r/HealthInsurance • u/Starlight-Seeker • Jul 27 '25
Plan Choice Suggestions How Screwed Am I?
My employer is changing from Cigna to Planstin Administration which is apparently something called a reference based pricing plan. What is this? Please explain this to me in the simplest terms possible.
My benefits manager said that before every single doctor's appointment and every single test (labs, x-ray, etc), I'll need to contact Planstin's Care Coordination Team. I have multiple chronic medical conditions. I see a lot of specialists, get a lot tests done, and take multiple prescriptions.
How screwed am I with this type of health insurance?
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u/LizzieMac123 Moderator Jul 27 '25
https://resources.planstin.com/help-center/what-is-reference-based-pricing03de4340
Basically, your insurance now has a max price theyll pay for every cpt visit, test, procedure- regardless of which provider you go to. So, you taking an active role in finding the cheapest price is going to save you the most money.
Pros are typically- you can pick any provider you want to go to.
Cons are that the referece price may not cover the full cost, leading to balance billing if there is no network agreements between insurance and the doctor.
In my opinion, this is NOT a good set up and its a sign of either a struggling company trying to save a buck or a company that doesnt care about its employees as now you have to call around to find the lowest prices.
If your plan has generous allowances and/or you have ample doctors near you, it will be easier, but if its something like 150% of medicaid pricing, that is going to be harder because medicaid has such low reimbursements, thats why many doctors arent in network with medicaid.
If i were you, id start looking for a new job.
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u/outsideman1986 Jul 27 '25 edited Jul 27 '25
One really important and complicated note: the No Surprises Act still applies to reference based plans even though they do not have a traditional network - at least for emergency care. If you are experiencing or believe you may be experiencing an emergency and you receive care from an out-of-network provider or at an out-of-network facility, you cannot be billed for any amount greater than the in-network cost sharing amount - even if the plan does not have a network.
What this means in practice is that the out-of-network doctor/facility can’t charge you more than what your plan tells you to pay on your EOB. You cannot be balance billed for emergency care. EDIT: worth noting that even many insurers, providers, and facilities don’t realize this. If your EOB arrives and says “you may owe the balance of the full charge amount,” then the EOB is incorrect. You would only be responsible for the patient portion of the reference amount.
This is a lot more complicated on the non-emergency side. Non-emergency care is only protected under the NSA if you are treated at an in-network facility. If your plan does not have in-network facilities, these non-emergency protections will not apply.
SOURCE: CMS
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u/Specialist_Dig2613 Jul 27 '25
If I were you I'd take the job because of the insurance. You payroll deductions could easily be half of a network plan with better benefits. The number of doctors that won't be happy with 150% of Medicare pricing is tiny. It's absurd to denigrate companies that choose RBP plans. Companies that have network HMOs with high deductibles are the ones that hate their employees.
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u/LizzieMac123 Moderator Jul 27 '25
I have experience with a "cash-pay" system that works through employer insurance. If one of my clients needs something like complex imaging or surgery, this program reaches out to potential providers and tries to negotiate a cash price that is then paid in full before any of the care is recieved. The self-funded employer plan covers it in full with often zero cost to the patient as a reward for going to a lower than average cost provider.
They strive for 225% of medicaid and arent always able to get a provider that will agree to 225% of medicaid- so that was my basis for saying 150% (which is what that RBP TPA's own website uses as an example reference point) may not cover the patient's cost fully and result in significant balance billing.
I also understand that employers are trying to get a grip on healthcare costs- but there are better ways to do this that dont put as much burden on the employee to have to shop around for a provider that will balance bill them the least. I would suggest an ICHRA over an RBP plan any day.
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u/QuantumDwarf Jul 27 '25
That’s honestly wild. I’ve seen providers completely unwilling to even sign a Single Case Agreement for OON care for MONTHS and months. I would not want to rely on a system like this for my loved one who was in excruciating pain and needed two wrist fusions over 2 years from different hospital systems.
I can’t imagine if getting PAs, claims paid, etc is such an administrative burden (and it is!) that doing all that PLUS negotiating a rate for anyone that needs care is going to be any better.
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u/SuspiciouslyGreat23 Jul 27 '25
Very thoughtful response, so I say this with respect but I work with clients that use RBP and only 1% get balance billed and as long as the employees let the employee know, they take care of it 100%. Employees pay 50% of premiums than they used to and have little to no out of pocket costs and they can go anywhere they want. No calling ahead.
I think the industry is way too big to paint with a broad brush with solutions like these. RBP vendors have come a long way and we have happy clients and happy employees.
On the other hand, this sub is full of employees complaining about major medical insurance with "BCBS" or any other major carrier with high out of pocket costs and likely high premiums.
It's all about education so people know what to expect, but if people want to pay more to not deal they can always go through the exchange.
I also don't agree ICHRAs are better as employer-sponsored coverage is almost always more generous and less costly than the individual marketplace plans.
