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DRASTICALLY thin provider networks on Obamacare Exchange plans

[Update] I've added some revisions, links and updates.

Thanks for adding me, Lambert

The past couple of days I’ve heard constant talk of the deals people are getting on the Obamacare Exchanges, (when the servers are up, of course). $120/month premiums, $500 or less deductibles. All of this sounds like a great triumph of liberal social policy. And if that were the whole story, I would definitely agree.

However, buried in the slimy underbelly of all of it is the new paradigm shift that has been defacto, if not purposefully engineered by the law. That is, the plans on the Exchanges offer **drastically** thin provider networks. I know Lambert has talked about this, but I am not sure that he understood how bad it really is. I know I didn’t, and I have a degree in cynicism (aka Political Science). People may see this in the abstract and think, oh well, a few doctors will be left out. But what is happening nationwide and in my Seattle area is that the highest quality and most major research, teaching and cancer hospitals, as well as a large portion of the top doctors in areas are being left out of the in-network provider list in Exchange plans. As I’ve said, this is a paradigm shift in how health insurance works in our country. People think they are getting the same kinds of plans on the Exchanges that they’ve always gotten through work or the individual markets. They. Are. Not.

[Update]Even Kevin Drum is saying this is going to be a festering sore. But he doesn't get how huge of a deal it really it is, especially how it DOES revive the Republican boogieman of rationed care. The provider networks for Exchange customers are thin. The thinning is done by eliminating research, teaching, and cancer hospitals and doctors of the same from the list, the orgs that provide cutting edge care. In addition, companies are dumping their employees onto these networks, so more people are going to be forced to access fewer and second tier networks of doctors and hospitals. Isn't this rationing of care? If you have difficulty picturing what will happen, Google Medicare and Medicaid doctor access problems. In addition, the thin provider networks coupled with the fact that out of pocket maximums for out of network providers are not CAPPED by the law means that effectively we are no longer financially protected by our insurance for catastrophe if we need to see an out of network provider, say, for cancer, for organ transplant, you know, the events that this law was supposed to save us financially from.

To bring the issue into sharp focus, here is a list of MOST of the hospitals in the Seattle area that are OUTSIDE OF the NETWORK on the Exchange plans offered by Premera, our only Washington Blue Cross affiliate:

  • Swedish Hospital (major Seattle Hospital with branches all over town and in suburbia)
  • University of Washington Medical Center (Our teaching hospital)
  • Providence Hospital (another major hospital)
  • Harborview Medical Center (Major trauma center affiliated with University of Washington. People all over the state are flown to this hospital for trauma treatment.)
  • Seattle Cancer Care Alliance (our Fred Hutchinson Cancer Research Center hospital).
  • Veterans Medical Center

I do not have a grasp of how many doctors in private practice have been dis-included, but I do know that no doctors at Polyclinic are included either. Polyclinic is a large Seattle area clinic, known for its rock-star doctors.

I’m finding a similar situation from Bridgespan, which is the Exchange plan offered by Regence (our Washington Blue Shield affiliate) Cambria. However, I cannot reach a person on the phone to confirm. When I called the number on the Bridgespan web site, the person I reached had no idea why I called him. He forwarded me to “Seattle Customer Service,” which turned out to be one individual's voicemail. Figuring if she got back with me at all, it would be days, I gave up. [Update] Bridgespan does appear to offer Harborview Hospital as an option, but the other hospitals are excluded.

At first, I thought, well, if a person is desperate they can just go to an in-area, but out-of-network provider. However, the new plans have 2 tiers of deductibles/coinsurance and out of pocket maximums, one for in-network and one for out-of-network providers. Out-of-network deductibles and copays on these plans are typically at least twice as high as their in-network counterparts, and they are not subject to cost sharing subsidies. In addition – and this is the greatest travesty – the law appears not to have regulated spending caps for out-of-network providers. Thus, the plans on Premera Blue Cross have an UNLIMITED out-of-pocket maximum for out-of-network providers. (Link to the Premera silver plan) Translated this means if you have emergency out-of-your-very-thin-network care needs, your cost burden is apparently UNLIMITED. [Update] The law does have a provision that insurers cannot charge more for emergency services using out-of-very-thin-network providers. However, they did nothing to prevent hospitals from balance billing, a policy that is legal in most states when you use out-of-network providers. And hospitals routinely do this. Remember that insurance companies pay very low reimbursements for care, so balance billing effectively makes your charge for an out-of-network ER unlimited. And assuming that you can afford to pay an unlimited cost, none of what you paid applies to your deductible, coinsurance or out of pocket maximum once you get to your home network. This all flies in the face of Pelosi's justification that Obamacare would stop people from contracting medical emergencies they can’t pay for. And of course, Obamacare cut funding to subsidize emergency care for the poor.

