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At Issue: ACA & HMO

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For some time now, ObamaPlans available here in The Buckeye State (and, it seems, pretty much everywhere else) have been buitl on the HMO chassis:

And with HMO’s if you’re out-of-network, you’re also out-of-luck.

So recently, one of my ACA clients reached out to me with a problem:

I’ve got several acute medical issues, and no nearby providers who can help me. For example, I’ve got some increasingly problematic thyroid issues, and the only nearby endocrinologist only sees diabetes patients. Plus, my Primary Care doc isn’t even in-network. Help?!”

We spoke for quite some time, and agreed that there weren’t a lot of options, but that I’d reach out to our carrier rep (I’m anonymizing the carrier here since they’ve done nothing wrong, this is purely to illustrate the frustration of this model, which the ACA basically drives).

To his credit, I quickly got this reply:

Good Morning Hank,

I’m doing well thank you, hoping the same for you.

I did some research on endocrinologists, I used a 50 mile radius from [a nearby zip code]; you are correct, the closest provider to this zip code is related to the [Diabetes Center], however I also saw in the search the below listed provider:

[Alternate provider who appears to handle thryoid cases]

While he is located a bit farther, he is the only other endocrinologists appearing in the network.

The member is welcome to reach out to Customer Care and request services from a non-network provider but I would not expect them to approve since there is another provider of this type within a 50 mile radius.  I had a similar situation in months past and it was not approved.

My client was decidedly not happy:

Wow… I am not in [that] area.  That is over 20 miles from my house, which I am not comfortable with going that far. They aren’t even close to the hospitals I would need to use if I have a further issue.”

As I pointed out, there’s nothing in the ACA that requires carriers to make convenience a factor when setting up their networks. It’s further exacerbated by the fact that we have competing hospital networks in this market (as in others, of course), and this creates additional issues.

From our rep:

As for the primary care provider, since they are in both the Premier and Kettering Health Network I’m going to assume they are independent and not owned and operated by either system.  With the Dayton HMO, Premier Health is exclusively the provider network, they provide MMO with the list of providers that are part of their contract. With these exclusive HMO contracts we do not contract outside of the list of providers that is provided to us by the contracting facility, in this case Premier Health.”

The key there is that the carriers’ hands are tied. To make matters worse, she’s already met her annual deductible for 2020, so moving to another carrier (even if that was an option, which is really isn’t) would be another disaster.

#ObamaCrap FTW.
Original content copyright © InsureBlog


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