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Posted 11/9/2014 7:16 PM (GMT -5)
I'm just very curious, for now....

What happens if you want to use a doctor and or facility like Johns Hpkins, Cleveland Clinic, or Mayo, and you live in another state?

I have great coverage as long as I stay in network, with Emblem Health, for medical,(formerly GHI), and Empire BCBS/NY for hospital. But if I go out of network, their "schedule of customary charges" pretty much sucks.

So if I wanted to go ti an out if state facility, with out if state docs, do they generally take what insurance pays, or do they just make you "bend over and take it like a man" (no pun intended)?

Like I said, just curious for now. I know I'm ahead of myself (again)
Posted 11/9/2014 7:25 PM (GMT -5)
Every provider is different. You have to ask each one. Many doctors and facilities have staff that do only insurance issues.

My insurance will not cover treatment at a distant facility if there is an in-network provider in my area. So I can't use those options unless I pay cash at the retail price.

But you'll quickly learn, get everything pre-approved and confirmed in writing.
Posted 11/9/2014 7:40 PM (GMT -5)
Thanks 142. Probably overkill to go to one of those out-of-state simple, considering what's available in New York City where I live. But I know that Hopkins mayo and Cleveland clinic are excellent. Assume Memorial Sloan-Kettering and Columbia Presbyterian Are not that far behind and maybe on a par with those

I'll be eligible for Medicare exactly 11 1/2 months, so I guess things change at that point. The insurance coverage I have now will then become the Medicare supplement. Coverage comes from my wife who is a retired teacher and the New York City to have a strong union so we get that for life at very low cost

Post Edited (Pratoman) : 11/9/2014 5:43:47 PM (GMT-7)

Posted 11/9/2014 9:17 PM (GMT -5)
Prat:

In-network, my ins. pays 90%. Out of network, they pay 70% (but probably of reasonable/customary charges, so it might be less). However, I do have in-network and out of network maximuma and I think they pay 100% after that.

My problem is that it gets so complicated and I'm never quite sure.

Mel
Posted 11/9/2014 10:09 PM (GMT -5)
Without single payer in our powerhouse of a country, it's huge unknown. Most insurance companies won't provide any information until claims are submitted. My treating RO, was out of network so I was responsible for 40%. The thing that saved me was the yearly cap on out of pocket. Once reached, everything was covered. So look into that aspect, what is the out-of-network rules and maximum that you will pay.

Mine was $5000, which I exceeded before I dropped my trousers.

It's the 6 month follow ups that are hurting now, since the yearly cap gets re-set. Becomes one very expensive day
Posted 11/9/2014 11:13 PM (GMT -5)
I looked at my insurance and it says sull coverage for out f area, n all services. I think it's the same 80% coverage, I network as out, but there is a deductible when. Go out of network of $250 with a $500 family max. But again, it's 80% of REASONABLE AND CUSTOMARY CHARGES, OUT OF NETWORK, which is determined by the insurance company.
Posted 11/9/2014 11:16 PM (GMT -5)

compiler said...
Prat:

In-network, my ins. pays 90%. Out of network, they pay 70% (but probably of reasonable/customary charges, so it might be less). However, I do have in-network and out of network maximuma and I think they pay 100% after that.

My problem is that it gets so complicated and I'm never quite sure.

Mel

That's good coverage Mel. I think I also have a $5000 max out of pocket in network, not sure out. I need to check that tomrrow
Posted 11/10/2014 11:16 AM (GMT -5)
"But you'll quickly learn, get everything pre-approved"

Make sure of this! My surgery was scheduled for Oct 8th of this year back in July. My insurance requires prior authorization on hospital stays, so I started checking with my insurance, and nope, hadn't been done. So when I called my urologist office they indicate they would do this until 8 weeks out max. I checked at eight weeks, nope, another call. Now five weeks, nope, another call. Then three weeks, nope, another call. By this time I had been on the phone with my insurance provider five or six times and my Dr's office about 8 or 9. I was told they would call me to confirm when it was complete, which ended up being a week and one day before surgery. I found this maddening, but regardless stay on them about it!

My first EOB's are trickling in, and showing everything covered except the surgeon and anesthesiologist. Reason code, "no prior approval or referral". I'm told this falls on the surgeons office, and it does show I owe nothing, but nothing paid to either of these two individuals, so fingers crossed this works out. I've also been told that it's a delay tactic of sorts, since I obviously didn't go stay at the hospital for the company and food.

Anyway, heed 142's advice here!

Post Edited (Thurman) : 11/10/2014 9:19:05 AM (GMT-7)

Posted 11/10/2014 10:26 PM (GMT -5)
Being on Medicare they covered out of state surgery at Johns Hopkins. Don't know about you younger guys!
Bob
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