Notes about my links in the last paragraph:
The balanced billing link is snarky at times and from an MD's perspective. But it provides a descriptive picture of why hospitals probably won't give this policy up any time soon.
My Kaiser link that summarizes the states that allow balanced billing for out of network providers mentions MANAGED CARE in its title. Don't confuse MANAGED CARE with HMO. Managed care includes HMO's AND Preferred Provider Organizations (PPO's)).

One of the issues this law was sold on was that it would eliminate medical bankruptcy for extreme care needs. However, in the Seattle area, none of the in-network Premera plans (and Bridgespan pending) have in-network hospitals offering bone marrow transplants. And as far as I can tell, only one of the hospitals offers organ transplants, but I haven’t gotten to researching if the doctors who do those transplants at that hospital are in-network providers. In-network providers exist for basic cancer or heart care treatment, however with the especially thin provider network, this care will likely be defacto rationed, as not enough providers are available to offer the care. I could go on, but you can fill in the blanks, I'm sure. People who need accelerated care may have no choice but to go to an out-of-very-thin-network hospital or doctor. If they do, because of either uncapped out of pocket maximums, balance billing for out of network providers or both issues, I believe their cost exposure will be nearly as unlimited as if they had no insurance at all.

Also, as we all know, more and more companies are dumping people onto the Exchanges. As the subscriber list on the Exchanges grow, because of the radically thin provider networks, the wait times will also grow even longer. The Republican boogie-man of rationed care may very well become real -- and for an increasing number of people, not just we poor sops who have been on the individual market or without insurance all along.

“Progressives” should be screaming. This should be front page news. The equivalent of Code Pink should be camping on the DC doorsteps and at every capitol building in our country. But the brilliance of this horrifying aspect of the law is that because the “progressive” grass roots love Obama or are otherwise living in denial, they remain silent. Worse yet, they sometimes cheerlead this policy travesty, saying it's "cost-cutting". It makes insurance more "affordable". For the last time, health insurance is NOT health CARE. Are they so naive that they don't realize that this change is the beginning of the destruction of the individual market as a place to get much care at all?

[Update]One of the reasons my hair is on fire is I hope it somehow makes the few employers who have shown some modicom(sp) of conscience rethink dumping their employees onto the Exchanges. When they do, they are not providing traditional insurance. They are providing very skinny insurance plans. Trader Joe's, I'm looking at you.

[Update]I noticed someone at Daily Kos copied my post into comments. I was flattered until I saw others trashing it, then I chuckled. The denial is strong, especially when we've been so effectively sold a bill of goods. I invite people to tell me where I'm wrong about this. But I'll warn you. Research and analytical skills are my strong suits.

But off my soap box. If you have decent coverage and are thinking of switching to a ‘cheaper’ Exchange plan, please do some detailed research into the provider network first. Don’t just look at premiums and in-network copays. And please tell your friends and family to do the same.

And I invite you to research the travesties of your local Exchange provider networks as I have, and post them in the comments. Also, please write your newspaper, your Congressperson, or on your blog and share the same with them.

Thanks for your ear. Sorry in advance for my typos ;-).

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jo6pac's picture
Submitted by jo6pac on

it really is the hurry up die health care system while enriching the 1%, I'm shocked I tell you.

Thanks to you teresa and everyone else that has worked on this. They don't call it affordable care for nothing the plans are cheap but you going to die anyway when the come for body parts to pay your unpaid bill. Monty P. we need you.

What sad little uncaring country we have become. I suspect that the hospitals doing the top end work will close after a while, there just won't be enough 1%ers to support them.

Submitted by Dromaius on

I suspect the hospitals in our area at least, are gambling that there WILL be enough patients to keep them open, and they're likely correct. Our city is home to the largest software company in the world, the largest internet retailer in the world, and one of the largest airplane manufacturers in the world. We have more than enough cadillac-insured patients to keep the doctors and hospitals happy.

quixote's picture
Submitted by quixote on

Um, dumb question, but how do you check who's included in Exchange provider lists? I'd been planning to explore the exchange sites, but I hear you first have to give them your DNA, fingerprints and shoe size, which just isn't worth it for me. Is there some more elegant way to look at that?

And thanks for this very informative piece. I hadn't realized the scope of this issue either.

