Out-of-network = out-of-pocket
Many insurance plans have narrow networks of hospitals or doctors to hold down coverage costs.
By Ben Sutherly THE COLUMBUS DISPATCH
Todd Koonce had what he thought would be his free annual physical last summer. Six weeks later, he received an invoice for $106.
His blood had been screened by a diagnostic lab outside of the provider network for his employer-sponsored health insurance. Only two lab companies were part of that network. Koonce’s physician didn’t use either of them. He was stuck with the bill.
If he wants free annual physicals in the future, Koonce, 43, of Westerville, will have to go through the inconvenience of a separate trip to an in-network lab such as LabCorp and have the lab send the results to his doctor.
- “Hopefully, individuals will take the time to find out what lab companies are covered and not be surprised, as I was,” said Koonce, who is himself an insurance agent.
That’s especially good advice for people who are buying coverage for themselves and their families through the new government-run health-insurance marketplaces. Many health plans offered through those marketplaces feature narrow networks of such providers as hospitals and doctors to hold down the cost of coverage.
- The limited networks have implications for some of the most-advanced kinds of health care because they cut out, for example, hospitals where the cost of care is higher but also specialized. An Associated Press survey published this month found that many of the nation’s top cancer hospitals are excluded from some insurers’ marketplace plans.
- The Arthur G. James Cancer Hospital, the only National Cancer Institute-designated comprehensive cancer center in central and southern Ohio, is not part of Anthem Blue Cross and Blue Shield’s marketplace plans. It is, however, included in the provider networks for the marketplace plans of the three other carriers serving central Ohio: Care-Source, Medical Mutual of Ohio and Molina Healthcare.
- But of nine insurance carriers serving certain other parts of Ohio, the James is considered out of network by marketplace plans, according to information provided by Ohio State University.
And of the four carriers selling marketplace plans in the Columbus area, only Medical Mutual includes the Cleveland Clinic in its provider network.
“The marketplace is relatively new, and as it develops, we may be contracting with additional plans,” Clinic spokesman Joe Milicia said in an email.
Although charges of “network inadequacy” have been made in other states, they did not hold up the approval of any marketplace plans in Ohio last year. The Ohio Department of Insurance reviewed and approved the plans.
Narrowing medical networks helps health plans offer lower premiums to customers, according to a report from the PwC Health Research Institute. But narrow networks also can lead to higher out-of-pocket expenses, “especially if a patient has a complex medical problem that’s being treated at a hospital that has been excluded from their health plan,” the report states.
Many people who are buying coverage through the health-insurance marketplace are uninsured. Often, for them, affordability will matter more than having the broadest possible choice of providers.
Miranda Motter, the president and CEO of the Ohio Association of Health Plans, said the Affordable Care Act has eliminated other tools that insurance companies once used to hold down costs. Using “high-value” provider networks — meaning those that provide good-quality care at a lower cost — is one way insurers can still do that, she said. “As a result of these high-value networks, what we can say is that premiums in the new marketplace are lower than expected,” she said.
The reasons given above make total sense to any thinking person. The Affordable Care Act is indeed a herculean effort no one thought would make it off the ground and it has; and from reports, many, many people are more than pleased for various reasons. All Good.
There will always be negative-sounding, hard-to-please people such as me who will complain. Locked into what was sold to us – universal healthcare for everybody, still take no personal joy in the outcome. But then, I rarely see a doctor and hope to never have to see one again.
On top of which, times are hard economically for too many of us. For the uninsured because they can’t afford it, they have no choice — and are mandated to buy anyway and I truly feel this is or should be unconstitutional. No one should have to buy anything they don’t want or can’t afford to buy. Since they are financially disadvantaged, they are required to buy the cheapest of levels which turns out to be the most expensive to own and live with — pay very much more in the percentages that wealthier insureds can have in the form of co-pays and deductibles. It amounts to a gun in their ribs. Paying a couple of hundred monthly out of money they can ill-afford, but with a $4,500 deductible before the insurance kicks in, there is no way they can use this new-found so-called advantage!
With the “narrow networks” and choices, there isn’t a chance that one’s choice and preference in type of doctor or treatment will be honored. So, in my opinion, ACA has a long, long way to go before it comes close to delivering honest-to-God, non-injurious healthcare. What is being practiced is disease-care run by BIG PhRMA. This won’t work for me. Thank God I can still use my own brain to try to navigate my own path. But then on some kind of scale (??), I may be one in a million and that may be a good thing depending on one’s perspective. At any rate. . . . it’s sure a lot more than we had before, and many will be helped, especially those who still trust medicine. And the way the Republicans are “STILL” trying to do away with ACA, President Obama probably saw right off the bat that he was never going to be able to deliver what he really wanted to give us. So, we’ll have to settle for bits and pieces and hope it can grow and get better. Jan