Health insurance with OON benefits

Cmon be nice ↓

Thu, Aug 08 2024, 2:21 pm

Hi maybe somebody here can help me to what is probably a common issue. DS needs therapy and his school needs him to have a private insurance plan with out of network benefits in New Jersey. W're currently on Jersey care, which doesnt cover it. Does anybody have any ideas of how we can get on a plan? Ive posted under my SN in case someone wants to PM me. Thanks

↑ Cmon be nice ↓

Thu, Aug 08 2024, 2:53 pm

amother Chestnut wrote:

I was told by Cosmo Insurance that you can't buy private insurance with out of network coverage. the only way is through an employer plan.

Right. So DH actually has a small corporation, and we were wondering if we could just get on a insurance plan

amother

Banana ↓

Thu, Aug 08 2024, 8:49 pm

Cmon be nice wrote:

Right. So DH actually has a small corporation, and we were wondering if we could just get on a insurance plan

Does he have one employee who could join the plan?

In New Jersey you CANT have an owners only group, does he have an employee who can enroll?

ETA To fix a typo

amother

Denim

Thu, Aug 08 2024, 9:00 pm

A plan like that could cost you $30k a year in premiums plus deductibles, copays or coinsurance. You’d have to figure out if the increased cost over whatever you’re paying now is going to cost less or more than what you’d pay out of pocket for therapies.

↑ Cmon be nice ↓

Thu, Aug 08 2024, 9:41 pm

amother Banana wrote:

Does he have one employee who could join the plan?

In New Jersey you CANT have an owners only group, does he have an employee who can enroll?

ETA To fix a typo

Not really, which I know is a problem 😕

amother

Leaf

Thu, Aug 08 2024, 9:53 pm

Why is the school dealing with health insurance? They should not be demanding you see a specific therapist or health care provider. Sounds like a kickback scheme....

There are no providers where you live that accept your insurance?

amother

Strawberry

Thu, Aug 08 2024, 9:56 pm

You can purchase insurance during Open Enrollment for coverage beginning 2005

However I am not sure you understand what out of network means.

You currently have a form of Medicaid which is generally accepted by a small group of providers because reimbursement is lower than from other health insurance.

Almost every plan you would purchase has a network. Some plans that are a PPO have benefits that for using a provider who isn't in the network. However, these cost more - the co-payment is higher, deductible could be higher and out of pocket expenses are higher.

Also you can be balanced billed as insurance will only compensate a rate that consider to be customary and usual.

Example

Go to a doctor in a network - doctor has agreed to accept the negotiate rate with insurance company so you are responsible for co-insurance and/or co-payment after meeting the deductible.

Go to a doctor out of network - Doctor charges $500. Insurance only believes the reasonable charge should be $250. You will be reimbursed for the $250 in accordance with the plan and responsible for the additional $250

Keep in mind that the cost after premiums, co-insurance, co-payments could be more than just paying a doctor out of pocket.

Also billing can be complicated when you have Medicaid and another insurance plan.

amother

↑ Emerald

Thu, Aug 08 2024, 10:01 pm

amother Marigold wrote:

Some agencies work with horizon Omnia gold. Is that an option?
(Anyone can purchase that but you might need to wait for open enrollment)

Connect plus takes Omnia Silver which is cheaper.

↑ Cmon be nice

Thu, Aug 08 2024, 10:29 pm

amother Leaf wrote:

Don't worry, not a kickback scheme.

amother

↑ Banana

Thu, Aug 08 2024, 11:11 pm

Out of network deductibles and oop maximums can be astronomical. It may not be worth your while even if you can get on a plan with oon coverage

You really need to know your numbers- How much you spend in oon providers.