Insurance in NY or CA: Empire Blue vs Oxford/United

[+ FreshFluff]

For medical personnel and others who’ve tied out different insurance recently: Who compensates better for OON care, Oxford/United Healthcare Choice Plus PPO or Empire BCBS PPO? I am asking my current doctors, but it’s very possible that new conditions will pop up and require new doctors. I use a lot of out of network care so OON coverage is important.

 

Which one has been more generous out of network rates that use when multiplying by coinsurance. Does that make sense? I keep hearing that Oxford/UHC is especially stingy. Is that right in your experience?

[+ blondeq]

It really depends on the policy. If it is an employer based plan, the OON benefit is usually a fixed %. However, if you are purchasing a private plan, you can typically structure different benefits based on cost. That said, Empire (parent company is Anthem), typically applies OON benefits without any hassle. Whereas, UHC, in my experience, makes the process a little more difficult; they may require pre-authorizations, etc depending on the type of care. Both have excellent and easy to use appeals process which is important in this age. All things considered, I would probably choose Anthem, but that could change based on cost and OON benefit offered. Finally, be very careful when discussing cost with providers. OON care may not follow negotiated rates. For instance, Anthem or UHC may have a negotiated rate of $200 for a physician consultation; the physician must accept the insurance payment + any copay/deductible. That rate may not apply to OON benefits, meaning the insurance may only pay a % of gross charges (some physicians may have a gross charge of $1,000 for the same consultation that was negotiated as $200 for in-network care).

 

PPO plans, Anthem or UHC are definitely the way to go if you think you’ll need OON care.

[+ nycman]

Depends. OON emergencies in NY?

You‘re pretty protected by NY OON laws.

 

Non-emergency stuff? You’ll need to read the

plan documents like the legal documents that they

are. Assume the insurance company is trying to

screw you (they are), assume the worst case scenario,

and select the best option for you.

 

They all suck. They are all evil. But if you need a shot

in the dark I’d say Empire pays better than most in NY.

 

Hope that helps.

[+ sniper]

Most companies offering PPOs still have a "usual and customary" cap on the out of network reimbursement so you can find yourself on the hook for more of the charges than the percentage they tell you. Though many (maybe most?) providers will simply accept the insurer's limit, you do need to be aware that there's the possibility they don't.

[+ FreshFluff]

Thanks, @nycman , @blondeq , and @sniper. Oh, I’ve already been screwed plenty by my $$$ exchange UHC HMO. They.denied an out of state urgent care claim for an x-ray when I tripped. (ERs only!) That’s why I’m so eager to switch to the best PPO coverage I can find. Even decent nationwide EPO would be great, but if a PPO is available, I’m going for it.

 

The current consensus from my own docs and my own experrience with HMOs agrees with both of you: I’m leaning towards Aerna/BCBS. As @blondeq said, UHC/Oxford demands more preauth. The plan details says their PPO requires preauth for outpatient hospital fees while BCBS does not. That alone is a big deal.

 

@sniper , so the UCR is a cap for OON compensation? I suspected as much, yet there see. But what I’m seeing, there are big differences in compensation across insurance providers even with similar counsurance %.

[Daverwr]

I used Anthem PPO for several years. My only complaint was how much the premium went up each year. $700 went to $1100 in two short years. I don’t know about OON charges. Anthem is almost universally accepted in CA. I did have a large co-pay when I was hospitalized for two weeks though.

[+ FreshFluff]

I used Anthem PPO for several years. My only complaint was how much the premium went up each year. $700 went to $1100 in two short years. I don’t know about OON charges. Anthem is almost universally accepted in CA. I did have a large co-pay when I was hospitalized for two weeks though.

 

The issue is that this is an NY based Empire BCBS plan. Some CA hospitals say they take our of state BCBS but their doctors aren’t listed on the directory.

 

You’re right. The premiums are high for all but lower than the near worthless exchange HMOs. As for the large copay, maybe they saw your tiara and thought you could pay.

[mike carey]

In the meantime, @RealAvalon and I are asking ourselves what this conversation even means.

[RealAvalon]

In the meantime, @RealAvalon and I are asking ourselves what this conversation even means.

I'm certainly not making a perfect analogy, this is more just a visceral reaction. There is an element with discussions of USA health care coverage, in terms of values and principles, with the complicated web of private insurance, that feels more akin to the health coverage I have for my dog, rather than for myself.

