond “usual and customary.”

Will benefits work at an Ambulatory Surgery Center?

For a lot of reasons, Ambulatory Surgery Centers (ASCs) are typically a much better option than a hospital for many elective surgical procedures. From the patient experience to the reduced infection rate, most patients should prefer to have outpatient surgery at an ASC if possible. Some plans dramatically limit Out of Network benefits at Ambulatory Surgery Centers. For example, many Blue Cross Blue Shield plans limit Out of Network ASC reimbursement to just $350 per day. That’s way less than what they will end of paying for the same procedure at their in-network hospital partners. So they are charging more for a “choice” product that gives you less choice!

So how do you figure all out what your plan covers? Your employer must provide you with at least a summary of different plan options. But, to really understand your plan, you should request the Summary Plan Document (SPD). The SPD is the actual plan the governs how claims will be paid. The SPD should have the details as to what will be covered and how. By reviewing it closely, you will be able to make the most informed choice about what plan is right for you and your family.

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