Submitted by Dromaius on

Not so dumb. They have not made it easy. If you live in an Exchange-friendly state, your state insurance commissioner web site will have a list of the plans offered on the Exchange. Otherwise, find out who the main providers operating in your state are and go to their web sites and see if they offer exchange plans. The web sites for the plans you find will more than likely have doctor search engines. However the search engines are typically really klunky, so you have to search 6 ways to confirm that you can('t) find a provider. But from my observation those search engines are probably the same as the ones you'll find on the Exchange, so it's klunky everywhere.

Submitted by Dromaius on

In California, you can go to the Exchange web site and "shop" plans without giving any of your personal information, other than generic zip code, fake birth date etc.

I know because I've done it ;-)

I have found that the states I've visited that opened their own Exchanges allow you to browse without creating an account. YMMV, of course, but I've tried it in WA, OR, CA, and NH.

Rainbow Girl's picture
Submitted by Rainbow Girl on

before being able to browse. But that's based on trying and not being able to get past the door frame, so to speak, yesterday. New York State is a very insurance-friendly place -- the Legislature is owned by the few giants who rule the roost here, and obscurity of prices and features (in policies) is pretty much the feature - not - bug of any health insurance experience in the state. I will check it out again tomorrow when I have a half hour to spare testing the functionality of the NY system and will report back in re whether useful information (what's on offer and for how much) is available upfront without having to first hand over DNA, astrological sign, etc.

a little night musing's picture
Submitted by a little night ... on

Actually, NYS is NOT insurance-friendly, relatively speaking. NYS regulates insurance (and in particular, health insurance) pretty heavily. It's been way easier to get insurance as a poor person, young person, etc., in NYS than in other states, until now (when I don;'t know what to say). NYS makes requirements of insurers. NYS has tried to make health insurance more available through the years. (And we always have a single-payer bill trying to get attention!)

I won't claim NYS is utopia. But my situation would have been a lot worse had I not been here.

My best friend, who has MS, just moved from NYS to NM. She CANNOT get health insurance in NM (until next year, presumably) because of her "pre-existing condition". This never was a problem while she lived in NYS.

You pay to live here, of course. Pay some, get a lot back, I've gotten.

Rainbow Girl's picture
Submitted by Rainbow Girl on

You are absolutely right that compared to the drecky baseline nationally NYS has actually done some people friendly things -- like the pools for patients with pre-existing conditions, HealthyNY, etc.

That said, for anyone in the private market, even under a lot of the employer provided policies, the laws are written by and for the insurance companies to enable them to screw their policy holders at every turn, with the Insurance Commissioner there pretending to be a consumer advocate whilst actually being a gorilla for the insurers.

So it is a mixed bag. It will be interesting to see whether any of the semi-humane insurance arrangements that NYS has had for people with pre-existing conditions (basically, the "uninsurables") will survive the PPACA.

a little night musing's picture
Submitted by a little night ... on

And even if you're in a public group plan...

They find every reason to deny your claims.

When people ask "isn't it better to be covered, than not, even by a sucky plan?" I just have to wonder how they think of their time and energy. I could fight and get docs to resubmit, because in the end, my condition was disabling but not totally. Had I had cancer, or a heart condition, etc, I would have needed all my energy to stay alive. Try to ask yourself about the tradeoff between having no health care at all and having to fight for every penny it was costing you, WHILE you were sick.

The alternative, maybe, being, you didn't see a doctor at all. Many conditions can go on for months or years this way. But it costs you nothing.

Or, you fight. In the end, it has cost you a lot of dollars and time (and we all have limited time).

Think, really, about what each entails.

That is only part of why "exchanges" are so stupid. We can't, really, judge what this will mean. Even if we could know, we don't know. The market is completely assymetrical, as completely as can be.

quixote's picture
Submitted by quixote on

About the thing of seeing which providers and their plans on the CA network? I didn't have to create an account. That's good. But I could not find the info. I went round and round, downloaded pdfs and searched through them, did everything except create an account, and ... no dice. I'd heard you're supposed to be able to search for your doctor's name in CA to see which, if any, providers include them in Exchange plans. Couldn't find that anywhere either.

Got exasperated after about half an hour and fifty screens. Maybe in this brave new world money won't ration health care as much as being able to keep your eyelids propped open.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Sounds almost as bad as private sector "health" insurance. Their websites have search sections for providers -- they are klunky and, worse, there's always a warning by the InsCo that the data may not be current, so always check by calling the provider to confirm he/she/it is in network.