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u/QuantumDwarf Jul 27 '25
Uh… working in the industry there’s virtually no provider who will accept 150% of Medicare. Even less who will accept 150% of Medicaid.
It might be a ‘fine’ choice for people who are otherwise generally healthy but absolutely horrific for anyone with a chronic illness.
Every plan I know who went to RBP either carved out their execs onto a ‘normal’ plan with OOPM / low copays / etc or switched back as soon as someone at the exec level had a family member who actually needed care.
So ironic as they are the ones who could actually afford RBP, but hey - execs gotta exec!
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u/IndyPacers Jul 27 '25
It's funny how different experiences can be.
I've seen cancer treatments, open heart surgery, etc all be done through reference based pricing programs. I'm confident I've had clients pay out at least $30mil in claims on RBP over my short career.
RBP has some struggles, not going to act like it doesn't. But it also works in many areas great.
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u/QuantumDwarf Jul 27 '25
Your clients - employers? How many people with chronic illnesses have you talked to about their experiences before and after RBP?
I am sure it IS great for employers - another way to pass the cost of health care that THEY can’t afford to their employee.
Everytime I see a company who says they can’t afford the cost of their employees healthcare I wonder how they think their employees are going to be able to afford paying all of the balance bills above the ‘fair price’ that they pay.
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u/IndyPacers Jul 27 '25
I promise you, I have talked to hundreds of employees. My phone # goes out as part of open enrollment and ongoing communication.
RBP alone doesn't support employees. I agree, no argument from me.
But direct contracts at better prices than default networks with at least 75% of the most commonly utilized providers and facilities for that particular groups claim history, wrapped with well trained advocacy and RBP works very well. Maybe throw in DPC or a mobile clinic to support folks more, depending on what the budget allows.
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u/EmberOnTheSea Jul 27 '25
The number of doctors that won't be happy with 150% of Medicare pricing is tiny.
Such a ridiculous statement could only come from someone on the sales side of things.
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u/Comntnmama Jul 27 '25
In my experience on the Dr office side, a lot of those pts had to pay upfront and be reimbursed like a cost share plan.
I'd look for a new job ASAP.
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u/Specialist_Dig2613 Jul 27 '25
And how is an ERISA plan where the plan is obligated to reimburse anything paid by an employee at the amount paid minus a copay like a cost share plan, where it may or may not happen? It isn't. At all.
Take the job. Ignore the comment.
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u/Comntnmama Jul 27 '25
He already has the job. It's usually a sign your employer is having issues.
On the health care side, people don't end up getting the care they need when they are required to front the insurance companies portion and wait for reimbursement.
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u/CuriousKatMiny Jul 27 '25
This sounds like my husbands new insurance, Sidecar Insurance. Huge rip off and we would probably have better luck being uninsured because they cap prices for every little thing. No 80/20, just “this is what we pay, you go find a cheap provider, and then if you find someone below the amount we pay, we return a whole 50% of the savings! Not all the savings, just half. Welcome to sidecar“.
All I can say is that it’s a freaking nightmare.
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u/Electrical-Ebb-8049 Jul 28 '25
I'm curious how long you've been on it u/CuriousKatMiny. I'm coming up on a year and our family's made around $800. Plus we have lower premiums (saving about $600/mo) and we can see literally any provider we want. Sometimes we do choose to pay more for a certain doctor but in almost every case that amount has been less than our old plan's copay.
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u/CuriousKatMiny Jul 28 '25
Only a few months. Our monthly premium is actually $75 higher than we were paying, and we were previously given a $3000 FSA card that was taken away. This has not saved us a dime. A normal Dr visit would have a copay and cost $50. I’ve only gone to the Dr once since we had it switched on us and it and it cost me $230 out of pocket. Because I was sick and needed an antibiotic. Now, I’m scared to return if I get sick again. In fact, I can’t even use the “credit card” issued by the insurance company until that balance is paid off (which it has about $50 balance left).
We have to get our two kids a wellness check and vaccinations before school begins in august. This previously cost us NOTHING. I’m literally so anxious about what these visits are going to cost us now. They won’t be free!
Not to mention having to submit all the information to the insurance myself. Like, the convenience of the dr office doing all that and me paying copay was well worth it so that I didn’t have to do all the legwork. And they want the sick and ill to “shop around for the best price”?! Give me a break, since when I’m sick id much prefer to go by whoes the best provider, not who offers a discount.
It’s SO embarrassing trying to explain the insurance to a doctor office. The corny script the insurance company sends to assist with this can suck it.
It’s cool you’ve had a good experience, but we have not, and only see this getting worse.
SidecarInsurance
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u/QuantumDwarf Jul 27 '25
I would run as fast as I could to somewhere else.
There are a lot of what I call snake oil salesmen who think they can ‘disrupt healthcare’ and find a simple solution to lower the cost of care.
One I worked with came up with a brilliant idea that anyone needing MKS surgery should just drive 4+ hours one way to have it done at a lower cost facility. Bypassing literally 10+ providers on the way. Never mind that the facility didn’t have access, or that you have to drive for multiple pre and post appointments or that where I live the winter could make it incredible dangerous to drive that much. He convinced so many people this was a good idea
Healthcare needs a good disruption but this is disruptive to anyone needing care.
