Tag Archives: limited networks

Obamacare doctor networks to stay limited in 2015

Obamacare doctor networks to stay limited in 2015 – LA Times.

“This is part of the Affordable Care Act that doesn’t quite work yet,” Edwards said. “This game of who’s in and who’s out is tiresome.”

Thankfully, network participation is not a big issue in Coloraodo except for the CoHealthOp plans with the EPO (Exclusive Provider Organization) network. That said, there is no easy way to look up network participation. Connect for Health Colorado has a doctor lookup tool, but it is unreliable and that’s being kind. I go to each provider website and look up doctors for my clients.


Doctors grade Obamacare

Why doctors give Obamacare a failing grade | TheHill.

  •  You can keep your doctors – NOT
  • Medicaid, not so great
  • Deluge of paperwork and reporting requirements

So what grade would doctors give Obamacare?

The Physicians Foundation made shockwaves last month when it released its 2014 Survey of America’s Physicians. The survey’s top-line finding: Of the 20,000 doctors surveyed, almost 50 percent stated that Obamacare deserves either a “D” or an “F.” Only a quarter of physicians graded it as either an “A” or a “B.”

Let’s take a closer look as to how Obamacare has affected Medicaid. Many of my (potential) clients are delighted if they qualify for Medicaid or if their children qualify for CHP+. Perhaps CHP+ offers better services than Medicaid for adults but I’m doubtful.

No matter which option they chose, Obamacare forced my patients to make trade-offs between pricing, access, and quality of care.

Obamacare’s Medicaid expansion exacerbated this patient crisis. Arizona, the state in which I practice, expanded Medicaid in 2013 under the assumption that it would give the poor better access to medical care. Yet many of the new Medicaid enrollees—perhaps as many as 80 percent of them, according to one recent study—were merely forced off their private insurance plans and into Medicaid.

Several of my patients experienced this first-hand. They have found that Medicaid offers sub-standard health care compared to the private insurance they used to have. Their choice of doctors has been severely curtailed, even more so when it comes to specialists. Often they resort to the local emergency room rather than waiting weeks to get medical attention in a doctor’s office. An Oregon study revealed a 40 percent increase in ER visits among new Medicaid enrollees.

Unsurprisingly, patient health suffers when illnesses and diseases remain untreated, hence Medicaid’s persistently poor ratings on patient health. Unfortunately, my patients were forced into this broken system without a second thought.

Perhaps it was without a 2nd thought or perhaps it was with malice. The government creates a problem and then only they can fix it. Of course, with their recent displays of incompetence, they may have overplayed their hand.

Let me also comment on Medicaid. Under Medicaid, reimbursement to doctors is much less than that of regular insurance or even Medicare. I don’t care how you slice and dice it, from a big picture point of view, if the doctors don’t believe they are being fairly paid, the qualify of care dispensed is going to decrease.


Exchange plans worry California docs

Exchange plans worry California docs | LifeHealthPro.

Dr. Mark Dressner says California’s public exchange need to act now to keep physicians in the networks.

Dressner, president of the California Academy of Family Physicians, said doctors who treat Covered California exchange plan patients feel confused, frustrated and poorly paid.

“We have never received such an outpouring of complaints about plans’ contracting strategies,” Dressner writes in a letter included in a Covered California board meeting packet.

And the problem?

Doctors say plan reimbursement rates are 20 percent to 40 percent lower than traditional plan rates.

“Our physicians describe these payment reductions as unaffordable to their practices,” Dressner says.

In some cases, Dressner says, carriers seem to think they can change contract terms by simply sending letters to the physicians.

Physicians have trouble finding out what the plan contract terms are, or even finding out whether they’re really in a plan provider network, Dressner says.

Dressner says his group is telling physicians they have to negotiate terms with the plan issuers just as they would with any other private payers.

And the answer is quite simple. Opt out of the system.


10 tips to make sure Obamacare works for you

A word to the wise from USA Today/Kaiser Foundabtion editorial board.

