Ny/nj health insurance?

amother

Mintgreen

Wed, Jul 31 2024, 12:01 pm

amother OP wrote:

Hi
We’ve always had health insurance through my husbands job but he is starting something new and will be receiving a stipend towards benefits instead of a benefits package. We are trying to match what he had before…is there such a thing as insurance that you can use in two states? Our regular (soon to be old) insurance has coverage anywhere in and out of network. But when I speak to agents for marketplace insurance seems it’s in state only. We are able to do cobra for now but trying to see what our options will be. Anyone knows? Tia!

If you are located in New Jersey call the LRRC 7329429292

amother

↑ Stonewash ↓

Wed, Jul 31 2024, 12:04 pm

Amarante 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.

Marketplace.

I was talking to Sloan Kettering. They have an office in NJ and NY.

↑ Amarante

Wed, Jul 31 2024, 12:07 pm

amother Stonewash wrote:

Marketplace.

I was talking to Sloan Kettering. They have an office in NJ and NY.

Again prefacing this by saying I don't know what your policy benefits are.

However, if you are discussing Sloan specifically, it appears they have an office in New Jersey which is probably in the normal network for your insurance.

If for some reason you were referred to a SK doctor in New York, the NY branch would have pre-negotiated to accept the insurance including the rates paid by your insurance because SK is one corporate structure

You should confirm whether there would be balance billing.

However most medical providers and doctors don't have affiliated offices in other states.

amother

↑ Stonewash

Thu, Aug 01 2024, 8:34 am

amother Impatiens wrote:

Right. It’s true. Sloan’s main business office is in NY, and I normally can’t go to NJ docs, but living in monsey, montvale, NJ is so much closer than the city and I can go there. I haven’t had that with any other hospital/doctor tho. Usually fully restricted to state

I don't know. Maybe I'm misunderstanding, but I just looked up university of Pennsylvania health systems on the omnia website, and it says in network, tier 1.

So definitely looks like it's included.

I have omnia silver through the NJ marketplace

bgs1

Thu, Aug 01 2024, 10:48 am

I don't have Standard Health Insurance. I use a healthshare which you will not be penalized by the government for being uninsured. I use United Refuah Healthshare for close to 3 years. BH, I have a young and Healthy Family so there we don't need much in the way of coverage. However, my son recently had a really bad break on his arm and we were able to use a top doctor since we are not limited at all. The way United Refuah works is that we pay out of pocket and once we reach our deductible they start paying back 80%. There is a second threashold that if you reach they will pay 100%.

I don't know if I would recommend for someone who has a complicated medical history, however, choosing a Healthshare over catastrophic insurance saved me so much money.

amother

Mintcream

Thu, Aug 01 2024, 12:38 pm

Be aware that any health share is NOT insurance and doesn't have any of the safeguards that health insurance does.

it can deny coverage for pre-existing conditions and it is medically underwritten which means that you fill out an application in which you list medical history for everyone. If you need expensive care, they will review it to look for any omissions or mis-representations.

Prescription coverage is very limited

Unlike ACA compliant insurance, coverage is capped at $1,000,000 which can be exceeded if one has a serious condition although one could then be able to get ACA compliant insurance during the next Open Enrollment period since those policies have no limitation on amounts they will cover

While you can theoretically see any doctor, you can be balanced billed since the amount that will be recognized in terms of reimbursement is only a maximum of 150% of Medicare allowable for the area where service is rendered and a doctor can charge well above this amount as can a hospital or other medical facility

Not sure how this would be interpreted but it might be problematic if one is overweight and is submitting a claim for a condition that could be linked to eating habits or weight

From the website as a "condition"

Exercise regularly and eat healthy foods that are beneficial to the body.