I have a feeling that your experience will be the norm and that it is a feature, not a bug. The reason is that nobody with vested interests in ObamaCare's "success" wants potential marks (consumers) to know how skinny (shitty) the actual networks are. Just as they don't seem to telegraph that the real cost of a policy is not just the friggin' premiums, but also deductibles, copay, not-covered, etc.

I predict that if the Obama PR machine can't silence the disclosures of this reality -- can't ever find what providers are actually in the networks of the policies that one is comparison-shopping for on the exchanges -- the spin will be that people don't need that information because Obama knows that any provider in an InsCo's network is a "stellar medical provider" or some such insulting nonsense.

In NYS you can't even get past the first page yet. If I ever can get past it I'll check to see how easy/impossible it is to find out what the provider network (and RX list) is for the advertized policy. (BTW A leak to the local news is suggesting that the NYS website is #FAIL because of a denial of service attack ... )

quixote's picture
Submitted by quixote on

It finally dawned on me, too, that maybe the inability to find info is not just me being stupid. It may be a feature. And then I had a thought I would have laughed at in the Old Days. If you have to sign up, even with fake info, in order to get any data, then they (They) have an explicit link to a known IP. They don't even have to ask the NSA who you are.

What is it Bruce Schneier says about loss of social trust in high tech societies?

Alexa's picture
Submitted by Alexa on


Please clarify for me: Are you saying that you've found a health insurance plan that has "dual-track" in-network and out-of-network costs to be met before the insurance carrier picks up the medical costs at 100% for the rest of the calendar year?

Or, are you saying that a health plan beneficiary, if he/she MUST go out-of-network, will only pay out-of-network costs--but that THERE IS NO CAP on the beneficiary's cost at all--and that there is no point at which the insurance carrier begins to pick up 100% of one's medical costs? (after deductibles, etc., are met)

I ask because our private industry "group" health plan instituted a "dual-track" network system this year. Thought that we have it bad because, (including premiums, we must pay just under $25,000 annually is we have an illness, that incurs even "one dollar" out-of-network.

But jeeezzz! What you describe would be a total nightmare!

Some people might survive a couple or three years of our plan, but how many could financially handle the plan which you describe?

Thanks again for this post. I will gladly "shout this bit of information from the proverbial rooftops."


Submitted by lambert on

I can do the political economy part well enough, but when it comes to this:

Or, are you saying that a health plan beneficiary, if he/she MUST go out-of-network, will only pay out-of-network costs--but that THERE IS NO CAP on the beneficiary's cost at all--and that there is no point at which the insurance carrier begins to pick up 100% of one's medical costs? (after deductibles, etc., are met)

MEGO (My Eyes Glaze Over). And I have a bad tendency to believe that things that are obviously crazy pants cannot be true.

A scenario might help... " I need my gall bladder removed and none of the hospitals that do this surgery are in network for any of the plans I'm looking at [this would have to be true]. Does that mean I get no subsidy from ObamaCare? Does that mean there is no cap on payment?"

Alexa's picture
Submitted by Alexa on

Out-of-network deductibles and copays are typically at least twice as high as their in-network counterparts, and they are not subject to cost sharing subsidies. In addition – and this is the greatest travesty – the law appears not to have regulated spending caps for out-of-network providers. Thus, the plans on Premera Blue Cross have an UNLIMITED out-of-pocket maximum for out-of-network providers. (Link to the Premera silver plan) Translated this means if you have emergency out-of-your-very-thin-network care needs, your cost burden is apparently UNLIMITED.

Sorry, Lambert, but I have "to take a pass on" doing chat transcripts due to Mr. A's "edict" that I stay away from the Federal Health Exchange "chat rooms," LOL!

That is--unless we find out in a few days that we are thrown into it for next year. If that's the case, I'll consider "chatting" on this topic. But for now, hopefully another reader (or commenter) is game.

I understand that this may be a "dry topic." But people need to realize that this topic is perhaps the single-most important one regarding the US health insurance system.

"Ignore it at one's peril," I say.

Of all the noxious proponents of our current group health insurance--this one is the very worst.

The only reason that I hope and pray that we aren't thrown out, is because, frankly, I do expect that most of the affordable policies in the Health Exchanges will be equally as bad--if not worse--which is exactly what teresa's post seems to indicate.

That, and the fact that we have VERY clear information on what is, and is not, covered.

And they pay promptly, and as promised. (This is a major multinational corp, with an impeccable reputation. They wouldn't dare do otherwise.)

Don't get me wrong--I figure that "gold" or "platinum" policies MIGHT be pretty decent. But as I've already pointed out--almost no reporters even mention them, much less there cost. And I'd guess that this is for a VERY good reason--they would be out-of-reach for the average person.

