Q: I like my doctor and local hospital. How can I be sure I can continue to go to them if I get an Obamacare health plan?
A: You have to ask. In fact, that should be one of your most important questions.
To hold down premiums, many insurers selling individual health plans on the state exchanges are offering narrower networks of doctors and hospitals than typical plans sold to large groups. In addition, the extra costs for going to a doctor or hospital out-of-network are often higher—sticking patients with around 40 up to 100 percent of the bills, for example.
Take New York. None of the more than 50 health plans in the state’s online exchange offer out-of-network coverage, including the top-tier “platinum” plans charging $600 a month in premiums. That means, for instance, if you are in a network hospital and under the care of a network doctor but treated by an out-of-network physician or specialist or surgeon, perhaps while you were unconscious, you would be liable for 100 percent of the out-of-network care.
To make matters worse, not a penny of those out-of-network bills would count against your out-of-pocket maximum of up to $12,700 for a family.
And again, even if your hospital is in the network, your health plan may only cover certain procedures, such as trauma care. So you need to ask a number of very detailed questions before you sign up for an Obamacare plan.
Insurance companies say the narrower networks will lower premiums by driving members to less expensive doctors and hospitals that nonetheless provide high-quality care.
Anthem Blue Cross, for example, lowered premiums by 25 percent for its New Hampshire exchange insurance in part by narrowing its network. Insurers say lower premiums are important to the working- and middle-class people the exchanges are trying to serve.
However, according to the New York Times, Anthem’s move “touched off a furor” in the state, because the plans exclude 10 of the state’s 26 hospitals. To make matters worse, Anthem Blue Cross is the only company selling insurance on the New Hampshire exchange.
Before you enroll in an exchange health plan, proceed carefully. You are buying a complicated product. According to some estimates, when Massachusetts launched its exchanges under Gov. Mitt Romney, people visited the state’s online exchange 15 to 18 times before they bought a plan.
Assuming your state’s online exchange has shed its computer glitches, you should be able to compare health plans side-by-side, much as you do buying airline tickets online.
But once you zero in on a plan, no doubt influenced by your premium costs after whatever federal subsidies you qualify for, you must study the plan details carefully.
You may even be wise to call the insurance company and get someone walk you through exactly what’s covered, including trips to your doctor and hospital, and what isn’t. Ask for the important details to be sent to you in writing, either through the mail or online. Unfortunately, talk is cheap.
And never buy insurance based on the premium alone, especially if that monthly charge is unbelievably low. The insurer needs to take something away to lower your cost. What the company is excluding may not be important to you. No harm, no foul.
On the other hand, the company may be taking away your doctor. Could you live without her? You may need to decide.