In Network Prices

[Derekweb]

Can someone help me with a few questions?

I am moving from employer coverage to individual coverage and need to do some spreadsheet work to chose the best plan for my case.

Are the in-network contracted fees the same for the network (say Aetna or UHC) regardless of what plan the participant chooses? For example, if I chose the Aetna network on the individual plan, are the contracted amounts the same? Can I use these fees to calculate my portion of the payments if the network is the same but the coverage using that network is different?

Also, anyone know where to find these fees published somewhere? DO they need to be filed with state regulators?

 

[somarco]

Most carriers have several networks and the group network usually is not the same as individual. Under Obamacrap the individual networks are mostly much smaller than pre-2014.

Provider "fees" are proprietary and vary by provider even within the same network.

 

[Derekweb]

Can I assume the fees will be much higher in an individual plan than in the employer group plan, even in the same network from the same carrier?

 

[Josh]

Can I assume the fees will be much higher in an individual plan than in the employer group plan, even in the same network from the same carrier?

You can make any assumption you'd like, but it's not that direct/simple. Unfortunately one of the greatest problems we have with our current healthcare system is a lack of transparency in cost. I would suspect they would be similar, but you'd have to know the exact plans, exact services, and exact providers to make the comparison. Usually the larger discrepancies are going to come into play when you're talking about Medicare vs Medicaid vs private health insurance as opposed to group vs individual.

 

[Derekweb]

Can I assume the fees will be much higher in an individual plan than in the employer group plan, even in the same network from the same carrier?

I am moving from employer coverage to individual coverage and need to do some spreadsheet work to chose the best plan for my case.

Are the in-network contracted fees the same for the network (say Aetna or UHC) regardless of what plan the participant chooses? For example, if I chose the Aetna network on the individual plan, are the contracted amounts the same? Can I use these fees to calculate my portion of the payments if the network is the same but the coverage using that network is different?

Also, anyone know where to find these fees published somewhere? DO they need to be filed with state regulators?

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Somebody must know if the same network is used by differing coverage plans, is the fee paid to the provider the same amount for the same procedure?

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Somebody must know if the same network is used by differing coverage plans, is the fee paid to the provider the same amount for the same procedure?

 

[somarco]

I addressed most of your questions yesterday. Not sure what happened.

The fee structure is proprietary. Not filed with the DOI or any public entity. Fees vary by network, even with the same carrier.

 

[kgmom219]

1. I have no idea where you are located, but you need to find an agent to advise you.
2. The questions you are asking, while they should be easy, are very difficult to answer. And will vary state to state, carrier to carrier
3. It sounds like you might have some medical issues that are ongoing. If you want to get that specific, you need to contact your current providers and ask THEM what their fees are for procedures on different networks and/or carriers. They may tell you, they may not.
4. Assuming there are medical issues that include prescriptions, you should also look at the plans formulary

Good luck!

 

[Derekweb]

Thanks for your comments. I am only looking for the answer to this question.



Same insurance company, different coverage plan, same network, same provider, same procedure, same year, SAME FEE or DIFFERING fess paid to provider?

 

[leevena]

A couple of things.

1. Answer to your question is that they could be the same or could be different fee. The reason why there might be a difference is the plan. A network may contract with a carrier that offers two different plans (HMO vs PPO, or larger vs. smaller network choice, etc.) and those contracted reimbursement rates may be different.

2. Your decision making is flawed. Instead of comparing the underlying reimbursement fee structures, you should make your decision based on; 1) what expenses you could expect to incur, 2) the benefit schedules available, and 3) the costs of those schedules.

3. You cannot assume that fees will be much higher in an individual plan than in the employer group plan. In fact, you should not make any assumptions about any plans/fees.

4. Reimbursement fees are readily available, if you are willing to either pay for them or work to find them. Every locale is different, so I cannot tell you how to access them

 

[Derekweb]

Thank you for the response. It was very helpful. Of course I was not making a decision based on fees alone, I already have all the other info you mentioned.