Admittedly, I'm simply speculating--just my fear/opinion, on this matter. ;-)

Pushed for time--apologize in advance for "garble" or typos.

Submitted by lambert on

Ick, ick. I am not the person to do this. Basically, I have no idea how to buy insurance and don't know how to ask the right questions...

Alexa's picture
Submitted by Alexa on

an email address.

If at some point in time, we find out that we will be "thrown into the Federal Exchange," I'd very likely be game to check this out, along with a bunch of other stuff (if I've got to get involved, in the first place).

But until that time, I agree with Mr A--and mind you, we don't "do" petitions for this very same reason--no Federal Health Exchange "chats" for us.

I've toyed with the idea of calling the Exchange again, but probably not, since when I did the first time, the preference for a "transcript" was given--and I do understand why.

Frankly, if I should decide to call again, I would not be willing to complete the call if I'm asked for any personal information.

Last time, the Health Exchange rep asked for my name and phone number. I gave him my "truthful" name, but refused to give a phone number.

I have a feeling that "this would not fly," now. ;-)

ELSEVAR's picture
Submitted by ELSEVAR on

If you do call, it won't help. It turns out that the federal phone agents are all contract workers for private contractors, are minimally paid, and are ONLY trained in helping you fill out the application. Sorry about the caps, but THEY HAVE NO TRAINING IN INTERPRETING OR COMPARING INSURANCE PLANS. Yes, I know: !!!

How do I know that? Because I have completed the account creation process (eff. Nov. 14, 2013) and have been able to bore into the .gov site and look at the offerings. They are NOT completely explained and they are NOT subject to comparison. Every comparison is apples and oranges guesswork ... and they don't even clearly state what kind of fruit they are.

My phone agent referred me to a "navigator" outfit which turns out to be an advocacy outfit for mentally disabled clients. I have yet to contact them, but I an not hopeful.

As for the out-of-network expenses, three of the plans I looked at (one was Humana) DO NOT COVER ANYTHING OUTSIDE OF THEIR NETWORKS. NOTHING. NADA. NO COVERAGE AT ALL. AND out-of-network payments DO NOT APPLY TO YOUR DEDUCTABLE. No reimbursement and no credit for payments. None.

Grr. Sorry about the fuming, but I am a very unhappy camper.

Submitted by Dromaius on

Yes, the Exchange plans are generally like that. Bare bones networks, few out of network choices.

And I'm especially sorry that you're having to go through the federal Exchange. At least mine is a state Exchange. I have no idea what our call center is like though. I do know it's separate from the federal one..

A broker might be a better choice for helping you with plan choices. Ehealthinsurance also might be more helpful? I wouldn't know since I can't see the fed Exchange to compare without "enrolling". I don't know what state you live in, but here, plans outside of the Exchange have better networks. If you don't happen to be eligible for subsidies, those are clearly a better way to go, plus you're sending the message that you won't participate in their garbage. And I don't know your employment situation, but if you're self-employed, look at small group plans. Some states allow groups of 1.

Good luck!

Submitted by Dromaius on

The out-of-very-thin-network out of pocket maximums are pretty much the same for Gold plans as well in Washington. We don't have platinum plans I only mentioned the silver plans because they are the only ones that qualify for BOTH premium and cost sharing subsidies.

The bottom line is that people need to recognize that they aren't getting anywhere near the same insurance that they used to. Don't be fooled by the pricing structure or co-pay and deductible.

And I loved your comment. I'm being cryptic as heck myself. Just trying to relay information that even our insurance commissioner seemingly wants to keep hidden.

Submitted by Dromaius on

All plans offered by either Premera/Lifewise (Blue Cross) or Bridgespan (Blue Shield), which are the major plans on our Exchange, have dual track deductibles. (I haven't looked at the other plans) Dual-track deductibles are allowed by the law, and were probably created to skirt the law. Given the skinny provider networks these plans are utilizing, people very likely could incur significant costs if they need to see someone out of the very thin network, if they have an emergency, etc.

I provided a link to the Premera Silver plan in my post. Here's a link to all of the Premera plans. Scroll down to find PDFs listing individual plan information. For all of them, if you go outside of the very skimpy provider network, the following is true. There is no point at which Premera picks up the whole bill:

Bridgespan's out of network deductible is $12,500 for individuals. Keep in mind again that "out of network" includes all of the major hospitals in Seattle. For families, Bridgespan lists "N/A" as their out of network deductible. On printed materials that Regence (Bridgespan) sent me, they replaced N/A with "Unlimited". Here's a link to Bridgespan:

So I've covered the Blue Cross/Blue Shield providers.

