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Health Insurance & Affordable Care Act

Limitations Of New Health Plans Rankle Some Enrollees

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Others had no choice.

Anthem, one of the biggest sellers of individual insurance, offers only HMO-like plans through the new markets in six of the 14 states it serves, including New Hampshire, where it is the only insurer. In California, where the insurer is the target of two class-action lawsuits, it offers plans with no out-of-network benefits in Los Angeles, San Diego and San Francisco, although another type of plan is available in other counties.

Anthem spokeswoman Kristin Binns said the insurer decided to move heavily into managed care in many of its markets after research showed most consumers, especially those who were uninsured, cared about price first and foremost.

“HMOs give them much more access than they were afforded before,” Binns said.

Still, she said Anthem expects to roll out plans with out-of-network coverage in 2015 in some areas where it does not offer them. She would not specify the regions.

Other insurers made similar decisions, offering managed care plans as the only choice for residents buying through the new marketplaces in entire counties in Indiana, Georgia, South Carolina, Virginia, Florida, Wisconsin and Mississippi, according to government data analyzed by Kaiser Health News. Nationally, 43 percent of mid-level “silver” plans offered in California, New York and 34 states using the federal marketplace have no coverage outside their networks, a study by the American Cancer Society Cancer Action Network found.

“They’re all doing it,” says Wall Street analyst Ana Gupte of Leerink Swann, an investment bank. “Obamacare is putting pressure on their margins, so they’re on the hook to moderate costs.”

But along with consumers, lawmakers and regulators have begun to push back.

In California, managed care regulators are investigating Anthem and another insurer, Blue Shield of California, after receiving numerous complaints about access to doctors and hospitals.

Lawmakers in 22 states debated laws this year and last related to network adequacy, although the vast majority failed to pass, according to the National Conference of State Legislatures. In Washington state, administrative rules announced this spring require insurers to provide enough primary care doctors so enrollees can get an appointment within 10 days and 30 miles of their home or workplace. Directories of participating providers must be updated monthly.

“I have heard from many consumers … who were upset to find their health plan no longer included their trusted doctor or hospital … and some discovered this only after they enrolled,” Washington Insurance Commissioner Mike Kreidler said in an announcement of the rules in April.

Scrambling To Find Doctors

Brian Liechty of TCU Insurance in Plymouth, Ind., said he has helped “hundreds” of clients sign up for tightly managed plans – including Pippenger, when her work-based plan was discontinued.

“For the right person who is willing to go where they must and live with rules, it allows them to buy a health insurance policy they could never touch before,” he said. “So, there are some good things, but balancing it out, there are some equally bad things for people who previously had insurance.”

Fri, Jul 25 2014

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