Edited August 3, 2020 by RealAvalon

[+ blondeq]

The issue is that this is an NY based Empire BCBS plan. Some CA hospitals say they take our of state BCBS but their doctors aren’t listed on the directory.

 

You’re right. The premiums are high for all but lower than the near worthless exchange HMOs. As for the large copay, maybe they saw your tiara and thought you could pay.

 

Fresh, under BC home/host rules, if a provider, hospital, physician or other service is a provider for Anthem BC of CA and you are physically located in CA, at the time of service, Anthem should cover the benefit as in-network,subject to whatever in-network rates Anthem has negotiated with the individual provider. In fact, in this scenario, Empire wouldn’t process the claim. Rather, the provider would bill Anthem of CA, under the home/host rule and Anthem of CA would process the claim. The key is to make sure that any provider you see, is contracted with the local Anthem plan.

[+ FreshFluff]

Fresh, under BC home/host rules, if a provider, hospital, physician or other service is a provider for Anthem BC of CA and you are physically located in CA, at the time of service, Anthem should cover the benefit as in-network,subject to whatever in-network rates Anthem has negotiated with the individual provider. In fact, in this scenario, Empire wouldn’t process the claim. Rather, the provider would bill Anthem of CA, under the home/host rule and Anthem of CA would process the claim. The key is to make sure that any provider you see, is contracted with the local Anthem plan.

 

This is really important. Thanks for letting me know. Nearly all providers take both but one regional hospital and a few private practice providers who take Anthem aren’t turning up in the Empire Blue provider directory. I’m calling them, but most are clueless. They just give you their tax ID and tell you you to call BC. So it’s tough to figure this out.

[+ FreshFluff]

Here are the 3 plans, from cheapest to most expensive. If you remove dental/vision, thmost expensive, the Oxford, is about $147 more than the cheapest. Oxford has the best coinsurance, but I keep hearing that they’re stingier.

 

FWIW, I’ll meet the $3000 OON deductible in a few months particularly if dental expenses count. I may use diagnostic imaging (likely OON) and labs and some minor outpatient procedures. I want to hedge against the possibility that I’ll need outpatient surgery and even have my first hospital admission.

 

Thanks again for all your help.

 

 

[+ blondeq]

It‘s a difficult decision to make when you have to factor in likely OON expenses. The last thought that I have is to be careful with HMO like plans such as Oxford. They may put up artificial barriers such as denying pre-auth for an OON service because a “like” service is available from another in- network provider; that may just be the cynicism in me.

 

Best of luck

[RealAvalon]

Here are the 3 plans, from cheapest to most expensive. If you remove dental/vision, thmost expensive, the Oxford, is about $147 more than the cheapest. Oxford has the best coinsurance, but I keep hearing that they’re stingier.

 

FWIW, I’ll meet the $3000 OON deductible in a few months particularly if dental expenses count. I may use diagnostic imaging (likely OON) and labs and some minor outpatient procedures. I want to hedge against the possibility that I’ll need outpatient surgery and even have my first hospital admission.

 

Thanks again for all your help.

 

 

If I understand what you wrote above, you would pay $3,000 out of pocket (as the deductible) before the health insurance would kick in? Is that right?

There is so much detail to go through. What does insurance like this cost?

[+ FreshFluff]

It‘s a difficult decision to make when you have to factor in likely OON expenses. The last thought that I have is to be careful with HMO like plans such as Oxford. They may put up artificial barriers such as denying pre-auth for an OON service because a “like” service is available from another in- network provider; that may just be the cynicism in me.

 

Best of luck

 

That’s precisely wha put me off too, @blondeq. They even require preauth in network. (“We don’t approve X before age 50.”) Plus it’s the priciest plan! That’s why Oxford is out, and it’s between thetwo BCBS plans. Thank you again; your posts are very helpful.

 

@RealAvalon $3000 is the amount I need to spend out of pocket before they start covering services with out of network doctors. Even afterwar that, they only pay a portion of what they consider the usual and customary rate, which is often very low. There is also an in network deductible, though that middle plan allows you to mostly circumvent it.

[RealAvalon]

That’s precisely what put me off too, @blondeq. They even require preauth in network. (“We don’t approve X before age 50.”) Plus it’s the priciest plan! That’s why Oxford is out, and it’s between the two BCBS plans. Thank you again; your posts are very helpful.