I suspect that this is a nationwide problem.

Submitted by Dromaius on

And if it's not obvious....

The Premera site will make you re-choose the year tab. So choose the 2014 tab, THEN scroll down and see the plan PDFs

On the Bridgespan site, select any of the Gold, Silver, Bronze plans to zoom in and see the out-of-thin-provider-network deductibles.

Submitted by Dromaius on

You're welcome. I've been trying to access Oregon, NY and California systems to see their plans but for some reason (LOL) the web sites aren't working.

I successfully accessed New Hampshire and found that while their out of network deductibles and OOP maxes are extremely high, they at least are not UNLIMITED, like ours. How sad.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Hi Teresa,

Thanks for a terrific and detail-rich first post, which I've forwarded to friends in Seattle.

As I posted earlier, NYS exchange is still 100% #FAIL -- as in first page that loads tells you there's no here here. Because massive program!

Frugal Nurse's picture
Submitted by Frugal Nurse on

I completely agree! I just went on the healthplanfinder and discovered that none of the doctors my family uses is "in network" for Lifewise, Premera, Bridgespan or Molina. Neither is Swedish hospital, the hospital I have used my entire life. I wasn't expecting this, as these companies have been around for ages and have always had great provider networks. I don't understand, either. All these companies have off-exchange plans that are only slightly more expensive than their plans on the exchange. And they don't pay the subsidies, so why the narrow network on the exchange plans? I am really, really disappointed (in premiums, out-of-pocket costs and provider networks). My guess is these provide networks will get smaller, too, next year.

Submitted by Dromaius on

When I spoke with the marketing guy at Premera, he said that it was because these providers wouldn't accept Premera's wonderful Exchange reimbursement rate. Those bad-bad hospitals! (LOL). And I've heard that Premera's rate is equivalent to what providers accept for Medicare. The difference with Medicare however is the government can blackmail the hospitals. My doc told me if a hospital takes federal funding, they have to accept Medicare.

If you have time, write some letters to this effect to the news media. I feel like I'm the only person in the world who gets this. Well, we all do now ;-). People are emphasizing the in network copays and deductibles. They aren't emphasizing the reality of the ultra-skimpy network.

BTW, Bridgespan has Harborview in network at least. I figure I'm going to choose them.

Submitted by Dromaius on

When you say network, maybe say "ultra thin network". The pre-Obamacare networks, at least in the Seattle individual insurance market were not ultra-thin, typically included almost all if not all of the in-area providers.

And I don't know if you want to emphasize TIERED copays, deductibles and out of pocket maximums. We have a regulated tier for in-network and an unregulated tier for out-of-network. Some of these plans don't make it easy for you to understand the tiers. Prior to Obamacare, we typically had one deductible and out of pocket maximum that encompassed in- and out-of-network services. I think we've always had different coinsurance (the 20-50% patient responsibility) for in-network versus out of network services.

This is all good. Feel free to take any of my information and mold it into your own text. I'm so tired from the outrage and your forum is so visible, I don't want to update my post in case I screw it up! Woke in the middle of the night and couldn't get back to sleep.

Thank you.

Frugal Nurse's picture
Submitted by Frugal Nurse on

"Narrow network" is the common insurance jargon. Usually, if there are extenuating circumstances, such as an emergency or you can't find the necessary treatment in-network, insurance companies will relax their in-network rules--although you would need to petition them in writing and get letters from doctors to back you up. Still, we are all going to be operating under a new normal, so who knows?

Submitted by Dromaius on

In the past we could access the cutting edge providers with our individual plans. Now we can't and maybe any negotiation will be minimally allowed too. Yes, it's a new paradigm.

I hated my individual insurance plan. I had no idea how good I had it. What really burns me is I've been paying into it for 12 years and hardly using it because of the high deductible. Now, if I get truly sick, I won't be able to use the Seattle Hospitals. It's just beyond sick.

And I feel even worse for people who've had NO insurance. Of course, we with high deductible plans don't necessarily have better care. We just have less money to pay for that care because we're paying the premiums.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Cost-Sharing (as distinct from fixed co-pays, which is -- apparently the ancient, now -- system where if you see an in-network doctor you pay a fixed fee for a visit, e.g., 5, 10, 15, 20, 25 bucks (those have been leaping up in normal private HMO plans, natch).

People associate "copay" with the comparatively small fixed payments. Cost-sharing is where if you're in a 60/40 plan, and you've paid the premiums AND deductibles up to the cap (if in=network, anyway), your cost *sharing* means you're shelling out 40% of the costs of the services, which is, or could be, a whole lot of money. (Or 30 % if you're in a 70/30, and so on.)