  1. Carry your membership card everywhere.
  2. Understand your plan’s doctor and hospital network.
  3. Stay in the network.
  4. Try to stay in-network even if it’s for emergency care.
  5. Avoid all emergency rooms unless it’s really an emergency.
  6. Pay monthly premiums on time and accurately.
  7. Register online with your new insurance company.
  8.  Save paperwork. Make sure you really owe what doctors and hospitals bill you for.
  9. If you don’t get satisfaction from providers or insurers, try regulators.
  10. Do read the plan’s summary of benefits and coverage.


Did they mention STAY IN NETWORK? GOOD. My advice to you: STAY IN NETWORK.

It’s interesting that as a rule, my healthy clients are not overly concerned with the network coverage. Clients with medical conditions have a much greater awareness. I suggest that the healthy clients learn a lesson from those with medical conditions.


10 Top Questions Consumers Ask About Obamacare

10 Top Questions Consumers Ask About Obamacare | The Fiscal Times.

  1. How do I sign up, and is the website working better?
  2. When is the deadline to sign up?
  3. How much is the penalty?
  4. What kinds of plans are offered under the new exchanges?
  5. Do I get to keep my doctor?
  6. I heard some of the top hospitals aren’t accepting Obamacare, is that true?
  7. How expensive are Obamacare plans compared to employer-based coverage?
  8. Who qualifies for subsidies?
  9. Where can you find out if you qualify for a subsidy?
  10. How does the subsidy work?


Additional information on the Obamacare penalty here.


Articles: ObamaCare May Devastate the Real Estate and Travel Industries

Articles: ObamaCare May Devastate the Real Estate and Travel Industries.

Check your network and check your doctors. Most Obamacare plans offer restricted networks in state and you are out of network if you are out of state.

Americans are among the most mobile people on earth, but ObamaCare may soon start freezing them in place. Millions are losing their health insurance policies and being forced onto the ObamaCare exchanges, where most plans only provide local medical coverage. As Americans realize they must pay for all non-emergency medical care when they leave their home county, their decisions may have a profound impact on the real-estate market, particularly the second home sector, and on the travel business.

I recently interviewed a woman I’ll call Sue, whose story may become increasingly common. Sue, a 60-year-old retiree, and her husband bought a second home in South Carolina to escape the Connecticut winters. “I had a Blue Cross Blue Shield policy in Connecticut, and I used it with no problem in South Carolina. I found an internist and ophthalmologist and dermatologist down here, and kept the rest of my doctors up north.”

“The price was reasonable. It cost me $450 a month, with a $2,500 deductible. It was slightly more for out of network; there was no co-pay, and I got my prescriptions filled in both states with no problem.”

“Then I got the letter telling me that my policy would no longer exist, because it didn’t comply with the new health care law. They wanted to transfer us into a new plan that doubled my premium to $900 a month. The deductible went up to $3,500, and it covered zero out of network.”

In Colorado, the only companies offering plans with nationwide networks are:

  • Rocky Mountain Health Plans
  • Cigna (only available for purchase in the immediate Denver metro area)
  • Assurant Health

In fact Assurant Health offers plans with nationwide networks in 42 states. HOWEVER, you won’t find them on any Federal or State “Exchange or Marketplace”. That means their plans are not eligible for premium assistance but they are still the same Bronze, Silver, Gold and Platinum plans required by Obamacare.

One issue that bothers me in the above article is this paragraph:

“My husband looked around and finally found a policy that has out of network coverage, but it comes with a very steep price. It’s $900 a month, with a $7,000 deductible and a co-pay on everything. Basically, it’s catastrophic insurance, and I’ll be paying my South Carolina doctors out of pocket.”

The maximum out of pocket per person for any ACA compliant plan is $6350. Either this plan is not ACA compliant (i.e. not a true major medical plan) or Sue is confused about the deductible.


An Obamacare supporter’s misadventures with HealthCare.gov

An Obamacare supporter’s misadventures with HealthCare.gov | The Daily Caller.

