Providers (like doctors, hospitals, labs, etc) who subscribe to network plans like PPOs, POSs or HMOs, agree to a pre-negotiated/contracted rate for each & every service they can possibly render. If you enroll in some sort of a network plan (such as an HMO or a PPO), you will benefit from those pre-negotiated rates before & after reaching your deductible, providing the benefit is considered “covered benefit”.
If by high deductible health plans (HDHP), you are referring to Health Savings Account (HSA) eligible HDHP, there is another way you can insure getting negotiated rates and that is by finding an HSA administrator that offers “Auto Reimbursement”. I am aware of a couple of institutions that offer Auto Reimbursement & the one that checks your claims against negotiated rates is Sterling Bank. You can learn more about Sterling Bank through the link below;
Keep in mind a licensed agent that deals with multiple carriers can help you with most of this information as well. You can find a local agent or look online for an agency (like www.eHealthInsurance.com where I work).
I am a care manager at a Health Insurance Company. I expected to see the insurance company "ripping" members and providers off. But I was very surprised to find that
things are done quite ethically.
The best source of health insurance informaton on the web is ahip.org, the website of America's Health Insurance Plans. There is a section with consumer information and a health insurance guide on it.
Snaildarter, you were right about the pre-arranged prices by contract for in-network providers. The term used is "contracted amount". If you have an hmo or a ppo and you go to an in-network provider, that provider CANNOT charge you anything beyond the copayment or coinsurance. To do so is called "balance billing", and it is fraudulent.
I'm not familiar with the High Deductible plans, but I was offered one and tried it for a day. The thing I was not told is that I could not use it and my husband's regular insurance policy at the same time (no coordination of benefits). I immediately called the insurance company and told them that I did not want the insurance!
If your major concern is affordability, you might be more interested in the HMO product. It generally gives you lower copayments and covers more medical needs. If your major concern is staying with a favorite provider, you probably want a PPO--and check to see if your provider is in that network before you sign up. If your employer changes insurance carriers somewhere down the road, you can try to get a "transition of care" to have that provider handled as in-network for a few months. If there is a sound clinical reason why that provider is the best provider for you, you may call customer service of your insurance plan, talk to in intake care manager, and make the case to get a "single case agreement", which may allow you to see an out-of-network provider as though they were in-network.
I want to post what I've found out... which isn't much. It seems that maybe the way it works is that managed-type plans, like HMO's, PPO's, etc., have pre-arranged prices by contract. So even before the deductible is met, the price has already been fixed, despite whatever the doctor/hospital may bill. I think it only works this way for in-network doctors/hospitals. Out of network, I think it becomes a battle between the insurer and doctor/hospital. But surely, the insurance company will not care to fight for good pricing very much before the deductible is met.
I think that with indemnity plans, it is like always being out of network. So only a very small incentive for the insurer to fight for low pricing for you until the deductible is met. And especially so if you have a high deductible.
I may be completely wrong, but it has been hard to find knowledgeable (and impartial!) information about this.
I think I'll probably go with a high deductible, PPO, HSA type plan.
Thank you for your help. Amir, your information clarifies things a bit. I had asked someone at ehealthinsurance.com before I posted this, and I'll just say that the person I talked to is not as knowledgeable as you, and was not helpful.
Amir, to further clarify, why does an HSA administrator, even one that does auto Auto Reimbursement, care whether or not I get the contracted rates? I don't see what their financial interest is in getting me those rates, especially since it seems to me like it would be a costly hassle for them. And looking through Sterling's site, they don't seem to brag about it anywhere that I can find. If what you say is true, then that is a major selling point, and Sterling should advertise it heavily.
Also, is the sterlingsavingsbank.com of which you speak the same as sterlinghsa.com, the one offered by eHealthInsurance? They seem to be different.
Thank you much
I am glad you found the information useful. You are correct about the difference between sterlingsavingsbank.com & sterlinghsa.com. I am verifying more details about auto-reimbursement feature of sterlinghsa.com & once verified, will post more information.
Thanks for giving eHealth a chance. You can reach me at extension 2628 if you want to chat in person.