Northwest
Herald, The (Crystal Lake, IL) October 29, 2018
Insurance shoppers
likely will have several choices for individual health coverage this fall. The
bad news? There's no guarantee they will cover certain doctors or
prescriptions.
Health insurers
have stopped fleeing the Affordable Care Act's marketplaces, and they've toned
down premium hikes that gouged consumers in recent years. Some even are
dropping prices for 2019. But the market still will be far from ideal for many
customers when open enrollment starts Thursday.
Much of the
insurance left on the marketplaces limits patients to narrow networks of
hospitals or doctors and provides no coverage outside those networks.
Plus, these plans
still can be unaffordable for people who don't receive help from the ACA's
income-based tax credits, and they often require patients to pay several
thousand dollars toward their care before most coverage starts.
"People
understand that things are kind of screwed up," Chicago-area broker Robert
Slayton said. "My objective is to give them what reality is, to give them
options. Their job is to choose what may work."
The ACA expanded
coverage to millions of Americans when it established state-based marketplaces
where people can buy a plan if they don't get insurance through work or qualify
for government programs such as Medicaid. But the expansion has been rough.
Several insurers
pulled back from these markets after being swamped with higher-than-expected
costs. Many that remained jacked up prices or started limiting the hospitals
and doctors included in their coverage networks.
Those narrow
networks give insurers leverage to negotiate better rates that can lead to
lower coverage prices, and the consulting firm McKinsey & Co. has found
that the quality of their hospitals is comparable to broader networks.
Plans with narrow
networks will cover necessary specialists such as cardiologists, but they often
exclude out-of-state care providers or academic medical centers, which tend to
be more expensive.
They can pose
problems for patients who have more than one physician or want to keep a doctor
covered under a previous plan.
Jodi Smith Lemacks
is nervous about changing or losing her job because that could mean cutting off
her 15-year-old son, Joshua, from heart specialists he's seen his entire life.
The Richmond, Virginia, resident said she looked last year for options on the
ACA's marketplace to trim the coverage bill she pays through work.
She didn't find any
plans that would cover his current doctors, including some at the Children's
Hospital of Philadelphia, who treat his congenital heart disease.
"The issue
with kids like Joshua is it really matters; it's life or death where you
go," she said.
Plans with some
form of a limited network made up more than half of the choices offered for
2017 on the ACA's marketplaces, according to the latest numbers from McKinsey.
That coverage particularly was common in the price range where most consumers
shop, which is within 10 percent of the lowest-priced plan.
These plans grew
more common from 2014 to 2017, especially in cities where insurers could choose
between competing hospital networks. But that trend has since stabilized,
McKinsey's Jim Oatman said.
Even so, brokers
aren't expecting narrow networks to go away. In some markets like St. Louis,
they were the only option shoppers had among 10 plan choices for this year.
The narrow networks
are grouped by hospital systems, and broker Kelly Rector has several customers
who see doctors in different systems. She advises them to pick their coverage
based on which doctor is most important and drop the others for in-network
options.
Plans with narrow
networks can make it harder to simply get to the doctor, especially if it's a
specialist.
Wichita Falls,
Texas, residents with individual coverage have to drive nearly two hours to see
an in-network neurologist, insurance agent Kelly Fristoe said. That can be
stunning to customers who buy an individual plan after having coverage through
work, which tends to come with wider networks.
"They don't
like it," Fristoe said. "They're forced to make a change, and they have
to go establish themselves with a new specialist."
Debbie Dean lives
15 minutes from a suburban Chicago hospital, but she'll have to travel about an
hour to an in-network location if she wants surgery on her injured shoulder.
Dean couldn't find affordable coverage that included the nearby hospital when
she bought her 2018 plan.
Instead, she
settled on insurance that comes with a $6,000 annual deductible she has to pay
before most coverage starts. That, plus the travel distance, keeps her from
seeking help.
"I'm grateful
that I have coverage, but it's really cruddy coverage," she said. "I
sit here with my shoulder killing me every day."
Narrow-network
plans with their lower prices can be good for shoppers who aren't tied to a
doctor and just want protection from big medical bills, said Paul Rooney, a
vice president with the online insurance broker eHealth.
"They're
younger and they're healthier and they're thinking, 'I'm going to get this
coverage in case I hurt my knee playing basketball,'" he said.
But it can be tough
for consumers when shopping to know if there's a decent selection of doctors
nearby until they need one.
People who
"have the most to lose from having a narrow-network plan are those who
have something unexpected happen to them," said Daniel Polsky, a
University of Pennsylvania economist.
Follow Tom Murphy on Twitter: @thpmurphy
The Associated
Press Health & Science Department receives support from the Howard Hughes
Medical Institute's Department of Science Education. The AP is solely
responsible for all content.
No comments:
Post a Comment