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Health care plan subscribers save with fewer choices of doctor, hospital, insurers say

| Friday, Feb. 7, 2014, 12:01 a.m.

The government is taking steps to address complaints about health plans that aim to lower premiums in the Affordable Care Act marketplace by restricting patients' choice of doctors and hospitals.

The Centers for Medicare & Medicaid Services told insurers that it will review plans they intend to sell on Health Care.gov in 2015 to ensure that they provide an adequate network of medical providers. The move could force insurers to expand provider choices for patients.

Across the country, some patients have been unable to get treatment from certain doctors and hospitals because of the prevalence of narrow-network health plans formed under the health reform law.

“These are important provisions and include requirements that insurers have adequate provider networks for consumers, including access to essential community providers that serve low-income, medically underserved individuals,” the agency said in its letter this week.

Management consulting firm Mc-Kinsey & Co. found that 70 percent of plans sold in 20 large urban markets used narrow networks.

Insurers are limiting choice to keep premiums low, said Karen Pollitz, an expert on insurance markets with the nonpartisan Kaiser Family Foundation in Menlo Park, Calif. But the strategy is catching some subscribers by surprise because “it's not very transparent,” she said.

That's the case in Western Pennsylvania, according to UPMC, the region's largest network of hospitals and doctors. It claims popular narrow-network Community Blue plans from Highmark Inc., which exclude UPMC hospitals and doctors, are causing confusion among some patients.

“They're showing up and they say, ‘We didn't know that UPMC hospitals and doctors weren't in the Community Blue network,' ” UPMC spokesman Paul Wood said. “Several hundred” Community Blue subscribers have been turned away from UPMC doctors and hospitals this year, he said.

The state Insurance Department has received two consumer complaints about Community Blue since the beginning of the year, spokeswoman Melissa Fox said.

Of the more than 37,000 people who purchased Highmark coverage on HealthCare.gov as of Jan. 13, at least 80 percent bought Community Blue plans, the insurer has said. Community Blue plans also are sold to employer groups, but Highmark has not said how many members it has in those plans.

Titus North, a certified application counselor with the Squirrel Hill advocacy group Citizen Power, said it's likely that consumers buying Community Blue plans on HealthCare.gov would be unaware that the plans exclude UPMC.

“It's not clear when they're signing up,” said North, who is certified by the federal government to help people sign up for coverage on HealthCare.gov. “I find I have to really make it clear that these (Community Blue plans) don't have access to UPMC facilities.”

Kristin Ash, a Highmark spokeswoman, said the insurer supplies a list of medical providers that are in-network to consumers who buy a Community Blue plan. Insurers are not required to tell consumers before they buy a plan which medical providers are in- or out-of-network.

“As far as I know, no health insurer touts who's out-of-network in their marketing materials, as that wouldn't be a good business practice,” Ash said. “UPMC Health Plan does not advertise that their members can't use Allegheny Health Network.”

UPMC Health Plan has refused to tell the Tribune-Review which hospitals are excluded from its narrow-network plans.

Alex Nixon is a staff writer for Trib Total Media. He can be reached at 412-320-7928 or anixon@tribweb.com.

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