So what’s a typical co-pay in one of those countries for a common procedure? Gall bladder out, or normal childbirth, or a few days in hospital for a heart attack for example? I’m kind of guessing it’s nowhere near $US20,000.
There have been discussions that perhaps Canada should have co-pays (i.e. $10 or $20 to get in the door for your GP). But of course, then there would be exemptions for people on welfare, or else it would simply be the same as the USA, people avoid the doctor when they actually need it because it costs money.
Note just because medical care is not billed to the patient does not mean there is no cost. Obviously, missing work is a hardship -particularly those in lower-paying jobs typically do not have short term disability or sick leave programs, and Unemployment only kicks in after two weeks unless immediately hospitalized - and only pays 55% of wages to a max of $22,000/year rate.
the difference is you do not lose your home or savings to pay some doctor’s country club bills, or to buy an insurance executive his second BMW.
As you said in post #14, there are two protections: hold harmless laws and prohibitions against balance billing. You benefited from New Mexico’s hold harmless law, presumably because your policy is issued in New Mexico. And you will benefit from that no matter what state you receive out-of-network services in.
There are some states that prohibit balance billing. Do you think that means that no provider in those states can balance bill, and that it applies to every patient? So if I lived (and had insurance) in a state that had no protections, but received services in a state that prohibits balance billing, I would be protected by that, and the end result would be the same, to me, as living in a “hold harmless” state, i.e., I don’t have to pay, just because I had the good luck to receive services in a particular state?
That seems to me like how it would work, but I’m learning that’s not a good basis for anything when it comes to healthcare coverage.
And another question: Do these provisions apply only if there is underlying coverage? More and more policies are providing no out-of-network coverage at all. In that case, is there even an issue with balance billing, or is it just that the patient receives the bill without any involvement by the insurance company, and we’re back to having no protections at all in those cases?
Or in the case of an emergency, if the insurance company covers only the costs in the emergency room, and the policy has no out-of-network coverage, is the insurance company involved only for the ER part, and the patient is on his own when it comes to every other bill?
I would not venture to give broad answers, I think you’d have to look at the specific legislation in each state.
As for the NM “hold harmless” legislation, you are correct. For emergency treatment, I am protected for out-of-network emergency treatment in any state, essentially it’s down to my NM insurer to sort out a settlement with the provider wherever they are. I must contribute only the same co-pay etc that I would have paid for in-network treatment.
Any you are also correct that it applies only to the emergency phase of the treatment, as I discovered, farcically. In order to leave the trauma center in Arizona, I needed a wheelchair - I literally couldn’t walk. Obviously my NM insurer had no approved supplier in Arizona, so with the help of hospital staff I just ordered one online for next day delivery. If I hadn’t done so, I simply could not have been discharged from the trauma center, where a bed alone probably costs $5,000 per night. My insurer eventually settled the trauma center bill, but refused to reimburse me $300 for the wheelchair, since it was not deemed part of my emergency treatment! I was by now intimately familiar with the appeals process, so I filed an appeal pointing out that I saved them thousands of dollars by doing this, and they did eventually pay up.
However, in addition to emergency treatment, the NM “hold harmless” legislation does cover “surprise” non-emergency medical bills. This is the all-too-common situation where you (say) go to an in-network hospital for elective surgery, and it turns out that (without your knowledge) one of the many people involved in your treatment is out-of-network and sends you a huge unexpected bill. It once again places the burden on your insurer to sort this out - so the insurers will presumably put pressure on providers to take responsibility for ensuring that every participating provider is in-network.
But the NM legislation would not cover elective surgery where you make a deliberate choice to go to an out-of-network facility, obviously that’s on you. In other words, in does not give you any right to go to (say) some specialist that you like who is not in your insurer’s network.
Sigh. I think about your comments about how someone who’s super busy and doesn’t have time to devote what you did to figuring this out, or someone whose first language isn’t English, and add to that people who are just genetically stupid and couldn’t figure this stuff out even with unlimited free time and perfect understanding of English. It’s so wrong.
In the article you linked to, for New Mexico, there’s a check in the “Setting” box for “Emergency department,” but there’s no check in the box for “Nonemergency care in network hospital.” The situation you describe is what I would think would be considered “Nonemergency care in network hospital.”
I also, to my surprise, noticed that a state might provide less protection to people in a PPO than those in an HMO. I think that was probably based on HMOs operating differently from PPOs, but increasingly, PPOs are transitioning to policies with small local networks and no out-of-network coverage–pretty much the same as HMOs have always been. I would hope the legislation keeps up with that shift–if I was right about the reason for the different treatment in the first place.