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My conclusion was that if you're young/healthy, HMO vs PPO may not matter as much. That said, I went with a PPO because in my case: (1) it's faster to see a spe

My conclusion was that if you're young/healthy, HMO vs PPO may not matter as much. That said, I went with a PPO because in my case: (1) it's faster to see a specialist, since a referral is not required; and (2) in my area, it has vastly more in-network doctors who are highly-rated. One gotcha I've run into is that most plans (both HMO & PPO) are only valid in a single US state. The one exception is "emergencies," but when I asked it seems this is basically only the ER (and I was told only if it turns out it's actually an emergency, whatever that means). I believe you can get out-of-state covered via out-of-network. But as mentioned, the out-of-pocket max on my plan is shockingly ~6x more for out-of-network than in-network. So you won't pay 90% of $200k, but it will still end up a very substantial amount. But maybe that could still be worth it to see an out-of-state specialist?

zamfi 3y ago
> I believe you can get out-of-state covered via out-of-network. But as mentioned, the out-of-pocket max on my plan is shockingly ~6x more for out-of-network than in-network. So you won't pay 90% of $200k, but it will still end up a very substantial amount. But maybe that could still be worth it to see an out-of-state specialist? See, this would be the expected, plain reading of out-of-network vs. in-network deductibles and coverage. But be very, very careful with out-of-network: the truth is that your insurance only covers whatever percentage they claim they cover of the "usual and customary" charges for out-of-network care, not the the actual charges you receive. Because out-of-network providers are by definition not contracted with the insurance carrier, they can (and do!) charge you whatever they want. And then your insurance only pays for 10% of that, because they then claim that the "usual and customary" charge for whatever care you received is only 10% of what your provider charged you. (And, of course, the out-of-pocket max for out-of-network care is only for "usual and customary", not any charges beyond that—so it offers basically no protection.) ...which leaves you with a bill for 90% of $200k that you're not particularly in a position to negotiate—neither with your insurance company, which has no incentive to cover it, nor with your care provider, which has already billed you and will happily send your bill to collections (most of the time, though not all the time) and take XX% of it rather than give you a 90% discount. So: on the one hand, you have zero price transparency before you receive care; on the other hand, your insurance contract has terminology that implies one thing but hides the reality behind reasonable-sounding legalese. One would be hard-pressed to design a worse system.
- ryandrake 3y ago
  I’ve always thought the whole “in-network” “out-of-network” thing is such a scam—a booby trap set to trip you up so you end up owing a fortune. You carefully went to an in-network hospital to see an in-network doctor, but SURPRISE a non-network doctor happened to stop by to draw blood and boom, you now owe 90%! Sucker! I don’t know why it is the way it is but it sucks. What even is this in/out distinction if not a conspiracy to fleece the public? I’d be in favor of regulation that simply makes all doctors in-network for all insurances, period. Get rid of the unnecessary complexity minefield.
  - zamfi 3y ago
    This particular surprise (out-of-network provider in an in-network facility) is getting addressed, albeit slowly -- surprise bills like these are not allowed in many states. But it wouldn't surprise me if they were still coming in under the assumption that most people don't know they're disallowed.
deleted 3y ago
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zamfi 3y ago

> I believe you can get out-of-state covered via out-of-network. But as mentioned, the out-of-pocket max on my plan is shockingly ~6x more for out-of-network than in-network. So you won't pay 90% of $200k, but it will still end up a very substantial amount. But maybe that could still be worth it to see an out-of-state specialist? See, this would be the expected, plain reading of out-of-network vs. in-network deductibles and coverage. But be very, very careful with out-of-network: the truth is that your insurance only covers whatever percentage they claim they cover of the "usual and customary" charges for out-of-network care, not the the actual charges you receive. Because out-of-network providers are by definition not contracted with the insurance carrier, they can (and do!) charge you whatever they want. And then your insurance only pays for 10% of that, because they then claim that the "usual and customary" charge for whatever care you received is only 10% of what your provider charged you. (And, of course, the out-of-pocket max for out-of-network care is only for "usual and customary", not any charges beyond that—so it offers basically no protection.) ...which leaves you with a bill for 90% of $200k that you're not particularly in a position to negotiate—neither with your insurance company, which has no incentive to cover it, nor with your care provider, which has already billed you and will happily send your bill to collections (most of the time, though not all the time) and take XX% of it rather than give you a 90% discount. So: on the one hand, you have zero price transparency before you receive care; on the other hand, your insurance contract has terminology that implies one thing but hides the reality behind reasonable-sounding legalese. One would be hard-pressed to design a worse system.

ryandrake 3y ago
I’ve always thought the whole “in-network” “out-of-network” thing is such a scam—a booby trap set to trip you up so you end up owing a fortune. You carefully went to an in-network hospital to see an in-network doctor, but SURPRISE a non-network doctor happened to stop by to draw blood and boom, you now owe 90%! Sucker! I don’t know why it is the way it is but it sucks. What even is this in/out distinction if not a conspiracy to fleece the public? I’d be in favor of regulation that simply makes all doctors in-network for all insurances, period. Get rid of the unnecessary complexity minefield.
- zamfi 3y ago
  This particular surprise (out-of-network provider in an in-network facility) is getting addressed, albeit slowly -- surprise bills like these are not allowed in many states. But it wouldn't surprise me if they were still coming in under the assumption that most people don't know they're disallowed.

deleted 3y ago

[deleted]