Agree with Teresa -- I would have "skinny network" (or ultra-skinny) as opposed to just "network" again because people have been trained to think of "network" as a normal part of health insurance since HMOs (and now Medicare, Medicaid).

Alexa's picture
Submitted by Alexa on

Apparently, the new "model" is to drop premiums, but drastically raise ALL out-of-pocket costs!

After I wade through what is close to a "quarter of a ream" of health plan info for 2014, I'll put in my two cents.

After watching an online presentation--"I see the handwriting on the wall."

You're on you're own, sucker! ;-)

Understand, this multinational "writes the regulations" for its industry in Washington, and basically sets industry standards. So, by the same token, it "sets industry standards for benefits," as well.

(I am sorry that out of respect for Mr A's privacy, I cannot name the employer. I would be shocked if there werer any readers who did not "know" this company. But, hey, I've already aggravated Mr A more than once--regarding divulging too much personal information online, that is--so I must be a bit more circumspect in my discussion, from now on.)

However, I believe that the status of our "group" health insurance plan is worth noting--not because of us, obviously--but because it will be the story of tens of millions of Americans, in time.


Alexa's picture
Submitted by Alexa on

broadest category (I would think).

And wouldn't it be a bit more clear to use the exact insurance jargon:

"in-network" co-insurance (costs)

"out-of-network" co-insurance (costs)

Instead of:


No caps if not in network

I'm thinking this since some plans will probably have a "cap" on their "out-of-network" costs (Sure hope so, anyway!)


Submitted by lambert on

Have I mentioned that I don't have insurance, and that the whole process is MEGO for me?

The more precise and accurate the language, the better!

Submitted by Dromaius on

By law, the plans are not required to have caps on their out of network out of pocket costs. Some do have caps, but they're rather large ($12500 for Regence-Bridgespan, but unlimited on Premera). Of course, in the many, many states that allow it, you still have balance billing to worry about, which means that you really have no caps.

Here's a credible-looking link regarding uncapped out of network costs. The article states that the unlimited out of pocket max rules are still pending, but based on Washington's Exchange site, they're a done deal now.

Submitted by Dromaius on

Heya, Lambert, I thought of one other issue that you haven't listed. That is "balance-billing". The term sounds like the love-child of humpty-dumpty and a duck, but actually it's the practice by providers of billing patients for the difference between insurance reimbursement and the actual billed amount.

Balance billing is only sometimes legal for in-network providers. But for OUT-of-network providers it is typically legal. Or if illegal, it's typically only illegal for emergency services. And of course, this has big implications for insurance that has skinny networks.

Here's a list of states and their laws regarding balance-billing:

Alexa's picture
Submitted by Alexa on

Does anyone know "how" I can check the "actuarial" value of our group health plan?

Or would the information needed in order to figure this out, be accessible only to the company?

Frankly, I thought about asking the Benefits Dept to furnish me this info, but Mr. A didn't think that this approach "would be too cool" (to say the least), LOL!

So I'll try to figure it out on my own.

Submitted by Dromaius on

You might just call Group Death.....or, you could look at some of their individual plans and see how close they come to what you have now. Based on bronze,silver,gold, you could guesstimate the nearest actuarial value. You could do this via GH's web site if you don't want to give your personal information away on the Exchange site.

Rainbow Girl's picture
Submitted by Rainbow Girl on

ObamaCare is a Squillionty-Dimensional ClusterFraud!

The Affordable Care Act is Neither Affordable Nor About Care. Continue to Discuss Amongst Yourselves. *

[* Ref. Linda Richman, SNL, a very long time ago. "The Civil War was neither Civil nor a War. Discuss amongst yourselves."]

Submitted by Dromaius on

Not about Affordable nor Care, but Definitely an Act.....a really, really good Act. And it would be pure comedy if it wasn't about us.

Submitted by Dromaius on

Well, I received a reply from my long rant to the Insurance Commissioner's office about thin plans.

Basically, the gist was, yeah, but we cover the 10 essential benefits. Everything else you say is true but we'd just as soon not tell our constituency about it (edit, because that would hurt Obama).

So, I have unlimited financial liability if I have a heart attack and don't happen to be near one of the few in-network hospitals in our area, but if I need a $25 flu shot, I'm golden.

Submitted by lambert on

Might as well add that to the mix, especially if others end up using similar verbiage.

