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#1 Posted : Friday, December 7, 2018 7:47:08 PM(UTC)

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For those wanting an FFS plan, the untold secret I learned this past month is to no longer focus on deductible or percentage coverage amounts offered by the plan. Those amounts are meaningless if your plan is setting fee rates for medical procedures using the Medicare fee rate schedule and not Fair Health (a non profit used by New York). For example, a plan may offer to pay 80% percent for an out of network charge, which sounds great. Except... the insurance company is only willing to pay 80% of the APPROVED fee amount of $100 even though most doctors in your area charge $1000.00. During one call, Blue Cross quoted me a plan allowance rate that was less than the Medicare rate for a certain procedure. Add in, it wasn't until I asked for multiple supervisors that I was able to even find out this information.

If you don't expect to have any health issues, then don't worry. But if you or your family want to make sure you are properly insured or have health issues, make sure that you are covered and that you understand how your insurance company determined the amount it is going pay for your out of network procedure. Also keep in mind that the so called maximum out of pocket amounts are based on the plan allowance rates and not what you actually paid to your doctor.

Good luck everyone! Other than those in New York who are fortunate to have benefitted from that law suit requiring in insurance companies to follow Fair Health Standard rates, I don't see this issue getting resolved anytime soon for the rest of us.
#2 Posted : Monday, December 10, 2018 3:11:08 PM(UTC)

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I think the best thing to do is to make sure your doctors are in network to your FFS plan. If they aren't and you want to keep your doctors, then to find a plan where they are in network.

If you want to keep your plan and your doctors are not in network, then to find doctors you would want see who are in that network.

I think for most jurisdictions, the large size of federal employee plan networks should provide a good selection of doctors.

For your example where the plan might approve a fee of $100 but doctors will charge $1000 for the same service, why should we expect a doctor to sign up with the network if he/she knew the plan would approve $800?

#3 Posted : Wednesday, December 12, 2018 5:29:07 PM(UTC)

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Always read the whole brochure about how out of network rates are set. The following thread is old but illustrates the vast differences in how plans calculate out of network benefits:

Some plans, like Foreign Service Benefit Plan, have favorable calculations.
Others do not.
#4 Posted : Thursday, December 13, 2018 3:12:07 PM(UTC)

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Pete says the allowances for out of network care are meaningless if based on the Medicare rate, which suggests he is not yet Medicare age.

For those Medicare age, Medicare rates are used all the time in FFS plans whether or not the FEHB enrollee has enrolled in Medicare Part B and whether or not the care is received in or out of network.

My question is, for plans such as BC Basic which have little to no coverage for non network care, is the enrollee still entitled to the Medicare rate, which presumably he/she would pay entirely out of pocket?

In such an instance, in denying the care out of network, would the FEHB plan at the same time indicate the Medicare rate and advise the enrollee there is no plan allowance but the Medicare rate is the limit? If not, how would the enrollee obtain the Medicare rate? How would this work?

If the answer to this question is covered in plan brochures, I've never seen it.

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