Healthcare workers have terrible health insurance?

[y4m]

Is this normal? SIL is a nurse and her health insurance covers only her hospital network. No outside specialists or anything--just her health system.

Regular life health stuff is well covered through this system I guess. But SIL had an accident a few years ago and has lingering bone infection issues that don't seem to be resolving. I'd like her to see a specialist at a teaching hospital outside her system, but supposedly her insurance wouldn't cover that at all.

Does that sound right? That seems insane to me. Could she do Obamacare or something else to supplement and get some coverage for an outside network? Other ideas?

[orangeblossom]

Not uncommon at all, unfortunately. The same came be said for some health insurers, in that they're employee's insurance sucks.

Has she called the insurance company or HR to be sure it's not covered?

I'm not sure what system she's with, but most systems don't have every single specialty, and surely people have had to get care outside of their employer. It may cost more, but I'd ASSume it could be done.

If she's going on hearsay and what other coworkers are saying, she could be getting wrong info. Definitely talk to someone. Worst case scenario, tell her to look at her benefits and see if a health care advocacy firm is a benefit. They can help her come up with a solution.

Good luck to her.

[nomad100]

DH used to work for a hospital system (in IT) and left to work for a bank. His insurance is better now and costs less. So based on my limited experience, yeah, not uncommon.

[Deleted]

I worked for a major long term care corporation from 2004-2006 as a nursing assistant by night and an office manager by day. The only insurance offered was a supplemental health insurance plan that maxed out at $10k/year. The nurses and high level managers in administration were eligible for a better plan, but not great. When I moved up to a regional trainer/consultant over several facilities I still wasn't eligible for a better plan because my management level wasn't high enough. I'm sure all that has changed with healthcare laws, but I'd say it's still pretty shitty.

[kicks]

I think my coverage is good. We can only go to our hospital system as well, but that includes everything that you'd need for the most part. You do pay more if you go outside of our hospital system, but the prices still aren't outrageous.

Yes you can price out to see if the ACA would be a better option. The website is fairly user friendly to see which doctors accept certain plans and the costs.

[scout8]

Is there not a specialist in network that she can see? Typically, it will cost more and/or not be covered if she goes outside of network. If there is no specialist in network, is there any sort of exception? I would call the insurance company to discuss.

She can look for an individual policy on or off the exchange. Prices are high though and will probably be quite a bit more than she pays now.

[hamster]

My coverage is ok (deductible is higher than H's) but there used to be a strong preference towards our health system. We just switched companies though so I'm not sure what it looks like. Last year H's was more limited than mine and he is not on healthcare.

[yentl]

Yes, this is very common. I'm a healthcare provider and I do all the billing myself. Clients affiliated with healthcare systems either don't have coverage if they see me (I'm a specialist who is not affiliated with any hospital systems) or tend to have higher copays than if they were to see someone within their system.

[awkwardpenguin]

Yes, this is very common. We have a few options at our health system, but all the options that aren't "use only our health system" are substantially more expensive.

She can buy ACA insurance, but she would not be eligible for subsidies so she'd need to pay full price. It's an option I have considered for myself, but since my out of network health expenses are fairly predictable, it turned out to be less expensive to just pay the out of network providers out of pocket than pay for an Obamacare plan at full price.

[followyourarrow]

It's very common. My sister and BIL are both in the health industry. They have to stay inside their healthcare employer system.

[mich1]

I worked in a major medical center and had pretty good insurance. However. I had to make a choice of paying more OOP for having more flexibility of providers outside my service area or paying less and staying within our medical system as an HMO. I chose the former.

[dr.girlfriend]

We have plans ranging from HMO to PPO. That said, if the specialist you need is not available in network, you should be able to appeal to your insurance for them to contract with an out-of-network provider. My BIL has Kaiser, which is the original HMO, but they managed to get an out-of-network oncologist who specializes in his very rare type of cancer covered.

[y4m]

Nov 23, 2016 9:44:30 GMT -5 scout8 said:

Is there not a specialist in network that she can see? Typically, it will cost more and/or not be covered if she goes outside of network. If there is no specialist in network, is there any sort of exception? I would call the insurance company to discuss.

She can look for an individual policy on or off the exchange. Prices are high though and will probably be quite a bit more than she pays now.

There is a specialist in network, but that specialist does not seem to be up to the challenge of fixing this problem.  I think if she were able to get into a teaching hospital where they are being more innovative and are up on better research, she'd have better chances.  And there's one in her city, just not in her hospital group

[y4m]

She did get a settlement for her injury, so if we could figure out something that looked more like typical out of network coverage, I think she could make that work. But she's probably not in a position to directly pay cash for anything and everything, since this would likely require surgeries, PICC lines, expensive drugs, etc. at a minimum.

[mich1]

Nov 23, 2016 12:44:21 GMT -5 y4m said:

Nov 23, 2016 9:44:30 GMT -5 scout8 said:

Is there not a specialist in network that she can see? Typically, it will cost more and/or not be covered if she goes outside of network. If there is no specialist in network, is there any sort of exception? I would call the insurance company to discuss.

She can look for an individual policy on or off the exchange. Prices are high though and will probably be quite a bit more than she pays now.

There is a specialist in network, but that specialist does not seem to be up to the challenge of fixing this problem.  I think if she were able to get into a teaching hospital where they are being more innovative and are up on better research, she'd have better chances.  And there's one in her city, just not in her hospital group

She really needs to discuss this with the local specialist.  Only they can say that they are not up to the challenge of the problem and refer to a specialist that can fix her problem.  IME, the specialist will be covered at her insurance company's rates but it needs to be approved within her system.  I had this happen too, and I really, REALLY wish I had switched out to a PPO first, where I would have had more of a choice of providers.  If you do this, then your local specialist chooses and they may or may not be the best person for the job.

Does she have an OON option with her insurance?