Health coverage shoppers may face network limits

Tom Murphy
Associated Press

Insurance shoppers likely will have several choices for individual health coverage this fall. The bad news? There’s no guarantee they will cover certain doctors or prescriptions.

Insurers have stopped fleeing the Affordable Care Act’s marketplaces and toned down premium hikes that gouged consumers in recent years. Some are even dropping prices for 2019. But the market will still be far from ideal for many customers when open enrollment starts Thursday.

Much of the insurance left on the marketplaces limits patients to narrow networks of hospitals or doctors and provides no coverage outside those networks.

Plus, these plans can still be unaffordable for people who don’t receive help from the ACA’s income-based tax credits, and they often require patients to pay several thousand dollars toward their care before most coverage starts.

“People understand that things are kind of screwed up,” said Chicago-area broker Robert Slayton. “My objective is to give them what reality is, to give them options. Their job is to choose what may work.”

The ACA expanded coverage to millions when it established state-based marketplaces where people can buy a plan if they don’t get insurance through work, or qualify for government programs like Medicaid. But the expansion has been rough.

Several insurers pulled back from these markets after being swamped with higher-than-expected costs. Many that remained jacked up prices or started limiting the hospitals and doctors included in their coverage networks.

Those narrow networks give insurers leverage to negotiate better rates that can lead to lower coverage prices, and the consulting firm McKinsey & Co. has found that the quality of their hospitals is comparable to broader networks.

Plans with narrow networks will cover necessary specialists like cardiologists, but they often exclude out-of-state care providers or academic medical centers, which tend to be more expensive.

They can pose problems for patients who have more than one physician or want to keep a doctor covered under a previous plan.

Jodi Smith Lemacks is nervous about changing or losing her job because that could mean cutting off her 15-year-old son Joshua from heart specialists he’s seen his entire life. The Richmond, Virginia, resident said she looked last year for options on the ACA’s marketplace to trim the coverage bill she pays through work.

She didn’t find any plans that would cover his current doctors, including some at the Children’s Hospital of Philadelphia, who treat his congenital heart disease.

“The issue with kids like Joshua is, it really matters, it’s life or death where you go,” she said.

Plans with narrow networks can make it harder to simply get to the doctor, especially if it’s a specialist.