One of the insurance industry developments this year that have us scrambling for solutions is the number of insurance companies that are reducing health care provider availability within their networks. This is happening by reducing the size of their networks or eliminating out-of-network benefits. These aren’t mutually exclusive: some insurers are doing both.
So why would a carrier that is trying to attract new members make a decision to restrict provider access? Well, like with most things, it comes down to expenses.
Many of us expected the ACA’s guaranteed issue provision would lead to adverse selection, and it did. A provision that allows for anyone to have policies without limitations or surcharges on pre-existing conditions created a scenario which led people with immediate and ongoing need for medical care to purchase coverage. Those who don’t have ongoing medical conditions did not. Individual medical carriers across the nation are announcing that they’re losing money due to this imbalance. In efforts to save the business, carriers are making changes to the plans they offer.
Of course, it’s not just the insurance carriers that are making changes in the way they do business. Health care providers are also making changes. Due to the ACA’s 90-day grace period for insureds receiving premium tax credits, health care providers are worried about not getting paid for services rendered. In response, many are making decisions to not accept the plans sold through the Marketplace. While some may argue that providers aren’t in the right to make that decision, because they’re contracted with the networks, many are doing it anyway. This is causing uncertainty for individuals who purchased plans via the Marketplace.
Recognizing the concerns, Healthcare.gov has introduced a new provider search tool, but it’s still in beta mode and not entirely helpful. Quoted from Healthcare.gov:
“This year, for the first time we've asked insurance companies for information about which doctors and drugs their plans cover. In this early stage, some data may be missing or inaccurate. We'll be updating it regularly. Check with the insurance company to verify network coverage.”
Regulators are considering actions that would require insurance companies to meet certain standards when designing networks. According to Managed Care Magazine, a National Association of Insurance Commissioners (NAIC) subgroup is working on a “new model network adequacy law”. In California, the Department of Managed Health Care fined two insurance giants for overstating their Obamacare doctor networks. As reported by the Los Angeles Times, the California “Department of Managed Health Care levied fines of $350,000 against Blue Shield of California and $250,000 for Anthem Blue Cross” because of “the companies’ error-riddled provider directories that frustrated many consumers statewide as they tried to find doctors.” Several consumer lawsuits against the insurers are pending.
A few things to consider: With all this turmoil, we thought we’d take this opportunity and offer a bit of friendly advice:
Trying to find plans that cover your clients’ doctors and hospitals can be frustrating and time-consuming. Breaking the news to your clients that there are NO plans that cover all of your providers is a painful conversation. Keep in mind that doing the research in advance for clients is a value added service. This and other similar services will keep clients coming back. Even when shopping Healthcare.gov, you have the opportunity to do the up-front work that could make the shopping experience stress-free for your clients.
Recognize the health insurance purchase experience causes a lot of people to shop for new plans rather than just renewing their current plan - make yourself visible, this is an opportunity to pick up some new clients.
Don’t forget about the benefits of off-exchange plans. For clients who are not eligible for the premium tax credit, they’ll likely have more options by shopping outside of the Marketplace. Non-Marketplace plans may offer the larger networks your clients are used to, keeping those clients happy.
If your clients are complaining about longer-than-normal wait times to see certain providers, suggest they consider visiting a Retail Health Clinic or Urgent Care Center for minor illnesses and injuries. These facilities can be more cost-effective options than doctor offices and emergency rooms. If their plans offer a telehealth benefit, suggest they use it, this allows members to call a doctor when it’s convenient for them. These alternative ways to seek care help your clients save money.
We work in an extremely agile market, which could sometimes make us question our decisions. Staying informed of the changes, being willing to adapt to the changes, and continually learning new ways help your clients keeps you providing the extra value your client’s appreciate and building trust to keep them coming back
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