Our troubles may strike some as trivial and particular, although they wouldn’t if it happened to them. And anyone who wants a successful system – as we do – must understand that these nightmares are happening across the nation to the very people who want Obamacare to work.

This story appears to be the Deliverance version of signing up for Obamacare.

Unfortunately, having dealt with many clients, it’s all to believable.

  • Restricted provider networks
  • Restricted formularies
  • Complicated subsidy eligiblity
  • Possibly higher premiums

All of the above are gifts of Obamacare.

If you don’t qualify for a subsidy or it is very small, my recommendation is:

  • Do NOT use the exchange
  • Contact a broker
  • Purchase directly from the carrier, which will also avoid security issues with the exchange websites.

Obamacare health network problems

This is more than a New York issue: New health plans sold through exchanges not accepted at some prestigious NYC hospitals – The Washington Post.

Be careful out there.

Another issue is a vast majority of exchange networks are “in-state” only. If you live on a state border that could be a problem. That is the case in Colorado on the Connect for Health Colorado Marketplace with the exception of Rocky Mountain Health Plans PPO offerings, which have a nationwide network. Also available in Colorado but NOT on the Connect for Health Colorado Exchange is Assurant Health, also with a Nationwide network.


Rate Shock seques into “Provider Shock”

New “glitch”: If you like your hospital, you might not be able to keep your hospital « Hot Air.

Turns out you can’t expand coverage, cap patient costs, and expect providers to work for less, just like you can’t create the conditions for a major adverse selection problem and expect insurers to flood into the new market. “Some hospitals and doctors don’t even know if they are in the network,” says one expert, a point also made in the WSJ story I flagged this morning about consumers often having no idea who’ the providers are in each plan offered on the state exchanges.

I spoke with a client today and her daughter is in the process of being diagnosed for a blood disorder under the care of Children’s Hospital in Aurora, CO. Shopping on the Colorado Marketplace, Connect for Health Colorado, the number of available plans shrinks from 78 to 13 if Children’s Hospital is required to be in-network.

An additional complication is the client is planning to move in July to another State. If she takes ANY Marketplace plan, she will have to get a new plan with a new deductible in the middle of the year.

Fortunately, there’s a solution with an off the marketplace insurer that will allow her to “keep her plan” when she moves. Well, that’s a helluva lot better then Obama can do.



Top Hospitals Opt Out of Obamacare

Surprise! – Top Hospitals Opt Out of Obamacare – US News and World Report.

“This doesn’t surprise me,” said Gail Wilensky, Medicare advisor for the second Bush Administration and senior fellow for Project HOPE. “There has been an incredible amount of focus on the premium cost and subsidy, and precious little focus on what you get for your money.”

Regulations driven by the Obama White House have indeed made insurance more affordable – if, like Health and Human Services Secretary Kathleen Sebelius, you’re looking only at price. But responding to Obamacare caps on premiums, many insurers will, in turn, simply offer top-tier doctors and hospitals far less cash for services rendered.

Not to mention that insurance is in many cases NOT more affordable.

Chances are the individual plan you purchased outside Obamacare would allow you to go to these facilities. For example, fourth-ranked Cleveland Clinic accepts dozens of insurance plans if you buy one on your own. But go through Obamacare and you have just one choice: Medical Mutual of Ohio.

And that’s not because their exchanges don’t offer options. Both Ohio and California have a dozen insurance companies on their exchanges, yet two of the states’ premier hospitals – Cleveland Clinic and Cedars-Sinai Medical Center – have only one company in their respective networks.

A good local example here is Colorado is Children’s Hospital is not in he Anthem BCBS network.

When looking at ACA/Obamacare plans, you must be concerned about the network. Also, if you are near a state border, travel a lot or have two residences, keep in mind that with a vast majority of the plans you are out of network for non-emergency care performed out of state.




Hospitals reject six ObamaCare plans

Be careful out there – Hospitals reject six ObamaCare plans | New York Post.

