Claire introduces bill to allow ppl in counties w/out insurers on individual marketplace to buy same

[Ms. Toad]

5. Nice concept, but there are some pretty significant logistical issues

Most plans are specific to the local providers. They don't provide coverage (other than emergency) outside of the geographical area in which they have negotiated contracts. Or - at best - they provide out-of-network rates. For out-of-network rates, there is typically no negotiated discount - but insurance is capped at the UCR for that service. The insured picks up the rest of the bill.

For example, a typical lab bill for me: $120, discounted to $12 for the insurer, I pay 15% of that - $1.80 so the insurer pays $10.20, the lab eats the $108 discount.

Out of network, I would typically have a higher copay (perhaps 25%), and there is no discount, but the insurer pays as if there were. So in that scenario, the insurer pays $9 (75% of the discounted rate), I pay $111, because the provider is not under contract to accept the discounted rate.

(Labwork is the most heavily discounted - at 80-95%, but most insurance discounts are significant. If out of network costs are covered at all, you typically lose the benefit of whatever discount there is.)