Ny/nj health insurance?

amother

Cantaloupe

Wed, Jul 31 2024, 7:08 am

amother Rose wrote:

Am I naive or clueless?
Aetna and United Healthcare are nationwide no?
I've have both and can go to any dr. Any state

Not in any plan that you purchase privately. Even if bcbs has a nationwide network, most plans only cover within state and it's impossible to buy a private plan with out of network benefits. There was one bcbs plan that let you go out of state, omnia gold but I believe it stopped this year
Your best bet is to call a broker. They will know what is available. I have found both Cosmo and diamante to be excellent

↑ Amarante ↓

Wed, Jul 31 2024, 8:08 am

amother OP wrote:

What a huge headache. Ok cobra it is for the time being and then I need to figure this out.

I just wanted to emphasize that if you opt for COBRA you can't drop it and be eligible to purchase ACA compliant insurance except during Open Enrollment or if you experience a Qualifying Event.

This may or may not be an issue for you but you should keep in mind. Open Enrollment starts November 15 for January 2025

Outside of Open Enrollment or a Qualifying Event, the policies would be medically underwritten and subject to exclusions for pre-existing conditions or have other issues.

amother

Cyclamen ↓

Wed, Jul 31 2024, 8:19 am

Amarante wrote:

That is extremely unusual because almost all health insurance has networks and there is either no coverage or more expensive coverage if you go out of the network.

All insurance will cover you out of state for an emergency but once you are medically stable, you need to get further medical care in your area.

Some networks in large states don’t cover outside of certain geographic areas. If you are in Mew York your network wouldn’t have providers in Buffalo for example.

I don’t think it’s unusual for plans through NYC employers. They’re so close to many other states that they have to offer plans that cover a large area so they can attract good staffing.

↑ Amarante ↓

Wed, Jul 31 2024, 8:23 am

amother Cyclamen wrote:

I don’t think it’s unusual for plans through NYC employers. They’re so close to many other states that they have to offer plans that cover a large area so they can attract good staffing.

Large employers are a completely different thing.

Most large employers are self insured and use the insurance companies only to administer their programs so the company decides what level of benefits they want to provide.

Also many large companies have locations in different states so it is administratively easy for them to have insurance which can be used in different states because they already have insurance for their employees who work in those states.

Also if they are large they are designing their own plan and so if they have Blue Shield administer their plan, they can work out a deal with Blue Shield to use the existing Blue Shield networks and administrative structure in other states.

amother

↑ Rose ↓

Wed, Jul 31 2024, 8:47 am

You're right, I do have through an employer.
When I turned 30 I got kicked off Oxford ( which I went to any dr I needed/wanted) on my parents plan, and was left without insurance for a few months as my husband is self employed and he has a single insurance plan in NJ ( through Oscar I think)
Called an insurance broker and went on Fidelis - disaster of a plan - for 900$ a Month with no Dr that I needed accepting it.
My husband eventually spoke to an insurance broker and he started an insurance policy through his own LLC something like that..and now I have Aetna, which I see now has a smaller network of Drs than Oxford, but I haven't had any issues going to a dr that I needed. And I can go out of state if I wanted

amother

↑ Cyclamen

Wed, Jul 31 2024, 8:49 am

Amarante wrote:

Not just large employers, those tend to be even better plans and better pricing but I had this when I worked for a company with well under 100 employees.
It’s something that people who work in NYC or nearby take for granted.

amother

↑ OP

Wed, Jul 31 2024, 9:05 am

amother Rose wrote:

Y
My husband eventually spoke to an insurance broker and he started an insurance policy through his own LLC something like that..and now I have Aetna, which I see now has a smaller network of Drs than Oxford, but I haven't had any issues going to a dr that I needed. And I can go out of state if I wanted

how can I do this?

amother

↑ Rose ↓

Wed, Jul 31 2024, 10:35 am

amother OP wrote:

how can I do this?

My husband spoke to a broker who works through allstate that someone reccomended. He already had an LLC, but helped us set up a plan through it. I'm not exactly sure how it works, but technically I can be an employee, or as a family member ( like I was on my parents plan)
I can get you the info if you want.

↑ Amarante ↓

Wed, Jul 31 2024, 11:10 am

amother OP wrote:

how can I do this?

This has very specific requirements and unless you do it correctly it will be disallowed and you will have IRS issues.

You should speak to a knowledgable attorney and CPA and then use a very ethical and experience broker.

It is not something I have done so I don't claim expertise but my understanding is that the corporation needs to have more than one employee and they should be legitimate in terms of receiving salaries.

↑ Amarante ↓

Wed, Jul 31 2024, 11:35 am

amother Rose wrote:

At least 1 employee, and I would sure hope insurance agents are ethical. I wouldn't have a reason to doubt it.
And how is anyone supposed to get insurance ( for Dr. If they need out of state)
if they're single or if they're office doesn't offer insurance?

Unfortunately not all insurance agents are ethical - or competent. Some are of course but some want to maximize their commissions.

