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Warning: Opting Out Of Your Insurance Plan's Provider Network Is Risky

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“The assessment doesn’t necessarily tell the consumer the full picture,” says Corlette. “If you sign up for a gold plan and it’s a really narrow network, you might end up paying far more out of pocket than you expect.” 

A McKinsey & Co. analysis of 120 silver-level exchange plans found that 70 percent were narrow network plans, in which at least 30 percent of the area’s largest hospitals are not in the plan, or ultra narrow network plans, in which that number grows to at least 70 percent.

Narrow networks can be a particular problem in HMO-style plans that don’t cover any out-of-network care except for emergency services. According to the analysis by Breakaway Policy Strategies, roughly a third of mid-level silver plans are of this type, typically leaving consumers on the hook for the entire bill if they get care from an out-of-network provider.

The health law does provide protection for consumers when they receive emergency care from a hospital that’s not in their provider’s network. In such instances, health plans can’t charge consumers higher coinsurance or copayments.

However, patients placed on observation status or admitted to the out-of-network hospital from the emergency department are no longer shielded from higher out-of-pocket costs.

“Once the patient is stabilized, the patient will be responsible for whatever the insurer doesn’t pay for that observation or admittance,” says Jeffrey Bettinger, an emergency physician who is chairman of the reimbursement committee of the American College of Emergency Physicians. Patients who will be admitted for any length of time may want to be transferred to an in-network hospital, says Bettinger.

Despite the financial risks, most consumers who are likely to sign up on the health insurance marketplaces say they would choose a lower premium over a broader network of providers, according to the Kaiser Family Foundation’s February health tracking poll. Among people who are currently uninsured or buy their own coverage, 54 percent said they would rather have a less costly plan with a narrow network, compared with 35 percent who said they would opt for a pricier plan that gave them more choice of providers. (KHN is an editorially independent program of the foundation.)

Mon, Mar 17 2014

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