While most people have only 4 classes of plans to choose from, Bronze, Silver Gold and Platinum the big issue is the completeness of the network. Many plans on the Colorado Marketplace are classified as HMO’s. That translates into reduced networks.

The bottom line, if you want a larger network, especially if you travel, you should seriously consider a higher priced plan with a PPO network.


ObamaCare rates trigger more sticker shock

ObamaCare rates trigger more sticker shock | Fox News.

Unfortunately this story is short on details….

Before the exchanges opened, his insurance company said his rates would soar. But now that there are subsidies, he’s been trying for days to find out how much he would get.

“To logically compare plans, I’ve been calling them every day since October 1st,” says Mangione, “several times a day on some occasions. Sometimes enduring 45, 50 minute holds, half an hour holds.”

Although Kentucky officials were unable to give him a firm number on his subsidy because of repeated IT problems, they did refer him to a Kaiser Family Foundation site, which suggests his subsidy will be $414 a month — on a premium of $868.

So we have a guess, most likely not accurate, regarding the subsidy that Andy and his family is eligible for. We don’t know if the $868 premium is for a Bronze, Silver, Gold or Platinum plan and we do know the family size if 4 (see below). We also don’t know what his present insurance costs, so how do we know he is experiencing “sticker shock”?

Moving forward, Andy has received some details on plans that are “similar” to what he apparently has, but one of his concerns is the ER visit copay…

And his co-pay for emergency room visits almost tripled — from $125 to $350 — an important factor for a family with two young boys.

“They’re climbing trees, they’re falling out of trees. They’re running around falling off their bike, they’re very active. They’re not unlike any other 8 and 10 year old boys,” their dad says.

That is an issue that’s easily addressed with a supplemental accident plan.

The bottom line is after reading this article, the only factual information presented is that Andy has a family size of 4 and he has a non-subsidized quote of $858 for some unknown metallic plan. I’m guessing it’s a Bronze plan based on the high ER copay.

Another very real issue is that he found a less expensive plan but his doctor is out of network. Expect to see that refrain repeated over and over.

Getting back to the subsidy, someone needs to explain to Andy that what really happens with the subsidy is the premium that he has to pay is capped as a percentage of his income based on the Federal Poverty Level. For example, if Andy makes $47,100 per year, the most he would pay for the  2nd lowest cost silver plan is 6.3% of his income, which would translate to $247/mo. His subsidy amount is determined as the difference between the $247 and the list price of the 2nd lowest cost Silver plan. That subsidy would be used to subtract from the list price of ANY plan he chose.

It sure seems like a knowledgeable navigator at the Kentucky exchange could use the above informatino to provide Andy with a very good ballpakr estimate of what his subsidy would be.


Lower Health Insurance Premiums to Come at Cost of Fewer Choices

Purchasing coverage on the exchange? Be careful out there. Lower Health Insurance Premiums to Come at Cost of Fewer Choices – NYTimes.com. And also, what lower health insurance premiums?

When insurance marketplaces open on Oct. 1, most of those shopping for coverage will be low- and moderate-income people for whom price is paramount. To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers.

Some consumer advocates and health care providers are increasingly concerned. Decades of experience with Medicaid, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers.

Consumers should be prepared for “much tighter, narrower networks” of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group.

“That can be positive for consumers if it holds down premiums and drives people to higher-quality providers,” Mr. Linker said. “But there is also a risk because, under some health plans, consumers can end up with astronomical costs if they go to providers outside the network.”

As an example, Children’s Hospital is not in the Anthem BCBS network in Colorado. Since my daughter has had 7 multi-day visits there and numerous other expenses, they are not an option for my family. If your shopping on the exchange you need to take network participation and potential out of network charges seriously.

Also, to repeat myself, the only reason to purchase on the exchange is if you are eligible for a subsidy. There is a broader array of plans, some with full nationwide networks available off the exchange. These are the same guaranteed issue plans with that meet the Bronze, Silver, Gold and Platinum acturial value levels.