By Stacey Singer
Palm Beach Post, Nov. 3, 2013
As consumers begin to comparison shop “Obamacare” health plans, a new problem has emerged: The cheapest plans may have such limited provider panels that the nearest in-network hospital could be about 30 miles away for people living in northern and western Palm Beach County.
Consumers shopping for health insurance plans typically focus on price, understandably, experts say. But this year, more than ever, they need to hold a magnifying glass to plans’ networks, the doctors and hospitals willing to accept their coverage.
It’s true for people buying plans for the first time through the Affordable Care Act marketplace. It’s also true for seniors who are long-time users of Medicare Advantage, the privatized Medicare benefit option. Both sectors are embracing what the industry refers to as “narrow networks” to cut their costs this year, analysts said.
The reason? Starting in January, health insurers can no longer charge more for people with pre-existing health conditions. Meanwhile, there are caps on consumers’ out-of-pocket costs. So insurers have less “wiggle room” to manage costs, said health marketplace analyst Allan Baumgarten.
“In the effort to meet a lower price point, they have to find another tool to use. That tool is network design,” Baumgarten said.
Humana’s HMO marketplace plans leave out two-thirds of area hospitals, those run by HCA and Tenet Healthcare.
Someone from Jupiter would face a minimum 27-mile trip, with tolls, to the closest in-network hospital. It’s Wellington Regional Medical Center. In case of emergency, they can use the nearest hospital, Humana spokesman Mitchell Lubitz said.
Humana buyers in Belle Glade and Pahokee face an even longer drive to stay in the network. That same Wellington Regional, the nearest in-network hospital, is a 35-mile drive away from the Glades.
The CoventryOne Carelink HMO catastrophic plan, from Aetna, also includes no HCA hospitals, a spokesman said. It leaves out JFK Medical Center in Atlanta, Palms West Hospital in Loxahatchee and West Palm Hospital, cutting out a large share of the limited in-patient psychiatric beds here.
Enrolling through the federal marketplace web site healthcare.gov continues to be difficult, although it’s gotten easier to see plans and prices. Those price lists show that Humana wins the cost contest on most scores. But Humana’s lower premiums may come with inconvenience that’s harder to spot.
Healthcare.gov doesn’t yet link to the insurance plans. If consumers do manage to use an Internet search engine like Google to find the provider panels, they may be surprised. Humana offers marketplace shoppers just four choices of in-network hospitals, all of them in central or south Palm Beach County. They include Bethesda’s two Boynton Beach hospitals, as well as Boca Raton Regional Hospital and Wellington Regional.
“We are trying to ensure the exchange plans in Florida are affordable, and so that has meant a smaller network of hospitals doctors and specialists to keep costs down,” Lubitz said.
Florida’s deputy insurance commissioner for health, Wences Troncoso, said the network issue is one more reason that insurance brokers remain important partners for consumers.
“Reach out to your local agents. They can help provide that information, they are well-trained at it,” Troncoso said.
It’s the job of CMS – the U.S. Centers for Medicare and Medicaid Services – to make sure that networks have adequate hospitals and doctors for both Medicare Advantage and marketplace plans. Humana has concluded that different rules are in place for each market, though federal officials weren’t willing to agree late Friday.
Medicare Advantage reviewers at CMS interpret “adequate network” to mean within a 30-mile or 30-minute drive, in most cases.
“I checked with our provider team for South Florida, and the 30-minute, 30-mile rule does not apply to commercial and individual health insurance plans, only to Medicare,” Lubitz said.
While narrow networks mean less choice for consumers and longer drives for care, they do allow for lower premiums.
But to come out ahead, consumers must be savvy, remembering to stay within their plan’s panel, and follow all of its rules, including getting referrals for specialists for HMO plans. It will be a steep learning curve for the uninsured, insurance experts predict.
Baumgarten predicted further that it may be the hospital industry absorbing the brunt of the troubles, as they struggle to collect thousands of dollars from low-income patients who can’t easily pay.
Medicare beneficiaries who use the privatized Medicare Advantage plans have grown used to the tough in-network rules of their HMOs. But the churn of providers is a newer trend.
This fall, UnitedHealth Group’s popular AARP-branded Medicare Advantage plan cut thousands of physicians from its networks in Florida, Connecticut, Rhode Island, Indiana and New Jersey. A spokesman said the move enables the plan to be more efficient, and control quality and costs.
It’s the plan of choice for about 20 percent of Palm Beach County Medicare Advantage customers.
Those consumers need to check in with their doctors, said Jennifer Vander May, the local coordinator for the Area Agency on Aging’s SHINE project, which stands for “Serving Health Insurance Needs of Elders.” The Medicare Advantage open enrollment period ends Dec. 7.
Thousands of seniors have recently received letters about the change from UnitedHealth Group, she said.
“Some are very frustrated,” Vander May said. “Every year we encourage them to find out what’s in their plans, ask what their doctor accepts.”
West Palm Beach dermatologist Dr. Howard Green recently learned his large dermatology group had been dropped by UnitedHealth Group’s AARP plan. He’s livid.
“We are losing patients with whom we have cared for continuously for two decades,” he said of Dermatology Associates of the Palm Beaches. “This is nothing more than rationing for profit. This is pure politics. They are grabbing profits under the anarchy of Obamacare.”
Stacey Singer is a staff writer at the Palm Beach Post.
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