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Health Insurance & Affordable Care Act

Limitations Of New Health Plans Rankle Some Enrollees

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Patient advocates agree that managed care can be done well but caution that some policies could leave patients scrambling to find doctors – and on the hook for thousands of dollars if they go out of network.

“If highly specialized care -- an academic medical center or a cancer center -- is not available in a plan’s network … some plans will send you to an out-of-network provider, but it’s not required,” said Laura Skopec, senior policy analyst at the cancer action network.

Going out of a managed care plan’s network often means patients foot the entire bill, which can be financially devastating in cases of serious illness. In other types of insurance plans, a portion of the out-of-network bill might be covered, but consumers still face sharply higher costs than if they see a network provider.

Pippenger said that because she was in pain and knew she might need surgery, she checked the provider directory for her new plan, looking for an orthopedic surgeon within 30 miles. She found five who specialized in hips and knees, but felt anxious because she knew nothing about them.

“I want to go back to the doctor who did my other knee,” she said.

She paid for an initial consultation with him, but realized she couldn’t afford the cost of having him fix her second knee.

Adding to the problem this year were some plans’ incomplete or inaccurate lists of participating doctors and hospitals.

Perez, 46, bought her insurance through California’s state-run website. Before enrolling, the immigration attorney says she was assured by the plan and her doctors that they were in Anthem’s network. Only later did she find out that none of those affiliated with her local hospital, Stanford Medical Center, are in it.

Perez said she was unable to find a doctor affiliated with Stanford or another nearby hospital, so she filed a complaint with state regulators and was  granted a waiver to switch plans.

“I’ve been paying a premium since March for medical care that I’ve never been able to access,” she said.

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

Fri, Jul 25 2014

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