MrConsumer has probably spent in excess of 30 hours doing research to help a self-employed New York friend find a new health insurance policy since his current company is being shut down by New York state because of its financial condition.
What the Affordable Care Act has done, at a minimum, is put policies for a dozen or more companies all in one place to help make price and benefit comparisons easier.
Shopping for a “platinum” policy — where there is no deductible and lower co-pays in exchange for paying more per month upfront — has been a challenge, not so much because of price, but rather because of the limited networks of doctors and hospitals being offered.
And that’s the dirty little secret or *MOUSE PRINT of many non-group plans. They are only able to achieve relatively low monthly premiums by having very high deductibles and/or very limited networks. For my friend, we’ve overcome high deductibles by paying more per month. But we can’t overcome the limited networks of doctors.
Of the 40 or so platinum plans listed on the New York health exchange, NOT ONE OF THEM had all four of my friend’s current doctors. And don’t think this is a problem peculiar to the exchange or because of “Obamacare.” The non-group individual plans offered directly to consumers by these same insurance companies use the same limited networks. To save money, presumably they have eliminated many of the most expensive doctors and hospitals in favor of “more efficient” ones.
As an example, Health Republic, the company being forced to close by New York, offered my friend access to 28 hospitals within five miles of his zip code.
By comparison, Empire Blue Cross and Oscar, two leading providers in the area, only offer 12 or 13.
And fewer doctors accept these two plans. Well, how big are the doctor networks for each company? They can’t or won’t tell you, making excuses that the number of doctors keeps changing or that they just don’t know. How can any health insurance consumer make an informed decision if you don’t know how limited the network is that you are buying into?
Given that lack of information about the number of doctors in an insurer’s network, how can you judge the size of the provider network that accepts your insurance? In addition to the number of hospitals test, MrConsumer created the David/John/Smith/Cohen test. If the website of the health insurance company allows you to search by first name only for primary care physicians and/or specialists, choose a radius of five miles from your zip code, and enter the name “John” or “David.” Then compare the number of Johns and Davids in each of the plans you are considering. One can presume that higher numbers indicate more doctors that accept that insurance.
If you cannot search by first name, enter a common last name like “Smith” or “Cohen” and compare how many doctors with that name each plan has.
Why is the size of insurer’s provider network important? If you are referred to a specialist by your primary care doctor for a new condition, or are diagnosed with a condition best treated at a specialty hospital, you want to be able to get treatment at this preferred provider rather than having to settle potentially for someone less expert or a less well-equipped hospital. Most of these policies do not have “out-of-network” coverage.
So what plan did MrConsumer’s friend wind up with? He still hasn’t decided, but will have to give up some of his current specialists.