But once you cross the border, some plans can be a little coy in whether they will cover any health care services. For both travel in the United States and abroad, you really need to study the health plan’s member agreement also referred to the Evidence of Coverage (EOC). The EOCs are those big documents that tell you have the plan works, what’s included, and what’s excluded. Some EOCs are specific about foreign travel coverage while others that I have studied make no mention of coverage outside the U.S.
Finally, some folks are considering just enrolling in Medi-Cal because they are eligible. They have very little or no income to report on their taxes because they are living off of savings, interest, and dividends. Here again, Medi-Cal would be used as a containment strategy to an unexpected accident or illness. Medi-Cal is typically a HMO plan which requires a Primary Care Physician to make referrals to specialists, order tests, or imaging.
The health plans don’t recognize the invoiced amount of the health care services from out-of-network providers as either accruing toward the deductible or for their cost-sharing of 50% before the maximum out-of-pocket amount is met. The health plans apply a Usual and Customary Rate (UCR) or the Allowable Amount. This limits their responsibility for payment and increases the health plan members costs.
I know people hate health insurance companies and their health plans. But once you read some of the restrictions contained in the health care sharing and short term medical plan, you begin to get a sense of how comprehensive creditable health insurance really is. Seriously, I could have a couple beers, hop on my motorcycle; lay the bike down at 35 miles per hour going around a corner in a 25 MPH zone, and my Affordable Care Act health insurance would cover my injuries related to my stupidity.
Access to health care services is not equal in the United States. Your health plan determines the type of care you receive. The health plans in the employer, individual, and Medicaid markets are separate and they are not equal. The ACA moved us in direction of more equality for all residents regardless of the market type of the health plan. Current Republican proposals under President Trump will widen the gap in disparity between group plans and individual plans. We need to move in a direction the guarantees access to the same level of health care services regardless of whether you work for government, a large employer, have your own individual plan, or are awarded Medicaid because of your income. It is time to dismantle the flawed ‘separate but equal’ assumption of health insurance in the United States.
But how does an enrolled individual in a standard Silver 70 plan, who is not eligible for the CSRs, feel about subsidizing lower income plan members? Could the argument be made that some individuals are paying an inflated premium, close to a Gold plan, but only receiving Silver plan level benefits? At a very minimum, the inflated Silver plan rates are a distortion of the health insurance market place. One of the goals of the ACA and the exchanges like Covered California was to bring more transparency and accountability to the health plan selection process for consumers. If the inflated Silver plan rates, along with artificially inflated subsidies, do become a reality, the market place for health insurance will take a step backwards as plan selection becomes more confusing for consumers.
If you are going to be spending an extended period of time outside of your plan area, for work, vacation, or going to college, carefully review your plan’s Evidence of Coverage to make sure the BlueCard Program is part of the covered benefits. I was surprised to learn that both Blue Cross and Blue Shield HMO plans included the BlueCard Program for 2017.
Before I start gathering coverage information, I create a table with preferred or “must have” providers, hospitals, and drugs in rows, with the available health plans across the top columns. I then mark which health plan has the providers in-network and if the drugs are covered and at which Tier.
Forcing either the health plans or the providers to post a list of costs for routine services is a very low impact way of adding consumer information to the health care market. The government is not telling the providers what they should charge. The government is not telling the health insurance companies what they should pay the providers. A law mandating a simple fee schedule like Kaiser Permanente has published will create price transparency and allow consumers to compare valuable health care cost information across a variety of health plans and providers. This will ultimately slow down the rate increases as providers compete not only on patient satisfaction, but on price as well.
However, I still don’t understand why the costs for services for Southern California Kaiser members are so much lower than prices for Northern California members. Does Kaiser just have more members in Southern California to spread the fixed costs of supplying the services over? Kaiser charges 29% more for a colonoscopy in Northern California than Southern California. Are more people getting colonoscopies in Southern California so the volumes of patients help drive down the costs?