A little boy’s love of monkey bars recently became a test for his health insurance plan’s network of providers.
Dr. Ramiro Gumucio, 50, the boy’s father and anesthetist in Chicago, says the plan failed the test. Gumucio’s seven-year-old son spent so much time on monkey bars that his hand got an angry-looking blister in September. The wound developed a severe antibiotic-resistant infection, says Gumucio, and had to take the seriously ill and vomited boy to hospital. But he couldn’t go to the best Chicago children’s hospitals near his home, he says, because those facilities don’t accept the Blue Cross Blue Shield health plan he bought through the Affordable Care Act market. Instead, he had to go to another hospital at about an hour away, where staff seemed unprepared to handle a pediatric emergency, he says.
Although the boy physically recovered from the accident, Gumucio says, more frustration followed when he tried to find psychological tests for his son, who has autism. His health plan website, he says, showed him many mental health providers in distant parts of Wisconsin and Indiana, and he couldn’t find an appointment with any local providers.
Gumucio thought of selecting high-end coverage when he signed up for the Preferred Provider Organization (PPO) plan. Compared to health maintenance organizations (HMOs), PPOs often have higher rewards but generally present fewer obstacles for members to gain access to suppliers. But in his experience, Gumucio says, “you pay more for less”.
As open enrollments for Affordable Care Act market health plans begin this week, consumers face a daunting and high-risk challenge: finding an affordable plan that includes a network of providers that can meet their healthcare needs. There are signs of “shrinking” in market health plans as insurers regulate supplier networks to control usage and costs, wrote Karen Pollitz, a senior member of the Kaiser Family Foundation, in a report earlier this week. year. An analysis of consulting firm Avalere’s 2020 market plans found that plans networks were the most restrictive since 2014, a change the company attributed to insurers’ efforts to curb premiums, with 78% of plans sold through HealthCare.gov which offers limited or no coverage outside their network. “Shrinking networks has been one of the primary tools insurers have used to figure out how to make money off market plans,” Pollitz told MarketWatch.
Blue Cross and Blue Shield of Illinois, the Gumucio insurer, said in a statement that they could not comment on its specific concerns due to privacy concerns, but that they “undertake to provide members with access to health care. quality and cost-effective consistent with the terms of their coverage of benefits, “adding that it has” some of the largest provider networks in Illinois. ”
The federal government sets standards of time and distance
After years of leaving the matter to the states, the federal government is resuming some oversight of provider networks in the 2023 plans sold via HealthCare.gov. The government has established time and distance standards for provider networks, which vary by provider type and county size. In a large metropolitan county, for example, 90 percent of plan enrollees must have access to a cardiologist within 10 miles or 20 minutes of travel. Other standards based on waiting times for appointments will also go into effect for plan year 2024.
The new standards are only a first step in monitoring and defining the nebulous concept of network adequacy, say health policy experts. The Affordable Care Act requires market health plans to have an adequate supplier network, and the Obama administration has gradually implemented some standards to define this. The Trump administration stopped direct federal control over network adequacy in the 2018 plan year, saying the approach would reduce the regulatory burden on insurers, but ultimately a federal court overturned that change, rejecting the ball in the federal government court. States, meanwhile, also regulate networks of health plan providers, but to very different degrees of effectiveness, the researchers say. The National Association of Insurance Commissioners has developed a Model Network Adequacy Act, but only a handful of states have adopted it.
Consumers buying market plans have few tools to evaluate a plan’s network and no easy way to compare plans based on the overall breadth and depth of their networks. On HealthCare.gov and many state markets, plan buyers can enter their doctors’ names and find plans that include those providers. But they should also call vendors directly to confirm that information, because plan vendor lists are often inaccurate, the researchers say. The No Surprises Act passed in 2020 includes provisions to address the problem, but has not yet been fully implemented.
Tips for finding a plan with a decent network
Avoid choosing a price-only plan, Pollitz said. “There could be all kinds of things that move that prize and a tighter provider network is definitely one of them,” she said.
If you’re switching from an employer-sponsored plan to marketplace, don’t assume you’ll get the same network of providers if you select the same insurer who offered the employer-sponsored plan, Pollitz said. “Insurers have designed a number of provider networks that they offer in different markets,” she said. “Their large employer clients could get their networks wider,” she said, while market plans could get tighter networks.
Even consumers looking for the right supplier network shouldn’t read too much into “PPO,” “HMO,” and similar labels, said Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms. Those classifications “mean a lot less than they used to, particularly when it comes to whether a plan has many suppliers or not,” he said.
Gumucio, the Chicago anesthetist, said he initially chose his Blue Cross Blue Shield plan because his son’s treatment center accepted insurance. For coverage of 2023, however, he will look for a plan that includes a major local children’s hospital, he said, even if it means his son’s speech therapy could be affected.