Health Insurance Exchanges: What Are You Really Buying Into?

By Marisa Torrieri

NEW YORK (Learnvest) — Scott Kraft, a 40-year-old marathon enthusiast, spent more than a decade covering health care policy in the Washington, D.C., area as a reporter before transplanting to Portland, Ore., a few months ago with his longtime boyfriend.

But while he knows the insides and outsides of the Affordable Care Act, and appreciates that he can get access to the same insurance as his friends without asthma (a pre-existing condition), he is having a hard time making the commitment to enroll in a plan through his state's health care exchange website (a handful of states launched their own health care exchange websites when HealthCare.gov launched, as part of the ACA).

The problem: He doesn't know what kind of access to doctors and primary care he'll have whether he enrolls in a premium "platinum" plan, a "gold-level" plan, a "silver-level" plan, or a basic "bronze-level" plan.

"The X Factor has been network availability," says Kraft, who is unable to get insurance through his domestic partner's employer because the two are not married. "I'm fairly new to Oregon, so I don't have a network of doctors. I don't have to worry about, 'Will I lose my provider?' But for all the information I can get on the site, I am struggling to find out, 'What if I can't find a plan ... with a good doctor with an open panel?'"

Kraft's anxiety about the actual "coverage" that comes with these plans—how easy it will be to find a doctor, make an appointment to be seen quickly and related needs — is at the heart of the uncertainty surrounding the enrollment in the Affordable Care Act's health insurance exchange plans. So far, about 100,000 consumers have already enrolled.

Still, many of those who have or plan to soon enroll may be in for a shock when they realize that finding a great doctor and getting the care and services they need may not be as easy as picking a plan on a website—or as "affordable."

According to a recent survey of more than 1,000 medical groups (representing more than 47,500 physicians) from the Medical Group Management Association, an organization that represents primary care physicians, 14% of physician practices currently say they won't participate in the new health insurance exchange plans, while only about one in three practices say they definitely will.

Another 40% said they are still evaluating whether or not they will participate with health insurance exchange products. One of the biggest reasons doctors don't want to participate: Financial burdens such as the pain-in-the-butt task of collecting payments from patients with high deductibles.

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Doctor interests aside, for consumers like Kraft who want to get the most for their money when it comes to affording health care, this begs a few questions: What kind of health care coverage are you actually buying into when you purchase an exchange plan? And could it change overnight?

Here's a closer look at coverage issues, and how to figure what insurance policy makes sense for you financially.

What Your Dollars Buy, Care-Wise

Kraft's hesitation to purchase a plan for $200 to $300 per month—which is what most silver-level and gold-level plans in Oregon cost, he says—is rooted in the unknown domain of what his actual coverage would be. Making matters worse, according to Anders Gilberg, senior vice president, government affairs for MGMA, is that some of the provider directories online may be inaccurate.

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We're hearing ... physicians are seeing their names in the directories even though they haven't signed up with the exchange plans," says Gilberg. "It could be [because of their] hospital affiliation, it could be the information is not accurate or up to date, but a number of physicians have indicated they shouldn't be listed as participating."

Lauren Stanley*, 31, who lives in Fairfield County, Conn., recently purchased health insurance in the individual marketplace for the first time a few months ago, about the time she got pregnant. She pays less for a basic plan through a local insurance carrier, ConnectiCare, than she believes she would for a plan on the newly unveiled Connecticut Health Insurance Exchange. Plus, she is also able to get the care and access to the doctors she needs—including her first choice of OB/GYNs to provide prenatal care and deliver her baby.

For the money Stanley would pay on her state's health care exchange website to join a similar, low-premium-level, or bronze-level plan—$500 plus a month for her and her husband based on her salary and pregnancy status—one would hope that she would have similar or even better access to care and services than she does now, paying the roughly $360 per month she currently pays for their coverage. But she isn't so sure. "I heard Obamacare sucks," she says. "I didn't bother to look into it because everyone told me it was more expensive and the website was confusing."

Lauren Kennedy, senior health policy counsel for the National Partnership for Women & Families, says a pregnant woman like Stanley is going to be better off picking a policy from an exchange than trying to strike out on her own.

"The ACA sets out a number of federal requirements for those health plans to ensure that what consumers are buying is high quality and offers a comprehensive set of benefits," says Kennedy. "Also keep in mind that when you go into an exchange, what you're going to find in a qualified health plan ... is a whole slew of health benefits that come with low cost-sharing protections. There's a whole host of preventative services that issuers are not allowed to charge any cost-sharing for."

