Patient advocates say the exclusion of one of Missouri’s top hospital systems from policies offered by the region’s biggest insurer under the Affordable Care Act could hinder treatment for some patients and force others to switch doctors, according to a report by Kaiser Health News.
The network for the Anthem BlueCross BlueShield plans, which will be sold through Missouri’s “Obamacare” marketplace, does not include BJC HealthCare and its 13 hospitals -- among them Barnes-Jewish Hospital, the area’s premier academic medical center, and St. Louis Children’s Hospital.
Consumers in other states including Florida may find a similar scenario when the marketplace launches Tuesday Oct. 1.
In addition to how much the plan costs, people with serious medical conditions will need to carefully review whether their medications are covered by the plan, and whether the specialists and facilities they visit regularly are in the plan's network. They' should also check the out-of-pocket costs to go out of the network, experts say.
The limited provider networks allow insurance companies to offer lower-cost plans, which they expect will be a competitive advantage in the marketplace. "Obviously, premium costs will be an important consideration for consumers," says Kaiser. "But just as important will be a realistic assessment of what kinds of out-of-pocket costs they could expect with different types of policies and what subsidies they will be eligible for."
Although the law requires new individual and small group plans to cover a comprehensive set of 10 "essential health benefits," including prescription drugs, hospitalization and doctor visits, the proportion of the costs that a consumer pays will vary with different plans -- and so could the provider networks.
The plans on the marketplace are each identified by a precious metal: Platinum plans will pay 90 percent of covered expenses, on average; gold plans will pay 80 percent, silver plans 70 percent and bronze plans 60 percent.
Tax credits will help people earning from 100 to 400 percent of the federal poverty level reduce the cost of the premium. And "cost-sharing subsidies will reduce the out-of-pocket costs for people with incomes up to 250 percent of poverty ($28,725 for an individual in 2013)," Kaiser says. "The maximum amount that consumers will owe out of pocket for in-network medical claims will generally be capped at roughly $6,400 for individuals and $12,700 for families in 2014. (Those figures do not include money spent on premiums.)"
How all those elements play together can have cost and coverage implications if you have high medical expenses.
"For example, even though the premium for a platinum plan will generally be higher than that of a bronze plan, the out-of-pocket spending cap may be significantly lower since platinum plans must cover 90 percent of expenses. In California, for example, the out-of-pocket spending limit on a platinum plan is $4,000, compared with $6,400 for other metal level plans.
"For people who expect to hit their spending cap, buying a pricier platinum plan may actually result in lower total spending, says Marc Boutin, executive vice president and chief operating officer at the National Health Council, a patient advocacy organization.
"Insurers anticipate that people with high medical costs will gravitate toward platinum and, to a lesser extent, gold plans, and they're pricing those plans accordingly, say experts.
"If only one member of a family has high medical expenses, families may want to consider splitting coverage between different plans.
"Depending on where people live, that strategy could run into snags. Although splitting family coverage is allowed on the individual market, state and federal officials say the Department of Health and Human Services is considering whether to limit the practice on the exchanges it will run in 34 states next year, as are some states setting up their own exchanges.
"In addition, platinum plans may not be available in every state. For example, none of the seven insurers that have been approved to sell plans on the Washington State Health Benefit Exchange will offer platinum plans next year, says spokeswoman Bethany Frey.
"A platinum plan may not be the best option in any case, even for people with expensive medical conditions. Although premium tax credits are available for any type of plan, cost-sharing subsidies that can substantially reduce deductibles, copayments and coinsurance are only available on silver plans.