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Health Insurance & Affordable Care Act

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

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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.)

Whichever type of plan they choose, the onus is on consumers to dig into the details and make sure they understand what they’re signing up for. There’s a tremendous amount of variability in exchange plans, even among silver level plans, says Richard Smith, executive vice president at Breakaway Policy Strategies.

“I don’t see a lot of standardization,” he says. “Consumers need to be really cognizant. There are design features of these plans that consumers need to be aware of.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Mon, Mar 17 2014

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