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A Tale of Two Networks

Friday, November 8, 2019 9:11

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For plan year 2020, history repeats:

“The other issue is that, at least in Ohio in 2019, all plans are built on an HMO chassis, which means basically zero out-of-network coverage.”

One way carriers have found to reduce their costs has been to offer ever-shrinking networks. For some, this isn‘t an issue, but for many, who have longstanding relationships with their current providers, this can be a problem.

Take, for instance, Larry: he’s a long-time client, lives up in the Cleveland area (Geauga County). As with most of the state, almost all of the plans available on the 404Care.gov site are offered by erstwhile Medicaid carriers, with two notable exceptions: Medical Mutual and new kid in town Oscar Health.

Larry’s in his late 50′s, and has some medical issues that make the Guaranteed Issue/Pre-ex coverage available on ACA plans attractive. He also has some specific doc’s that he likes, including some at Cleveland Clinic.

Now, it turns out that The Clinic is in-network for only one carrier here: Oscar. And the question arises, how much is that relationship worth, in actual dollars? I have long wondered this, but until now had no way to quantify it.

Now, I can, and it’s breathtaking:

[click to embiggen]

The plan on the left is from CareSource (one of the aforementioned “Medicaid carriers“) and the one on the right is from Oscar. The only substantive difference other than the fact that the latter actually has higher potential out of pocket exposure) is that Oscar includes the Cleveland Clinic, and CareSource does not.

So, is The Clinic worth $3,600 a year?

Is access to The Cleveland Clinic (or *any* specific provider, really), worth over $3,000 a year?

Source: http://insureblog.blogspot.com/2019/11/a-tale-of-two-networks.html

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