Submitted by Dromaius on

Sorry, I deleted it. Trust me, she provided no information. She's a PR person. Her job is to get me to like the plans. Kreidler (our insurance commissioner) has talked about the skinny plans, was responsible for reviewing their provider networks. His office should know full well about the situation, but his "consumer advocate" (aka PR person) acted like she was in the dark about it . Worthless. So I screeched in frustration and deleted the email. Sorry.

It honestly scares me how little real information and how much spin people are getting. It's very 1984'ish. And even when people (like us) try and educate them, the denial is so strong, enhanced by the disinformation campaign, that people can't see it. People will have to experience these plans themselves to really understand how bad they are. They apparently need an internship in awfulness.

Submitted by Dromaius on

So I found this. Apparently the health insurance law stipulates that insurance companies can't charge more for out-of-network emergency care than they charge for in-network emergency care. Whatever the hell that means. Does it mean that the in-network deductible and out of pocket max applies to emergency? If so, then why don't the plan summaries say so. Does it mean that the emergency room provider can't balance-bill (bill for charges beyond the insurance reimbursement)? When does ER care end and out-of-network in-hospital care begin?

The bottom line is even if theoretically this law is in place, it doesn't mean the insurance companies and care providers won't try and overcharge. People will likely need to come out of the hospital expecting a fight.

And the thin provider network means that people will have more occasions when they have to fight.

Rainbow Girl's picture
Submitted by Rainbow Girl on

What you just described is typical of the utterly (and deliberately) incomprehensible language of what is and isn't covered that is found in the so-called insurance policy (disclosure) documents. They are written like this precisely to give the insurance company the chance to reflexively deny coverage or pay one penny on the $10,000 bill, string it out for as long as they can (*) or just plain get away with it because they *count* on most people simply getting overwhelemed and believing there's nothing they can do (which is reinforced by the utter uselessness of most insurance commissioners that I'm aware of).

Absent a real simple rule issued and enforceable by the DOJ or the FTC or the CFPB (or God forbid Insurance Commissioners) -- under commercial fraud jurisdiction -- that says "if the policy is ambiguous" (unintelligible to the reasonable person), it's construed against the drafter (the insurance company) period end of story. And the claim can be brought in an emergency -- very fast -- procedure, and with a mechanism to ensure immediate payment on whatever the claim in issue is. I don't see this ever happening because the so called regulators are by definition captured entities serving the Banksters, the White House they run, and all the corporations of the FIRE sector by ensuring that the game is rigged against the consumer to maximize extraction period.

It's funny how this rule of contract interpretation is one of the bulwarks of our common law of contracts, but it doesn't apply to adhesion contracts like insurance policies (written by the corporation and given on a take it or leave it basis) -- especially since most of them now force you to waive your rights to sue in court and make you go to private arbitration which is inaccessible because outrageously expensive and 99.9% run and biased in favor of corporations.

I see a role for a dynamic new public interest law firm that would organize across the 50 states to assist the 1000s, 10,000s, 1000000s, Millions (?) who will be getting scammed once engaged with the ObamaCare juggernaut.

(*) As we all know, or should know, one of the insurance companies' main techniques for preserving that perfect business model of collecting premiums and paying as little to zero as possible, is to deny, deny, deny, which is equivalent to delay-delay-delay. The mere fact of delaying any payout (however pitiful or inadequate or outright illegal) keeps their Profit and Loss statements glossy for the purpose of reporting their ongoing "health" to shareholders, and to the SEC in filings, etc.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Disturbingly, the National Consumer Law Center has been "crickets" in re ObamaCare and its nature as potentially a very rich source of consumer frauds requiring some proactive preparation by a so-called consumer agency. So maybe this organization is a clone of Sierra Club and those other "public interest" shops that are really just happy-face extensions of the elite extraction system.

Rainbow Girl's picture
Submitted by Rainbow Girl on

There's an urgent need to establish a cross-states network of advocacy places where these issues can be collected and addressed as best we can within current limitations. I don't see anyone handing out funding for such a thing -- a non-Obama-sponsored assistance program -- but maybe on the model of the decentralized OWS efforts -- "Occupy Health Insurance/Medicare for All" -- chapters everywhere with interweb network, etc. And with nothing to hide, so NSA spying a non-issue.

Splashoil's picture
Submitted by Splashoil on

I was able to pass along your information in the comments on this WA Kossacks first post on his "exchange experience."
Most of the people who really know the details are on the other team shilling for the insurance companies and other "stakeholders." We may need a new Insurance Commissioner here in WA!
This is the kind of detail we need to arm "new shoppers" with some questions to ask. Beyond that it is a call to action.