amother

Wine ↓

Fri, Aug 09 2024, 6:43 pm

I am genuinely confused by why so many Imas here are professing to know about “every” insurance policy and Marketplace (I.e., “no policy on any Marketplace covers out-of-state”) when Marketplaces, their options, and the attendant laws differ *dramatically* from state to state and sometimes county to county. You should know that there are many states that still offer nationwide coverage (as well as plenty of out-of-network coverage) through Marketplace plans. Google BlueCard Marketplace if you don’t believe me. At least one part of Upstate New York still has a nationwide coverage option on the Marketplace if I’m not mistaken—as do Maryland, Hawaii, and even Florida, which is known for its poor ACA support. I only have familiarity with 6 states’ Marketplaces, and of these, already 4 of them do offer that coverage. (And, of the 2 states I know that don’t, there is one Marketplace plan in that state that claims to offer nationwide coverage, I just doubt it based on the reviews.) So please don’t be so quick to proclaim with absolute confidence that insurance is or isn’t a certain way! Laws in this country vary GREATLY among states and if you try to extrapolate from one state to the whole country, you are likely to be wrong.

Case in point: I used to live in one of the 4 states mentioned that DO offer nationwide Marketplace coverage. When we moved to a state that is in the 2 I know of without such coverage, I spoke with an insurance expert through the local chesed umbrella organization, who recommended that I maintain legal residency in my old state for the purpose of keeping better health insurance. We checked the laws of both states and in this case, it was fully legal for me to do so. Boy, am I glad I did. Right after we renewed our coverage in the old state, I was diagnosed with a complicated tumor which ended up requiring ~$1 million in medical treatment. B”H, I was able to get all of the surgery, scanning and treatments at the absolute top hospitals, with the top doctors in our new state—every penny of which was covered by my out-of-state insurance. (Not to say we didn’t pay anything out, but it was only copays. Insurance paid about 99% of the cost. I am well now, too—thank G-D!!!)

All this to say that yes, as of 2024 you can still get Marketplace insurance with excellent nationwide coverage in many states. Also, it seems that the vast majority of non-HMO plans do include some form of out-of-network coverage. Even HMOs will cover out-of-network (and, generally, out-of-state) in emergencies. Heck, even Medicaid will.

I don’t say that such coverage is cheap. My individual premiums were about $750 a month and when I added my family, it went to $1300, which, granted, is a stack of money. B”H we have help from my family to pay this particular expense or else we couldn’t do it. But I’m so glad we did.

azoygeshmak

Fri, Aug 09 2024, 8:00 pm

Hard-won Marketplace insurance advice:

Avoid United Healthcare and its subsidiaries like the plague. Trust me on this one.

If you have the option of BlueCross/BlueShield (or some state variant under a different name), and you can afford it, go with that. They are much better about everything and your life will be about 10000 times easier than with United.

A healthshare has a cap of $1,000,000 on lifetime coverage if I’m not mistaken. If ch”v you had a catastrophic accident or serious illness you could easily require twice that. Think carefully and have a backup plan (potential option below) before choosing a health share or short-term plan as your only form of coverage. You may be eligible for Medicaid, which is dirt cheap and will cover you MUCH better.

Pro tip: in many states, you can buy ACA-compliant plans privately, not through the marketplace, at any time of year. You don’t have to wait for open enrollment. You just need to be sure that the plan is in fact ACA compliant and does not have spending caps nor underwriting for preexisting conditions, if the latter applies to you. The other downside of buying privately is that you don’t get any income-based or other subsidies that could reduce your premium. But if you find yourself ch”v with a difficult medical need, and are underinsured, buying an ACA-compliant plan privately—through an insurance broker (recommended), or directly from the insurance company—could be a good option for you.

More pro tips if you need out-of-network/out of state coverage but don’t have it available through your marketplace:

1- Check every plan very carefully. Read the detailed benefits packet for exactly what you’re eligible out-of-network and call them if you have questions. A plan that’s available may suit your needs after all.

2. Consider being an official resident of a state that does offer out-of-state health insurance through the marketplace. This may be entirely legal, even if you live elsewhere, if you have another type of connection to the state. Check carefully on the laws though, and make sure you know the implications for car insurance, taxes, etc.

3. Consider getting a group health insurance plan by joining an LLC, as another poster mentioned.

4. Look in to a plan called Geoblue. It may work for you, and may be especially advantageous if you spend time abroad. The network is even more than nationwide, and it is ACA-compliant. I believe some other companies such as Cigna have similar options. You don’t have to live in a particular state to buy it, though it may be expensive.

Hope I could help. Hatzlacha!