According to the National Partnership for Women & Families, cost-sharing assistance available under the ACA lowers the amount that beneficiaries pay out-of-pocket—through copays, deductibles, and coinsurance—for covered, in-network care. Additionally, those eligible for cost-sharing assistance will benefit from a maximum out-of-pocket limit—meaning, the amount that they must pay in cost-sharing charges each year will be capped. (Such cost-sharing limits will apply to in-network services only and will be set on a yearly basis.) Beginning in 2014, individuals or families with incomes up to 250% of the federal poverty level ($28,725 for an individual and $58,875 for a family of four in 2013) will be eligible for reduced cost-sharing, paid for by the federal government.

But while a slew of plans are available online, documents outlining provider networks are subject to change. In fact, that's apparently what's been happening already. To keep premiums low, major insurers in a growing number of states are reportedly limiting the number of physicians and hospitals in their networks.

In California, for example, insurers in the state's new health insurance exchange are keeping premiums down by limiting choices, which is raising concerns that patients will struggle to get care, The Los Angeles Times recently reported.

Health Net Inc., which has the lowest monthly premiums across Southern California, is expected to be a popular choice among consumers. But the carrier also has the fewest doctors, less than half what some other companies are offering in Southern California, according to a Times analysis of insurance data. And other major insurers have reportedly cut their list of medical providers, too.

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As a result of this sort of uncertainty, Kraft plans to ask his broker about urgent care coverage offered by the different plans he's considering. As the number of patients seeking primary care rises as projected among health care policy experts, while the number of healthcare providers to meet patient demands doesn't, Kraft expects to have a harder time getting an appointment if he has an acute-care need.

"I plan to ask an insurance broker, 'What do these plans pay for urgent care?' " says Kraft. "I already see the model of primary-care delivery shifting toward a patient who has an acute allergy attack or sinusitis going to the local clinic or Walgreens and paying $40 to be seen by someone. If I'm paying $300 for a gold plan ... but I can't access routine medical care, the value prop just plummets."

How to Figure Out Your Best Plan

While some things are uncertain, most people agree that they need health insurance. And under the ACA, they face a penalty for not having it. Given this, how do you figure out the best plan for you—whether a Cadillac-like, platinum-level plan or basics-only bronze plan—and know you'll have good access to the care and health care providers you need? Here are four considerations that will improve your likelihood of picking the best plan:

1. Evaluate your current (and future) health care needs. If you consider yourself "young and healthy" and rarely visit the doctor, a high-deductible plan with a lower premium might be the best option—for now. But you should also consider your future health care needs. For example, if you're young, but considering starting a family soon: "What they might be interested to know is, if they are anticipating a lot of pregnancy-related visits to the doctor or ancillary care services, then how does that factor into the premium that they want to pay versus what they might be facing in a deductible or out-of-pocket costs?" says Kennedy. "If a family has children, they might evaluate differently how often they are visiting a doctor." While you may not know whether you have a condition that would require a greater-than-average number of physician visits, she recommends consulting your existing primary care doctor to see if there are any health issues that might require an extra level of care.

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2. Read the fine print: Geoff Kees Thompson, a 31–year-old single I.T. project manager who lives in Philadelphia, recently opted for a $279-a-month gold-level BlueCross BlueShield plan using HealthCare.gov after receiving a notice from the insurance broker he used that his policy did not meet minimum requirements set forth by the ACA and would therefore be cancelled. (In the fall, when HealthCare.gov launched, many insurance plans that no longer met "minimum criteria" were cancelled, and people like Geoff were given notice that they'd have to find a new plan. So that's what he did—through Obamacare.

"What I did notice is that there were plans that had very minor differences between services with very large cost differentials," says Thompson. By using the exchange website's comparison tool and reading the details closely you can more easily see, for example, that one plan doesn't cover mental health nearly as much as the other. And if you tend to utilize mental health services, a plan with a lower premium and less mental health coverage might not be your best option.

3. Factor in tax breaks and subsidies. The face-value premium price might not tell the whole story of what you end up paying. While $300 a month might seem like a lot for a gold-level health insurance plan, Kraft says it's a lot less than that over a year when he takes into account the tax deductions he receives as an independent contractor (the net savings is about 40% off the premium price, he says). Similarly, you might also be eligible for other breaks: Working families with annual earnings between $47,100 and $94,200 are usually eligible for federal subsidies, according to a recent analysis by Families USA, a consumer advocacy group.

4. See what your doctors say. Perhaps the most basic way to figure out whether your existing doctors will participate in your network is actually calling and asking where they stand in terms of insurance-network participation for your particular carrier.

RELATED: Why I Have Health Insurance—and Still Need Obamacare

"Patients shopping for insurance on the exchanges don't necessarily have access to provider directories, so they can't see if their physicians are in or out of these networks," says Gilberg. "One thing we would encourage them to do is to call physician practices directly to verify whether or not they will accept these new exchange-sold insurance products."

 

 

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