People shopping for coverage through the Affordable Care Act need to pay close attention to the provider networks, which are narrower than many private insurance plans were in the past – so narrow that some major hospitals aren’t in-network in some plans.
If a doctor you are accustomed to visiting isn’t in an insurance company’s provider network, you will have to change doctors or have no insurance coverage – at all – for treatment by your old doctor. The same goes for hospitals.
If you live in Lexington County and expect to go to Lexington Medical Center, the hospital is only in-network on one of the four companies providing coverage on the Health Insurance Marketplace in South Carolina, Coventry Health Care of the Carolinas. If you buy a marketplace plan from BlueCross BlueShield of S.C. or BlueChoice Health Plan, you would want to schedule hospital procedures in the Midlands at Providence Hospitals or Palmetto Health facilities. For another insurance provider, Consumers’ Consumers’ Choice Health Plan, both Lexington Medical Center and Providence Hospitals are out-of-network.
Lexington Medical Center spokesperson Jennifer Wilson said the hospital negotiated with all of the insurance companies but couldn’t agree on terms. BlueCross BlueShield spokeswoman Patti Embry-Tautenhan said the company doesn’t comment on individual provider contracts, but the goal for the provider network is “to offer appropriate access to health care services through a network that is value-based and efficient.”
That used to be nearly unheard of, according to Steve Hinson, an insurance agent with Insurance Management Group in Columbia and a former BlueCross BlueShield employee. “It used to be if (BlueCross) lost a hospital, it would be a disaster,” Hinson said.
But the new Health Insurance Marketplace is changing many rules in the business. Insurers have slimmed down provider networks for marketplace policies to hold down costs. In some cases, doctors and hospitals have agreed to be paid less under marketplace policies than in the past, industry officials have reported.
If you receive health insurance through your employer, none of these changes apply to you.
Provider networks can be fluid, with more doctors or hospitals added throughout the year, said Embry-Tautenhan. But Hinson said he would “find it hard to tell somebody to take a policy on the hope that a hospital would be added by Jan. 1.”
While Lexington Medical Center isn’t in the BlueCross and BlueChoice networks and Providence isn’t in the Consumers’ Choice network, the McLeod hospitals in the Pee Dee aren’t in the Coventry network. Coventry, which was purchased by Aetna last year, has been in the South Carolina market for years.
Coventry plans are available in 11 counties in the state, so there are some areas where they have fewer physicians in their network than other companies. BlueCross, BlueChoice and Consumers’ Choice offer plans in all counties.
Many of the shoppers on the new marketplace are new to insurance coverage and don’t have physicians they are used to seeing. They will find plenty of family physicians on the networks, though some might not be accepting new patients. Also, there are limited choices for some specialties in some counties.
For instance, BlueCross and BlueChoice networks have two speech language pathologists in Richland and Lexington counties, while Consumers’ Choice has one and Coventry has none. Consumers’ Choice has three local allergists in its network, while BlueCross and BlueChoice have seven and Coventry has eight.
Shoppers have until Dec. 15 to buy policies on the marketplace that provide coverage starting Jan. 1. The Affordable Care Act requires most people to have health insurance coverage in 2014 or face a penalty. Many low-income people in South Carolina, however, are exempt from the penalty. Because state leaders turned down Medicaid expansion, individuals in the state making less than about $14,500 aren’t eligible for Medicaid, but they also are exempt from the penalty for not having insurance.
Most people in the state can ignore the Health Insurance Marketplace. People covered by Medicaid, Medicare and most group health plans aren’t eligible for tax subsidies. Without the subsidies, few people with group policies would save money with marketplace policies.