 

@RealAvalon $3000 is the amount I need to spend out of pocket before they start covering services with out of network doctors. Even after that, they only pay a portion of what they consider the usual and customary rate, which is often very low. There is also an in network deductible, though that middle plan allows you to mostly circumvent it.

Does 'in network' and 'out of network' mean that the health care system is made up of different 'teams,' that are somewhat mutually exclusive for coverage?

 

What would these plans cost on a monthly basis? Would a family pay more money for insurance than an individual?

[+ FreshFluff]

Does 'in network' and 'out of network' mean that the health care system is made up of different 'teams,' that are somewhat mutually exclusive for coverage?

 

What would these plans cost on a monthly basis? Would a family pay more money for insurance than an individual?

 

Each insurance plan has its own set of in network providers, who agree to accept the compensation that the insurance company offers. The plans with OON coverage run about $1000-1300 in NY for an individual and 2-3x that for a family. Plans offered on the state exchange cost the same but with much smaller networks, no non-emergency coverage out if state, and no OON coverage.

[RealAvalon]

Each insurance plan has its own set of in network providers, who agree to accept the compensation that the insurance company offers. The plans with OON coverage run about $1000-1300 in NY for an individual and 2-3x that for a family. Plans offered on the state exchange cost the same but with much smaller networks, no non-emergency coverage out if state, and no OON coverage.

Is that the annual cost?

[+ FreshFluff]

Is that the annual cost?

 

[+ nycman]

that may just be the cynicism in me.

One cannot be “too cynical” when dealing with health insurance companies.

Trust me. They are pure evil.

Is that the annual cost?

Don‘t worry @RealAvalon, the 12X area of the multiplication table was always the hardest part for me too.

Grin.

[mike carey]

Don‘t worry @RealAvalon, the 12X area of the multiplication table was always the hardest part for me too.

Grin.

We know about that and for the most part can do our 12x tables, but that doesn't reduce our wonderment at the US health system. My hospital insurance which I'm not convinced is value for money is about $200 (AUD) a month (I could rely on the public hospital system). I know I can go to a doctor and either pay nothing or pay some relatively small amount that they charge over the medicare rate for the service. Specialists may charge a premium over the standard (free to the patient) amount. But on a reasonable, not high income I don't worry about it, and I have no reason to do so.

[RealAvalon]

We know about that and for the most part can do our 12x tables, but that doesn't reduce our wonderment at the US health system. My hospital insurance which I'm not convinced is value for money is about $200 (AUD) a month (I could rely on the public hospital system). I know I can go to a doctor and either pay nothing or pay some relatively small amount that they charge over the medicare rate for the service. Specialists may charge a premium over the standard (free to the patient) amount. But on a reasonable, not high income I don't worry about it, and I have no reason to do so.

Sorry, I know this is off topic of the OP. I do get a bit dumbfounded with the USA health system though.

 

I had a bad medical year last year (for me it was bad, as I usually don't have much to with the health care system). Off the top of my head I've had: my once every two year physical exam and all the blood tests involved; a referral to a dermatologist for a couple of treatments for a possible pre-skin cancer; a referral to a podiatrist; physio-therapy for what is turning into a chronic joint issue; referral and several follow-up calls (close monitoring as prevention) to a urologist and all the blood tests involved.

 

Total calls to insurance about coverage: Zero

(Amount of time spent thinking about insurance coverage: Zero)

Total out of pocket expenses: Zero

Wait times: my appointments were more about prevention, a specialist second opinion, even so, it took, at most, two months to see the specialists

Standard of care: I was very pleased with the standard of care. My doctors encouraged my questions. No complaints

[+ FreshFluff]

Payroll firm (big national one) won’t each plan’s legal documents. “You get those after you sign on.” Is that even legal?

[+ FreshFluff]

 

This was definitely not meant as an insult. To an American, the idea of getting full coverage—or even poor HMO coverage—for $1000 a year is fantasy.

Edited August 6, 2020 by FreshFluff

[RealAvalon]

This was definitely not meant as an up insult. To an American, the idea of getting full coverage—or even poor HMO coverage—for $1000 a year is fantasy.

No offense taken. I didn't realize I had asked an obviously stupid question.

Edited August 6, 2020 by RealAvalon