New (ish) Individual Health Plans in Maryland

[Sam]

I really don't think it is too good to be true. If you look at the numbers of what kind of discount they get in network, it just makes sense. Their biggest advantage is their pricing power, and that can really drive rates.

When they rolled out the group HSA HMO, the rates were also too good to be true, but they are true and the claims are going very well for my groups on that plan.

 

[Crabcake Johnny]

You don't think $264 for a family of 5 where husband and wife are both 45 and smoke is too good to be true? The individual deductible is only $2,600? Wellness is free? Maternity is included?

If I stripped down Right Start with the lowest coverage limits it's $335 and that's still a $2,500 deductible.

Golden Rule's HSA saver is $380 with no drug coverage and only lab testing 14 days before or after a surgery.

Yes - it's too good to be true. Doesn't mean it isn't.

 

[Sam]

The deductible is $2,700. In any case, their networks, Mamsi, Aetna, PHCS etc... are more more expensive than Carefirst's is and more importantly, this is an HMO. Those plans all have out of network benefits, this one does not.

 

[Crabcake Johnny]

My understanding of the Carefirst HMO is they can see any Blue Cross doctor in the country. At least, that's what was conveyed to me during my fantastic training a few years back:-) If that's not the case, please correct me.

Out of their summary for Blue Choice:

If you use a provider who does not participate with any BlueCross and BlueShield plan, you will be reponsible for any applicable deductible, copayment, and coinsurance plus amounts over the Allowed Benefit.

It says "any" which to me means they can see any Blue Cross provider in the country. And that's a pretty extensive network.

 

[Sam]

From experience with their group plans, I can tell you that that is not correct. Where are you seeing that?

 

[Crabcake Johnny]

It's under the exclusions and limitation section of Blue Choice for individual plans.

Best way is to go directly to the source. I called Carefirst at 866-241-6442 and simply asked them what happens if I'm out of their service network.

They said if I'm out of state and it's a non-emergency I just call and they'll find me a local HMO doctor - and it HAS to be a HMO Blue Cross doctor, not a PPO Blue Cross doctor. Obviously for emergencies it's neither here nor there since you're fully covered even with a non-network doctor or hospital.

 

[STIBROKER]

did someone delete my post here....

 

[Crabcake Johnny]

Not I. Repost it.

 

[somarco]

HMO's have emergency services only out of network. In GA, just because a doc is in a BX network does not mean he is also in the HMO network.

Their PPO network is quite extensive. The HMO network is much smaller, perhaps 20% of the docs in the PPO network are also in the HMO network. The POS is smaller still.

If you have the BX HMO and go to a PPO doc for non-emergency services, you have no coverage (unless that doc is also in the HMO).

My guess is this is the way this works as well.

 

[Crabcake Johnny]

You nailed it on the head. To be a HMO Blue Cross doctor you need to be a primary care physician. And there are far less of them then PPO doctors who specialize.

Per my phone converation, if you're out of network on Carefirst's HMO and need non-emergency you must call them. Then in turn will send you to a HMO primary care doctor. That may or may not be close by.

However, we are talking about non-emergencies so at least they're offering an alternative. I don't see anyone getting into any trouble financially over this since all emergencies are never balanced billed and covered in full.

The only potential problem would be the definition of an emergency. If it's a broken leg you're fine. If it's bad stomach pains and you end up in the ER it's possible they might claim that's not a medical emergency - especially is it turns out to be nothing.