The reason your employer is doing this is to save money. That’s all they care about. Saving money so their financials meet their goal of more and more profits for those at the top.
I would run, but then I don’t know the job landscape where you live.
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u/branchymolecule Jul 27 '25
The employees will have to spend half the day on the phone trying to find a provider who will see them for an affordable price while the company falls further into deficitland.
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u/Desert-Democrat-602 Jul 28 '25
This is the real cost - how much time do your employees waste during the work day trying to get a doctor who will take this awful excuse for insurance? Factor that in, and there is NO savings at all. Likely the opposite.
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u/Packing-Tape-Man Jul 27 '25
This is a really bad sign that your employer is struggling (or run by sociopaths). Independent of your short term questions about how the coverage will work, you may want to start looking for your alternative employment options.
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u/MountainFriend7473 Jul 27 '25 edited Jul 27 '25
I’d look into marketplace plans because it would be one thing if you had an annual check and a blood draw and that was it. But that’s so much effort on your end at this point if you’re looking at much more specialized care than that.
Or I’d look for another job all in all
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u/Initial-Success-5073 Jul 27 '25
You shouldn’t have to seek out the cheapest care.
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u/Dapper-Palpitation90 Jul 27 '25
Why not? You probably would if you were paying your own bills. Why should you be less careful with somebody else's money than you would be with your own?
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u/VelvetElvis Jul 28 '25
Benefits are part of employee compensation, no different than salary. From the moment you sign an employment contract, they are yours by legal right. It's not "someone elses money."
When an employer swatches to cheaper insurance, it's a pay cut and an ample reason to seek new employment.
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u/mholger Jul 27 '25
Because cheapest(now) and cheapest(long term) are very rarely the same thing, and I would expect any decent benefits administrator to manage the plans funds for the long-term but most individuals don’t have that luxury, so on their own they would be shopping for cheapest immediate solution.
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u/SuspiciouslyGreat23 Jul 27 '25
If you call, you may find them helpful for coordinating your care and you should be paying significantly less for premiums and out of pocket costs.
If you know you don't want to deal with all that, then sure look for a new employer. However, I will say you may be hard pressed to find an employer who can afford to offer insurance that is (1) low premiums (2) low out of pocket costs and (3) has no restrictions. If you can find some, let us know.
HMOs, HDHPs, etc. all generally satisfy 2/3. Any carrier limits you by the network.
Employers are scrambling to find better ways to deliver all 3 but it only happens with some engagement from employees.
RBP CAN be one of those ways, but without more details cannot say for certain. In my experience with clients, when we roll out RBP solutions, employees are asked to call but not required to. The plans cost 50% less or more and typically better benefits (lower copays, lower deductibles etc.). There is a risk of balance billing, but it should be small and the employer may already have a way to address that.
I would first ask about what happens if you don't call and what happens if you get balance billed. If they don't commit to helping remove that risk, then definitely leave!
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u/Accomplished_Boat499 Jul 27 '25 edited Jul 27 '25
Agree. There are several RBP plans that work well, but it depends on a lot of factors on how the plan was setup. Is there balance bill protection built in? I would assume by using the concierge there is.
A few things to consider… on some plans you can have RBP for hospital services but a PPO you can use for providers, urgent care, etc.
For prescriptions, RBP shouldn’t be a factor but you’ll want to ask for the formulary list and check where/how your scripts are covered.
Lastly, it’s very location dependent. For example, if you only have one major hospital system around you, they are more likely to push back on how your plan pays and balance bill.
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u/Initial-Success-5073 Jul 27 '25
Doesn’t look good. Just another third party who will scrutinize your every need. You will need them to with you going for care
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u/SorryHunTryAgain Jul 27 '25
I, curious. Does this type of plan protect you with a max out of pocket amount?
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u/Starlight-Seeker Jul 27 '25
They haven't given us those details yet. We're supposed to receive the information on Tuesday.
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u/steven132929 Jul 28 '25
It is the absolute worst. Had to deal with it during the birth of my first kid and we fought bills for forever. They rejected the claims for a variety of reasons always a new excuse.
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u/VibrantGoo Jul 27 '25
My insurance unfortunately uses it. I hear it's best to go to private offices and get lab work done at LabCorp or Quest. Avoid large hospitals if you can as they are unwilling to negotiate to a lower price. You can have your doctors order tests outside of their facility - just ask.
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u/Comfortable_Two6272 Jul 27 '25
Curious if this meets minimum plan requirements under ACA? Or if op would now be eligible for ACA subsidy (provided meets income requirements)?
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u/Starlight-Seeker Jul 27 '25
I'm being told it does meet the minimum requirements for the ACA.
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u/Comfortable_Two6272 Jul 28 '25
I believe they need to provide written statement to that. Its been awhile since come accross non traditional employer insurance though.
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