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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


Best Out-of-Network Coverage?

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Question: I make about 18,000 annually and live in the 90021 zip code. I am looking for a plan that will give me the most out of network benefits, because I need a spinal surgery, and my surgeon is not part of any networks. Personal pay and medicare only. Can you tell me of any plan options that include out of network benefits?

Answer: To receive out-of network benefits you must select a PPO plan. In your zipcode, there are two carriers offering PPO plans, Anthem Blue Cross and Blue Shield of California. Their out-of-network benefits are identical. Your income makes you eligible for a Silver 87 Plan with enhanced benefits, so here's how your surgery would be paid for. For all in-network costs - like hospital, drugs, and physical therapy - your in-network maximum-out-of-pocket expense will be $2,250 (Silver 87 plan). The out-of-network cost for you surgeon will probably meet the separate out-of pocket maximum of $9,250. Your total cost for this surgery will run $11,500. If you can find an surgeon in-network with whom you are equally comfortable, your total cost would be $2,250.

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