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/branchymolecule Jul 27 '25

Thank you for a clear and concise summation.