Wednesday, November 4, 2015

Premiums, Provider Networks, And Other Changes To Affordable Care Act Plans (Adventures in Health Insurance Post No. 7)

It's been a little over two years since I wrote about my experiences buying insurance under the Affordable Care Act (a/k/a Obamacare). Many insurers, including mine, are changing plans or premiums or both this year, so it's a good time for an update.

I still work for myself and and remain thrilled that I can buy an individual health insurance plan. For reasons I wrote about before, I was denied individual health insurance after I started my own law firm, and there is no group coverage available to me as a sole proprietor. I bought coverage through the Illinois ICHIP program, paying about $300 a month for a $5,000 deductible/out of pocket limit. After the ACA/Obamacare, I bought a PPO Silver plan from Blue Cross Blue Shield. The premium was somewhat higher, the deductible was lower, and the out of pocket limit higher. The first time I picked up a prescription from the pharmacy I got a surprise.

Northwestern Memorial Hospital is the hospital my doctor is affiliated with.
Under the ICHIP plan I had before the ACA went into effect, I paid everything out of pocket until I met the $5,000 deductible. Not a percentage. Not a co-pay. Everything. So when my pharmacist told me I didn't owe for my prescription, I thought he'd made a mistake, as I hadn't met my deductible. The drug normally cost me about $8-$10 for 30 tablets. He explained that under my PPO Silver plan, I paid only a co-pay amount for prescriptions even before I hit the deductible, and because this drug was an inexpensive one on an agreed-upon list, I did not need to pay at all. Who knew? Then when I went in for a yearly check up, I found out that was covered, too, with no co-pay. A yearly mammogram also cost me nothing.

The second year my premium increased a bit, to about $420 per month. I didn't mind. It was wonderful not worrying that unavailability of individual insurance would force me to close my business and go work for a large employer. And the timing of the ACA, for me personally, couldn't have been better. In the past two years, I've gradually shifted my law practice to part time and started writing full time. Because of the ACA, I can run two businesses, both of which provide work to other small businesses and send work to freelancers.

This October I received a letter about my Blue Cross Blue Shield health plan. First surprise: the premium is going down. Second surprise: it is because Blue Cross is discontinuing the PPO Silver plans in Illinois (as well as the Gold and Bronze versions) under which I'd been covered. I was offered a different network, but when I checked, I learned my doctor was not part of it. And more important, neither is the hospital with which she is affiliated. The Blue Cross person I spoke to was very nice and helpful, but there is now no Blue Cross plan I can buy that includes either my doctor or Northwestern Memorial Hospital. If I got care out of network, I'd pay entirely out of pocket up to $45,000 a year and at the full price rates, not negotiated Blue Cross rates. (To give you an idea of the difference, the PPO rate can be as little as one-third of a total hospital bill, meaning an uninsured person would owe $75,000 where a Blue Cross insured would owe $25,000 (which would be paid mostly by the insurer).) My doctor's staff person was less pleasant--perhaps she's fielding a lot of calls--but she did refer me to the website to see what other Healthcare Exchange Plans my doctor's practice accepts.

I checked the one PPO plan with an insurer I'd never heard of. The premium and deductible were significantly lower than my current plan. But the top results in a quick Google search included numerous Better Business Bureau complaints about failures to pay, delayed payments, and inept/non-existent claims handling. I figured that probably explained the lower costs and decided against that plan. The other plan is offered by an insurer I'm familiar with, and it's a Bronze plan. The premium is higher ($508 v. $420), as is the deductible, and the benefits lower (higher co-pays, less covered even after the deductible) but both my doctor and Northwestern are in the network.

A Wall Street Journal article this week explained why people are encountering these types of changes. While health insurers gained many new policyholders under the Affordable Care Act/Obamacare, many lost money on the very plan I had--the Silver PPOs. That meant significant premium increases. In Illinois, Blue Cross Blue Shield opted to drop all the PPO plans, not just the Silver ones, with the wide networks, offering instead to shift people to less pricey plans with more limited networks.

The company's reason is one I'm familiar with from my work as a lawyer. For the most part, when people buy insurance, what they care most about is the cost, not the benefits. Sometimes it's because their budget doesn't allow them to buy higher priced plans. Other times it's because they simply don't think ahead to what will happen if they do need to use the insurance. (Unfortunately, this can lead to disappointment--and sometimes to unfounded lawsuits--when people who chose the lowest priced coverage need to make a claim. Only then does it sink in that the lower premium means certain things are not covered, or at least aren't covered to the extent the policyholder now desires.)

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I felt frustrated and a little worried. While I hope to not need to enter the hospital, if I do, it's important to me that it be one I feel confident about. For years I worked as a paralegal at a firm that handled medical malpractice cases. I learned a lot about errors in medical care and bad outcomes, including that mistakes can happen anywhere, that sometimes when everything is done right, a patient still does not do well, and that some doctors and hospitals are sued all the time, while others are sued rarely. I want to go to one of the places where mistakes, including those that lead to lawsuits, are comparatively rare, and I've already done the research regarding Northwestern and feel comfortable going there.

As for my doctor, I've been seeing her for more than a decade. She is a good doctor, and she knows me. Not just my health history but me, which saves money for me and the insurance companies and leads to better care. If I call her to say my ongoing neck and shoulder issues (from so much computer work as well as my neck being where my tension tends to settle) have worsened but are pretty much what we dealt with three years ago, she doesn't need to insist that I come in for an MRI or even a visit. We can talk over the phone about what's worked in the past and try that first. On the other hand, if I tell her I am so sick with a respiratory illness that I missed work, she'd probably have me come in to be sure it's not pneumonia, as she knows very little keeps me out of my office.

Before cursing the ACA for the loss of the Silver PPO, I remembered that I'd chosen it because Blue Cross Blue Shield in Illinois is the gold standard for health insurance. I could only buy directly from Blue Cross in the first place because of the ACA. Also, I realized I had to compare what I can buy now to what I had before the ACA/Obamacare. When I did that, I realized I am still far better off. My premium will be higher, but I am two years older, and the increase is still offset by the fact that instead of paying hundreds of dollars out of pocket for a yearly check up and associated tests and a mammogram, I will pay 0-$20. And if I do become ill or need a prescription, which obviously I hope I won't, I won't have to spend $5,000 before anything at all is covered.

Unfortunately, with health insurance, it's next to impossible to make everyone happy. Some people qualify for subsidies, others don't; some can afford to buy broader plans, others can't or don't want to; some people are concerned about seeing a particular doctor or having access to particular hospitals, others are not; some believe if they are overall relatively healthy, they will never need coverage, others have serious illnesses or are healthy now but recognize that unforeseen accidents, injuries, or illnesses can happen to anyone. I do hope that next year the statistics are such that Blue Cross Blue Shield and other health insurers limiting their networks will consider going back to offering the broader plans.

What about you? Has the ACA directly affected you? Is your plan changing? Please drop me an email to let me know ( or comment below.

Lisa M. Lilly is the author of the occult thrillers The Awakening and The Unbelievers, Books 1 and 2 in the Awakening series. A short film of the title story of her collection The Tower Formerly Known as Sears and Two Other Tales of Urban Horror was recently produced under the title Willis Tower. If you'd like to be notified of new releases and read reviews of M.O.S.T. (Mystery, Occult, Suspense, Thriller) books and movies, click here to join her email list and receive free a short horror story, Ninevah, published exclusively to M.O.S.T. subscribers.

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