Health Law Insurance Plans to be Rated by Network Size
By ROBERT PEAR
MARCH 6, 2016 - The New York Times
WASHINGTON — The Obama
administration, responding to consumer complaints, says it will begin rating
health insurance plans based on how many doctors and hospitals they include in
their networks.
At the same time, the maximum
out-of-pocket costs for consumers under the Affordable Care Act will increase
next year to $7,150 for an individual and $14,300 for a family, the
administration said. Consumer advocates said those costs could be a significant
burden for middle-income people who need a substantial amount of care.
Under new rules to be published
Tuesday in the Federal Register, insurers will still be allowed to sell health
plans with narrow networks of providers. But consumers will know in advance what
they are getting because the government will attach a label indicating the
breadth of the network for each plan sold on HealthCare.gov.
About 12.7 million people signed up
or had their coverage automatically renewed in the third annual open enrollment
season, which ended on Jan. 31.
Many health plans offered in the
public marketplaces provide a limited choice of doctors and hospitals, and some
insurers narrowed their networks this year by excluding some doctors and
dropping popular teaching hospitals.
Consumers have grumbled about the
changes, and some say they have had difficulty finding medical specialists. But
cost-conscious consumers have gravitated to these plans because they tend to
offer lower premiums than health plans providing a greater choice of doctors and
hospitals.
Consumers can already find out
which health plans include a specific doctor. But until now they had no reliable
way to determine if a health plan had a large or small network of providers. The
new ratings will indicate how the breadth of a health planfs network compares
with that of other plans in the same geographic area.
gThis could be really helpful for
a lot of consumers,h said Sabrina Corlette, a consumer advocate and professor at
the Health Policy Institute of Georgetown
University.
Consumers have also complained
about the out-of-pocket costs for many health plans under the Affordable Care
Act.
gFor many people, $7,000 of costs
can be a huge impediment to actually receiving care,h especially if patients
incur those costs in a month or two at the start of a year, said Marc M. Boutin,
the chief executive of the National Health Council, a
coalition of advocacy groups for people with chronic diseases.
Out-of-pocket costs, as defined by
the government, include deductibles and co-payments, but not the premiums that
people pay for insurance. Each insurer sets limits on out-of-pocket costs for
its health plans, and the limit cannot be higher than the maximum specified by
the government. The maximum for an individual will exceed $7,000 next year for
the first time. It will go up by $300 in 2017, after an increase of $250 this
year.
Consumer groups say this rate of
increase is unsustainable. Moreover, they say, high out-of-pocket costs have
deterred some people with insurance from using expensive prescription drugs.
Ben Wakana, a spokesman for the Department of Health and Human Services, said
that in setting the new ceiling on out-of-pocket costs, the administration had
used a formula laid out in the Affordable Care Act. Before the law was adopted,
he said, people with cancer or other serious illnesses could be bankrupted by
hundreds of thousands of dollars in medical bills, and the law provides new
protections.
People with low incomes can obtain
discounts that reduce their deductibles and other out-of-pocket costs if they
choose midlevel silver plans. Slightly more than half of the people with
marketplace coverage received such gcost-sharing reductionsh last year.
Ms. Corlette, the Georgetown
University professor, said that in writing the new rules, gthe administration
was walking a very delicate line, pushing forward with consumer protections
while trying to keep insurers onboard and participating in the
marketplaces.h
In some markets, consumers can
choose from dozens of health plans. In a move intended to simplify the shopping
experience, the Obama administration has devised six model health plans that it
describes as standardized options. Federal officials specify the amount of
deductibles, co-payments and other charges for doctorsf services, hospital care,
X-rays, laboratory tests and prescription drugs.
The standard features will make it
easier for consumers to compare plans, officials said, and the government will
highlight these plans in some way on HealthCare.gov. But the government is not
requiring insurers to offer the standardized options or limiting their ability
to offer other plans in 2017.
Another new requirement is meant
to guarantee gcontinuity of careh for certain patients. If a health plan drops a
doctor from its network without cause, the insurer must allow patients in gan
active course of treatmenth to continue seeing the doctor for up to 90 days.
This protection would apply, for example, to patients receiving chemotherapy or
radiation therapy for cancer and to women in the second or third trimester of
pregnancy.
Under the new rules, consumers
using the federal marketplace will be able to get help year-round from insurance
counselors financed by the government. The counselors, known as navigators, help
people sign up in the annual open enrollment period. The administration is
expanding their duties to include teaching people how to use insurance, appeal
denials of coverage and obtain exemptions.