Ambetter. / Cigna PPO .... Plan docs?

[GreyDawg]

I am trying to compare the Ambetter PPO that uses the Cigna network to the FLBlue options, but cannot find documents with the nitty-gritty details of the Cigna PPO.  Does anyone have a link to the docs?

 

thanks. 

[Blues]

Where are you getting that Ambetter uses the Cigna network?  Ambetter's website has a provider finder, and it doesn't mention Cigna, and from what I can tell from entering a bunch of difference zip codes in the provider finder, Ambetter doesn't have in-network providers in states where it doesn't offer policies.

[GreyDawg]

Kyle's site, rverinsurance.com option #2.

Potentially very promising for Xscapers but I need to see the details.

[Zulu]

14 minutes ago, GreyDawg said:

Kyle's site, rverinsurance.com option #2.

Potentially very promising for Xscapers but I need to see the details.

For one thing, you need to be working 30 hours a week.

[Blues]

40 minutes ago, GreyDawg said:

Kyle's site, rverinsurance.com option #2.

But you asked about "Ambetter PPO that uses the Cigna network."  There's no mention of Ambetter in Option #2.

[GreyDawg]

Yes. This is apparently a union group health plan administered by Ambetter which uses the Cigna network.  That is what I am trying to get details on.

and yes, you need to work 30+ hours per week ... Which is why it might be suitable for self-employed Xscapers.

[mkc]

Quote

On 11/1/2017 at 9:14 PM, GreyDawg said:

Yes. This is apparently a union group health plan administered by Ambetter which uses the Cigna network.  

 

Where are you finding that it is an Ambetter plan?  I don't see any mention of that on Kyle's site. 

"The reinsurer is Amalgamated Underwriters. They are A+ AM BEST rated. American Healthcare is the pharmacy benefit manager on the plan. Cigna is not the insurer–only the network here."

[GreyDawg]

Yes, you are right. Somehow my (very tired after three days of looooong drives) mind turned Amalgamated into Ambetter

Alamgamated makes me a bit nervous:. I have heard of Ambetter for health insurance, but not Amalgamated.  I don't know that "the reinsurer is ... " means .

maybe next week I will pester Kyle. 

[Blues]

Since Ambetter has been mentioned, I'll throw in something, in case someone's considering them. 

Last year, on the Ambetter website I would click on TEXAS as my state, and then look for providers.  The vast majority of doctors and hospitals they had were in the area around Austin, Dallas, and the Rio Grande Valley, and I don't t remember any any outside Texas at all.  Obviously not good for a fulltimer, even one who only bounces around cities in Texas, since they don't provide any out-of-network coverage at all.

But yesterday I looked for providers on their website, and when I clicked on TEXAS as my state (as I did last year), it showed lots of providers outside Texas when I would enter various zip codes.  So maybe the Ambetter network isn't just the customer's local area any more.

The rub is that they have providers, with only a very few exceptions, in only the 15 states where they offer policies, and the Ambetter policies I've looked at provide no out-of-network coverage at all except for emergencies.  But if your travels keep you in the states they cover, it might work for you.  It is a PPO.

You can see the states where they offer policies, and look for providers here:

https://www.ambetterhealth.com/find-a-provider.html

I would definitely confirm (probably more than once) that a person's network extends to any state where Ambetter writes policies, and that this isn't just some sort of website glitch. 

And I still think the Blue Cross PPO option is better because it's not limited to 15 states, but if for some reason that's not available, if Ambetter's available network really has improved this much over what was offered last year, it might be a viable option.

And here's a tip.  The default radius for searches is 200 miles.  But if you enter a zip code that is more than 200 miles from more than just a couple of providers, there will be an option to select a bigger radius.  One of the options is "no distance limit," but it looked more like 1,000 as the crow flies to me, so it won't show the entire country.

To see what I'm talking about, enter 04671 as the zip code, and HOSPITAL as the provider, and you'll get two hits, as well as the box to change the search radius.  Change that to NO DISTANCE LIMIT and you'll get a map that is very helpful for showing where their providers are in that part of the country.

You can do the same thing with a Rapid City, SD, zip code, since their aren't any hospitals OR primary care physicians within 200 miles of there.  And be aware that "provider" can include a pharmacy or durable medical equipment provider, so be careful to look for doctors or whatever, and don't just glance at the pushpins.

Again, if you're even considering this, triple check that the network really does extend to all the states they do business in and that this isn't just website weirdness. 

[KHenson]

Here is some clarifying information I just posted at rverinsurance.com/ppo about this new Elite Series 2 plan option we have available now. 

Here is how the Elite Series 2 plans work:

These plans are major medical health insurance plans that are offered to members of Local 713 out of New York. When you enroll in this plan option you are joining and paying dues (they are rolled into the premium already) to Local 713 in order to have access to their health plans. Your membership in the union (which requires the primary applicant to be working 30+ hrs per week) is what allows you as an individual to enroll in their level-funded health insurance plans. Local 713 has over 18,000 of their own members enrolled in these plans.

Employer’s Network Association (ENA) is the billing administrator for Local 713 as well as many different organizations including mini-med insurance companies and association plans. If you read about complaints on the internet involving ENA understand that they stem from some of those since-failed organizations and not ENA itself. All of the claims are actually handled by a Third Party Administrator (TPA) called Cook Group Solutions and not ENA.

Amalgamated Underwriters is the reinsurer. This means that they are the stop-loss for the union. They share the risk with the union and financially back medical claims. Amalgamated Underwriters is A+ rated by A.M. Best.

