Comparing Out of Network on MAPD PPO's

Nov 25, 2016

  1. yorkriver1

    yorkriver1 Guru

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    This hasn't been on my radar much, yet. Client has been on MAPD PPO pretty much since T65. Do any of you have experience with clients going out of network extensively? The feared thing, high out of pocket, but potential client is calm and reassured by the $10K max OOP on both plans, just wants to choose an option that fits the situation. Likely to need back surgery and has options for in and out of network providers. Needing surgery pretty much wipes out going to a MedSupp for this 76 YO on multiple drugs.

    Whether to go out of network for surgeons or PCP on MAPD PPO. I vote for PCP. First the client has to understand what happens at PCP. Quick reading of EOC says that the OON PCP should still get pre-approval for procedures. That's really the same as Original Medicare and all the insurance as we now know it.

    My understanding is on hospital charges when everyone is in network, the surgeon fees are included. I guess if the surgeon isn't, their fees would be out of network standard pay option. I am downloading both EOC's for plans being reviewed.

    So far it looks like there are some items out of network that still have a copay, like ambulance, on one plan anyway.

    This process is going to be a help to my understanding, even if tedious for potential client, who didn't get that there is either a $750 or $1,000 deductible for going out of network.

    I want to get ahead of this, so the client isn't blindsided by fees they didn't expect. I feel a moral obligation to point out what the situation entails, even if I don't choose to be the agent.
    Last edited: Nov 25, 2016