A little boy’s love of the monkey bars recently became a test of his health insurance plan’s provider network.
Dr. Ramiro Gumucio, 50, the boy’s father and an anesthesiologist in Chicago, says the plan failed that test. Gumucio’s seven-year-old son spent so much time on the monkey bars that his hand got an angry-looking blister in September. The wound developed a severe, antibiotic-resistant infection, Gumucio says, and he had to take the boy, seriously ill and vomiting, to the hospital. But he couldn’t go to the top Chicago children’s hospitals that are close to his home, he says, because those facilities don’t accept the Blue Cross Blue Shield health plan that he purchased through the Affordable Care Act marketplace. Instead, he had to go to another hospital about an hour away, where staff seemed ill-prepared to handle a pediatric emergency, he says.
Though the boy recovered physically from the incident, Gumucio says, more frustration followed when he tried to find psychological testing for his son, who has autism. His health plan’s website, he says, was showing him a lot of mental health providers in far-flung parts of Wisconsin and Indiana, and he couldn’t find an appointment with any local providers.
Gumucio thought he was selecting higher-end coverage when he enrolled in the preferred provider organization (PPO) plan. Compared with health maintenance organizations (HMOs), PPOs often have higher premiums but generally present fewer hurdles for enrollees to access providers. But in his experience, Gumucio says, “you pay more for less.”
As open enrollment begins this week for Affordable Care Act marketplace health plans, consumers face a daunting and high-stakes challenge: Finding an affordable plan that includes a network of providers likely to meet their healthcare needs. There are signs of “shrinkflation” in marketplace health plans as insurers adjust provider networks to control utilization and costs, Karen Pollitz, a senior fellow at the Kaiser Family Foundation, wrote in a report earlier this year. An analysis of 2020 marketplace plans by consulting firm Avalere found that the plans’ networks were the most restrictive since 2014–a shift the firm attributed to insurers’ efforts to rein in premiums–with 78% of plans sold through HealthCare.gov offering limited or no coverage outside their network. “Narrowing networks has been one of the primary tools that insurers have employed to figure out how to make money off marketplace plans,” Pollitz told MarketWatch.
Blue Cross and Blue Shield of Illinois, Gumucio’s insurer, said in a statement that it can’t comment on his specific concerns due to privacy issues, but that it is “committed to providing members with access to quality, cost-effective health care consistent with the terms of their benefit coverage,” adding that it has “some of the largest provider networks in Illinois.”
Federal government sets time and distance standards
After years of leaving the issue to states, the federal government is resuming some oversight of provider networks in 2023 plans sold through HealthCare.gov. The government has set time and distance standards for provider networks, which vary based on provider type and county size. In a large metro county, for example, 90% of a plan’s enrollees must have access to a cardiologist within 10 miles or 20 minutes travel time. Other standards based on appointment wait times will also take effect for the 2024 plan year.
The new standards are just a first step in monitoring and defining the nebulous concept of network adequacy, health policy experts say. The Affordable Care Act requires marketplace health plans to have an adequate provider network, and the Obama administration gradually implemented some standards to define that. The Trump administration halted direct federal oversight of network adequacy in the 2018 plan year, saying the approach would lessen the regulatory burden on insurers, but a federal court ultimately struck down that change, kicking the ball back in the federal government’s court. States, meanwhile, also regulate health plans’ provider networks, but with widely varying degrees of effectiveness, researchers say. The National Association of Insurance Commissioners has developed a model law on network adequacy, but only a handful of states have adopted it.
Consumers shopping for marketplace plans have few tools for evaluating a plan’s network–and no easy way to compare plans based on the overall breadth and depth of their networks. On HealthCare.gov and many state-based marketplaces, plan shoppers can enter the names of their doctors and find plans that include those providers. But they should also call providers directly to confirm that information, because plans’ provider directories are often inaccurate, researchers say. The No Surprises Act passed in 2020 includes provisions designed to address the problem but hasn’t yet been fully enforced.
Tips for finding a plan with a decent network
Avoid choosing a plan based on price alone, Pollitz said. “There could be all kinds of things moving that premium around, and a tighter provider network is certainly one of them,” she said.
If you’re switching from an employer-sponsored plan over to the marketplace, don’t assume that you’ll get the same provider network if you select the same insurer that offered the employer plan, Pollitz said. “Insurers have designed a series of provider networks they offer in different markets,” she said. “Their large employer clients may get their broadest networks,” she said, while marketplace plans may get narrower networks.
Consumers searching for the provider network that suits them also shouldn’t read too much into “PPO,” “HMO,” and similar labels, said Justin Giovannelli, associate research professor at Georgetown University’s Center on Health Insurance Reforms. Those classifications “mean a lot less than they used to, particularly when it comes to understanding whether a plan has lots of providers or not,” he said.
Gumucio, the Chicago anesthesiologist, said he initially chose his Blue Cross Blue Shield plan because his son’s therapy center accepted the insurance. For 2023 coverage, however, he’ll be looking for a plan that includes a top local children’s hospital, he said, even if that means his son’s speech therapy might suffer.