Cigna Open Access Plus (OAP) is simply the network that the Elite Series plans utilize. As long as you see providers in this network then your benefits are paid in-network (out-of-network benefits are paid at a lower level). The Cigna OAP network is nationwide and should provide RVers ample choices no matter what state you are traveling in. It’s important to understand that you are not enrolling in a Cigna health insurance plan here but are simply utilizing their network per the plan’s allowance. You do not call Cigna at any point because they do not handle the customer service for this plan—Local 713 does.

The upside to this plan option is that you are able to get a Major Medical health insurance plan that is both Minimum Essential Coverage and Essential Health Benefits as required by the ACA and you have access to Cigna’s large nationwide OAP network. Since these plans are ACA-compliant you can expect that thiey will provide the same level of benefits as an On-Exchange ACA plan.

The plan is stable. The collectively bargained Local 713 would have to stop offering health insurance to all of its members for this to go away so that is not likely to happen.

The downsides to these plans are that they are only available if the primary member is employed/self-employed 30+ hrs per week (work from your RV? No problem!), require members to answer health questions to qualify, are Off-Exchange (so not subsidy-eligible), customer service is handled by Local 713 (and some of those employees may be less than enthused about their job), and there are a few exclusions in their Summary of Benefits and Coverage (SBC), namely coverage for non-emergencies outside of the US and no coverage for transplants. You can see the actual SBC by clicking right here: SBC-CIGNA-3000-Plan-2017

[GreyDawg]

Thanks!   Now I can compare this to FLBlue Select --- which I hope still has the BlueCard program for care outside of FL.  Still working to get that confirmed.

 

 

[mkc]

On 11/4/2017 at 12:03 PM, KHenson said:

major medical health insurance plans that are offered to members of Local 713 out of New York. When you enroll in this plan option you are joining and paying dues (they are rolled into the premium already) to Local 713 in order to have access to their health plans. Your membership in the union (which requires the primary applicant to be working 30+ hrs per week) is what allows you as an individual to enroll in their level-funded health insurance plans.

Cigna Open Access Plus (OAP) is simply the network that the Elite Series plans utilize. As long as you see providers in this network then your benefits are paid in-network (out-of-network benefits are paid at a lower level). The Cigna OAP network is nationwide and should provide RVers ample choices no matter what state you are traveling in. It’s important to understand that you are not enrolling in a Cigna health insurance plan here but are simply utilizing their network per the plan’s allowance. You do not call Cigna at any point because they do not handle the customer service for this plan—Local 713 does.

 

Kyle,

Can you clarify - since this plan simply references Cigna's network list, but isn't actually insurance through Cigna, does the union have the same negotiated reimbursement rates with these providers as Cigna, or is billing done at full cost?

Example - a $250 in-network charge.  Cigna negotiated rate for that item is $75.  Local 713 shows 30% co-insurance on in-network.  Assuming the deductible has been met for the year, is the patient responsible for 30% of the billed amount of $250 ($75) or 30% of the Cigna negotiated rate of $75 ($22.50)?

Also, being level-funded (which, if I understand it correctly, means this insurance is basically self-funded by the union with a stop-gap insurance policy to protect the union against particularly high claims cost), this means the member would have no assistance from their (or the union's, in this case NYS) state insurance regulatory board if there were a complaint, correct?

Michelle

[GreyDawg]

Kyle --

the summary doc that you linked to (Thanks!) is the 2017 doc.  Is the 2018 doc available?

 

cheers!

[Blues]

I'm trying to wrap my head around a self-employed person joining a union whose principles include guaranteeing better pay, better working conditions, job security, etc. 

But in doing so, I think I found a workaround for those who aren't working 30 hours/week.  Be a blogger for 30 hours one week.  The next Monday, join the union.  On Tuesday, come to the realization that you need more pay.  Demand more pay.  Refuse to pay yourself more.  Go on strike.  Continue to refuse to pay yourself more, but don't hire scabs.  Stay on strike until you qualify for Medicare. 

[mkc]

12 hours ago, Blues said:

I'm trying to wrap my head around a self-employed person joining a union whose principles include guaranteeing better pay, better working conditions, job security, etc.

https://insurance-forums.com/community/threads/elite-ppo-health-insurance.90215/

 

Take a look at post #3, the first paragraph of the response 

"It's a NY union that exists solely to offer health insurance"

 

The following article came up in one of my Google searches when I was researching the union.  One of Local 713's officers is one of the individuals banned from the Teamsters for the health insurance issue.  The last paragraph is the reason we are staying with ACA for 2018.  Too much risk for us with this option.  That's not to say it's not a legitimate option, it just isn't right for us, and anyone considering it should do their own due diligence research.

 

http://www.nytimes.com/1994/04/03/nyregion/health-plan-of-a-union-is-investigated.html

"A lot of people who joined through Premier are innocent victims who thought they were in a legitimate plan," Mr. Flaherty said. "Many of them were desperate for health insurance and they have suddenly learned that thousands of dollars in bills will not be paid by Local 819."

[GreyDawg]

mkc, I agree with you:  too many sketchy aspects to this union deal.

I will stick with my FLBlue plan, which gives me out-of-network coverage, and the Blue Card program (PPO) when I am not in FL. Also has limited worldwide coverage when I travel.

Though I admit that it feels a bit iffy having changed my domicile to FL in 2017 wtih no intention of spending much time in the state.  At least I used to spend about two weeks a year in Texas (though not in Polk County).