As a breast cancer survivor, Donna Catanuchi said she knows she can鈥檛 go without health insurance. But her monthly premium of $855 was too high to afford.
鈥淚t was my biggest expense and killing me,鈥 said Catanuchi, 58, of Mullica Hill, N.J.
A 鈥渘avigator鈥 who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket 鈥 or about three times what she was paying for her follow-up cancer care.
She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.
Catanuchi鈥檚 switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.
With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have 鈥渘arrow networks鈥 of medical providers or which hospitals and doctors are in or out of an insurer鈥檚 network, despite federal rules requiring plans to keep up-to-date directories.
鈥淚t鈥檚 very frustrating for consumers,鈥 said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. 鈥淗ealth plan provider directories are often inaccurate, and doctors are dropping in and out all the time.鈥
These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and 鈥渟urprise鈥 medical bills from unforeseen out-of-network care.
More than buy health insurance on the individual market 鈥 largely through the ACA exchanges, and they will be shopping anew this coming month.
Trend Appears To Be Slowing听
For 2018, 73 percent of plans offered through the exchanges were either health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), up from 54 percent in 2015.
Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.
PPOs typically provide easier access to out-of-network specialists and facilities, and partial 鈥 sometimes even generous 鈥 payment for such services.
Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a by the Robert Wood Johnson Foundation.
For example, in California, HMO and EPO enrollment through Covered California, the state鈥檚 exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.
In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation鈥檚 of employment-based health insurance.
The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.
鈥淲hen premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums,鈥 said Chris Sloan, a director at Avalere. 鈥淲ith premium increases slowing, at least for now, that could stabilize.鈥
Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with from 25 percent in 2016 to 21 percent in 2017.
Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain 鈥渞elatively constant鈥 for this year and into 2019.
鈥淔ewer insurers are exiting the marketplace, and there鈥檚 less churn in the plans being offered,鈥 said Polsky. 鈥淭hat鈥檚 good news for consumers.鈥
Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.
鈥淣arrow networks are a trade-off,鈥 said Paul Ginsburg, a health care economist at the Brookings Institution. 鈥淭hey can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy.鈥
Ginsburg also notes that there鈥檚 no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.
Mike Kreidler, Washington state鈥檚 insurance commissioner, said ACA insurers in that state 鈥渁re figuring out they can鈥檛 get away with provider networks that are inadequate to meet people鈥檚 needs.鈥
鈥淧eople have voted with their feet, moving to more affordable choices like HMOs but they won鈥檛 tolerate draconian restrictions,鈥 Kreidler said.
The state is stepping in, too. In December 2017, Kreidler fined one insurer 鈥 Coordinated Care 鈥 $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company鈥檚 head.
Centene Corp, which owns Coordinated Care, has .
Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.
鈥淲e think and hope insurers are gradually building more stable networks of providers,鈥 said Altman.
New State Laws听
Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.
About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.
Even more have rules on maintaining accurate, up-to-date provider directories.
The problem is the laws vary widely in the degree to which they 鈥渢ruly protect consumers,鈥 said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. 鈥淚t鈥檚 a patchwork system with some strong consumer protections and a lot of weaker ones.鈥
鈥淪ome states don鈥檛 have the resources to enforce rules in this area,鈥 said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. 鈥淭hat takes us backward in assuring consumers get coverage that meets their needs.鈥