MA PPO Out of Network Charges

[yorkriver1]

After searching archives, I didn't find this topic. I am not recalling if this was in any of my training, and am not locating it in my materials. Need accurate source for what an MAPD PPO plan uses as a guide for maximum charges for an out of network doc. Do they use Medicare approved amount?
The agent help desk at the carrier has no idea. They say only CMS can tell me that. Huh?
My client will pay 30% "of the cost" according to the plan's Summary of Benefits for a non-network provider. The client has an appointment soon, and I want to give them some idea of the danger here, so they may be willing to seek out a network doc.
Learned my lesson. Our trainer did warn us to call the PCP office to confirm they are in network. Old info in their system if doc doesn't notify them of dropping out, changing offices, etc.
In under 65 insurance the out of network claim is paid at a % of "Usual and Customary", which gives no upper limit to the clients exposure, only to that of the carrier. My guess is that they use Medicare Allowable for the 70% the carrier will pay, and then, hmmm, what if the doc is one who doesn't take Medicare at all? (not the case here, but it's a question..I suppose they wouldn't take too many Medicare patients either)
Thanks for helping out a relative newb. Was I alseep during AHIP slides....probably.

 

[Josh]

If they're par with Medicare then they're going to be using that as a basis. With Original Medicare they would be paying 20%, with this they're paying 30%. There is the potential for some excess charges as well, but the best next step would likely to be to ask the provider.

Why are they going to see a non-par doc? They are usually going to have another deductible for being out of network too, above and beyond the coinsurance.

 

[yorkriver1]

Reply appreciated. I have just been reading the "Evidence of Coverage" for the specific plan on the carrier website, which is helping answer my questions. Thought of it just after posting this. I just had a brief lapse not remembering that the MA plans operate with Medicare's rules for paying docs.

It's what you said. The doc will bill the carrier, and from reading the EOC, the insurance won't pay anything to opt out docs, just as Medicare wouldn't. So, no, the client isn't going to an opt-out doc. Then, the only question would be is the doc par or non-par, & do they charge excess, which is legal in my state.

Thanks for pointing out that the client will be paying more OOP for OON doc 30% vs 20%.
Not some huge $ involved here, so the client may go ahead for convenience.
Will suggest she seek PCP in network, maybe from the specialists in network she trusts.

 

[BobbyMcGee]

Better check on the Plan's MOOP as well for out of network.

 

[yorkriver1]

Total OOP is $3,000 higher for "in and out of network" than for "in network". Yes, the client needs to be reminded that out of network is not a casual decision, particularly for high dollar expenses. The occasional visit to a non-network PCP may not be so bad.
I will suggest she look for a network PCP. We will call to confirm whether all her specialists are in network, for certain.
Thanks for OOP reminder.

 

[Josh]

Thanks for pointing out that the client will be paying more OOP for OON doc 30% vs 20%.
Not some huge $ involved here, so the client may go ahead for convenience.
Will suggest she seek PCP in network, maybe from the specialists in network she trusts.

Let's not ignore the deductible, if it's a $1,000 OON deductible they'll basically be paying cash for the services.

 

[yorkriver1]

No deductibles for services on this MAPD PPO. It's all copays or % of charges for in and outpatient services. Hospital is $250/day for 1st 7 days, $0 after, for example.

Thanks for adding to the discussion.