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Health Insurance & Affordable Care Act

Limitations Of New Health Plans Rankle Some Enrollees

WebMD News from Kaiser Health News

By Julie Appleby

Fri, Jul 25 2014

Nancy Pippenger and Marcia Perez live 2,000 miles apart but have the same complaint: Doctors who treated them last year won’t take their insurance now, even though they haven’t changed insurers.

“They said, ‘We take the old plan, but not the new one,’” says Perez, an attorney in Palo Alto, Calif.

In Plymouth, Ind., Pippenger got similar news from her longtime orthopedic surgeon, so she shelled out $300 from her own pocket to see him.

Both women unwittingly bought policies with limited networks of doctors and hospitals that provide little or no payment for care outside those networks. Such plans existed before the health law, but they’ve triggered a backlash as millions start to use the coverage they signed up for this year through the new federal and state marketplaces. The policies’ limitations have come as a surprise to some enrollees used to broader job-based coverage or to plans they held before the law took effect.

“It’s totally different,” said Pippenger, 57, whose new Anthem Blue Cross plan doesn’t pay for any care outside its network, although the job-based Anthem plan she had last year did cover some of those costs. “To try to find a doctor, I’m very limited. There aren’t a lot of names that pop up.”

Consumer groups argue many enrollees were misled. In California, consumers filed class-action lawsuits against some insurers, alleging they were given inaccurate information about their plans’ limitations and about which doctors and hospitals participate in them.

Nationally, regulators and insurance agents are inundated with complaints, while state lawmakers are considering rules to ensure consumers’ access to doctors. For 2015 plans which will be on sale beginning in November, the federal Department of Health and Human Services said it will more closely scrutinize whether networks are adequate.

Insurers say they are simply trying to provide low-cost plans in a challenging environment. The new federal health law doesn’t let them reject enrollees with health problems or charge them more just because they are sick. So they are using the few tools left to them -- contracting with smaller groups of hospitals and doctors willing to accept lower reimbursements; requiring referrals for specialty care and limiting coverage outside those networks.

“Obamacare products have lower prices than they would have if they had had [larger] commercial networks,” said Robert Laszewski, an industry consultant and former insurance executive. “They’re one-size-fits-all networks designed for low-income people accessing insurance for the first time.”

Lower Prices, Limited Choice

Lower monthly premiums made such plans attractive to many consumers on the new exchanges. Some chose tightly managed plans -- often called health maintenance organizations (HMOS) or exclusive provider organizations (EPOS) – specifically because of their cost, in some cases, without realizing the tradeoffs.

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