How Screwed Am I?

[u/Starlight-Seeker]

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?

[u/LizzieMac123]

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.

[u/outsideman1986 → u/LizzieMac123]

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

[u/branchymolecule → u/outsideman1986]

Thank you for a clear and concise summation.

[u/Specialist_Dig2613 → u/LizzieMac123]

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.

[u/LizzieMac123 → u/Specialist_Dig2613]

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.

[u/QuantumDwarf → u/LizzieMac123]

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.

[u/SuspiciouslyGreat23 → u/LizzieMac123]

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.

[u/QuantumDwarf → u/Specialist_Dig2613]

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!

[u/IndyPacers → u/QuantumDwarf]

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.

[u/QuantumDwarf → u/IndyPacers]

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.

[u/IndyPacers → u/QuantumDwarf]

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.

[u/EmberOnTheSea → u/Specialist_Dig2613]

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.