If your job doesn't offer benefits either get a better job or get insurance through the marketplace. Depending on income, you could get a nice subsidy.

Most people don't have the ability to see doctors out of their network - let alone out of state. It is only available for the most part through insurance through a large employer with generous benefits.

Even if you could purchase it the premiums are extremely high. This is one of the reasons why it isn't offered - it is expensive. Most people don't want to pay the high premium and so the only people who are willing to pay an extremely high premium are those who anticipate having very expensive medical costs - and so the pool of people buying these kinds of plans is actuarily unprofitable and insurance companies have dropped them.

They are also expensive for employer which is why most employers don't offer them - but there are exceptions when an employer is larger enough and has locations in various areas and is typically self funded so it doesn't cost them significantly more since they already have contracts in multiple states.

amother

Stonewash ↓

Wed, Jul 31 2024, 11:43 am

hello12341 wrote:

Based on your question, I'm assuming you are in New Jersey.

This year there is no longer any personal insurance plans on or off the marketplace that offer out of state coverage. The only way to get nationwide coverage is through an employer plan. (Someone mentioned Horizon Omnia Gold. That used to have nationwide coverage but as of 2024 no longer does.)

This is a problem for many. Some people have found ways to create their own business and get health insurance that way.

One thing you can look into is going onto a Horizon BCBS plan. You won't get NY coverage, but they do cover HUP (adults) and CHOP (kids) in Pennsylvania, which is a great hospital network with good options for doctors.

For all of your NJ coverage options, you can call an insurance broker that deals with personal plans. Diamant and Associates in Lakewood does this, and I believe Cosmo Insurance as well.

Are you sure about this?

I have omnia silver and was just told by someone that I can use NY and PA doctors, but I'd need to get prior authorization. It didn't seem like that would be an issue though.

amother

↑ Rose ↓

Wed, Jul 31 2024, 11:47 am

Oy, that's definitely not something I want to believe. Is it worth it for them to maybe get "caught", and the person on the policy can get caught as well.
I have an ongoing medical issue and need to see doctor often, so we made sure whatever plan it was, it covered doctors that we needed - and copay, prescription etc... its not cheap but worth it in the long run.
It wasn't so simple to set it up like that, DH had been on his own for 12+ years, ( b"h no medical issues) and it is costly, but better than me being stuck and limited.

amother

↑ Rose

Wed, Jul 31 2024, 11:49 am

From all theses posts, aside from my owm experience, I see the whole insurance thingy as soooo complicated.... but you definitely have to speak to trusted Ehrlich insurance broker. When I was kicked off my parents plan, I called every doctor to see who accepted Fidelis and none of them did.
It was ridiculous, and I paying close to 900$ for it as I didn't qualify for subsidized.
At least if it was free I couldn't complain....

↑ Amarante ↓

Wed, Jul 31 2024, 11:50 am

amother Stonewash wrote:

Did you get your insurance through the marketplace or through an employer?

Employers can structure plans however they want since they are the ones who are paying for it Very Happy

That said, often you would have to prove there is a medical necessity for going to a doctor outside of your network and that can be hard to prove if there is a doctor in the network who has the same specialty.

Also - depending on your plan, if you go to an out of network doctor, you can be balanced billed because the doctor or facility is not required to accept whatever insurance wants to pay and you could be responsible for the amounts in excess of what insurance paid.

Not saying this is true because I have no idea what benefits are in your plan - just pointing out some of the pitfalls that people have found themselves in.

amother

Latte

Wed, Jul 31 2024, 11:56 am

amother Stonewash wrote:

You can apply for prior authorizations for doctors in adjacent states. However, this is primarily for "continuity of care", which means that you are already using that doctor. It's a lot of paperwork and you have to be on top of it, because you have a time limit for getting it done- I think o0 days, but that includes the whole process, not just you getting the paperwork submitted. They don't guarantee anything, and definitely don't guarantee for new doctors- like if your primary in NJ sees you for something and recommends a specialist in Columbia. That's a whole other deal.

And if you have a kid who goes to school or camp in a non adjacent state, or even in NY state and needs to see a doctor there, that's harder. There is a program they have, I think called Horizon Blue, where you can apply for a sort of carve out for that fanily member in that staye if you can provide the address they live at (you need a dorm room number or apartment number). Then they have a separate mini plan that allows use of doctors that are on the BCBS plan there.

And non of this gets you any put of network coverage anywhere.

And we were told Omnia Silver BCBS/Horizon is the only plan that gets you any out of state coverage- none get you out of network. But we did manage to spend down the in network coverage and get zero copay on most medications pretty quickly, more so than usual.

↑ Amarante ↓

Wed, Jul 31 2024, 12:00 pm

amother Latte wrote:

Also continuity of care is generally limited in time scope to give a patient some time to find a new medical provider and is not indefinite.

It is most often done for maternity when a woman is at the end of their pregnancy or if someone is in the middle of chemotherapy or is in post recovery and so a few follow up visits with the surgeon makes sense.

It is not routinely granted as a way to see doctors out of the network because you prefer those doctors.