Uninsured patients trying to choose the right Affordable Care Act medical plan on deadline could end up out of network and out of luck if they want to use certain Columbus medical providers.
Of the 19 plans available for purchase in Bartholomew County on the federal website, only three will be accepted as in-network by Columbus Regional Hospital and many local doctors.
The three that will be accepted —MDwise Marketplace bronze, silver or gold coverage — carry more expensive premiums than many of the 16 plans from Anthem Blue Cross and Blue Shield, plans that most local providers will consider out-of-network.
The difference between in-network and out-of-network affects what customers pay for health care. Plans require consumers to pay more out of pocket if they are not using an in-network doctor or hospital.
That could take the “affordable” out of the Affordable Care Act, as one Columbus family has discovered.
Monday is the deadline to begin enrollment, although insurance shoppers in the system by then will have until mid-April to finalize buying health insurance.
With the clock ticking, Paul and Melinda Johnson are still unsure how to proceed.
Paul is unemployed, and Melinda is not offered insurance through the Columbus preschool where she is a teacher.
They met with an Affordable Care website navigator at Mill Race Center and felt confident they had found a plan that would work for them. The Anthem Silver Plan accounts for more than half of all Marketplace plan selections in the United States.
But after a casual exchange with an acquaintance, they learned that the plan — or any other Anthem plan from the Affordable Care Marketplace — will not be accepted as in-network by the physicians group they have been with for years.
Denise Glesing, director of planning and marketing at Columbus Regional Health, said the only health insurance exchange product the hospital will accept as in-network is MDwise.
That means those who have signed up for one of the Anthem plans through the Affordable Care Act will pay out-of-network costs if using Columbus Regional Hospital Services.
Although the total cost to patients depends on many factors, Anthem’s website lays out a scenario for in-and out-of-network costs for a $250 procedure:
Anthem already has negotiated a $75 discount with the in-network doctor, and will pay an additional $140 toward the bill. That leaves the patient with a total cost of $35.
There are no discounts negotiated for an out-of-network doctor, but Anthem will still pay $140 toward the bill. That leaves the patient with a total cost of $110.
Many Columbus patients enrolling under the Affordable Care Act may need to find a new doctor to get service at in-network costs. Only three doctors in Columbus will accept the Affordable Care Anthem plans as in-network, according to the Anthem provider directory.
Going out-of-network with an Anthem plan could mean the patient is required to cover a higher percentage of total care costs, a higher
co-insurance payment and higher out-of-pocket maximums, according to information on the provider’s Frequently Asked Questions page. Anthem representatives did not return telephone calls seeking specific information about its plans or providers.
“To get the most of your health insurance plan, it’s best to make sure your doctor or hospital is in your network,” according to the website.
That means to stay in-network, patients in Columbus shopping for insurance will need to sign up for a MDWise plan or switch to one of three primary care physicians accepting Anthem Marketplace plans: Dr. Robert Goode or Dr. John Nieters and Dr. Theodora Saddoris with Columbus Physicians Associates.
Paul Johnson said he does not fault Columbus Regional Health for not accepting Anthem plans, and he was happy with his navigator’s knowledge — but he said he wishes the process was more transparent about what will be in-network or out-of-network.
A Health Insurance Marketplace expert did not respond to a media request seeking
information about customer confusion about the plans. Attempts to speak to a navigator were unsuccessful because the navigators are trained to inform the media that they only to speak with individuals seeking coverage.
“You have to know the right questions to ask,” Paul Johnson said of buying insurance on the federal exchange. “If not, the implications are big. It changes what’s accessible and what’s affordable.”
Enrolling in an Anthem plan could make health care less accessible. To stay in-network, patients will need to find a local practice still accepting new Anthem Marketplace patients. Those practices could be as far away as Greenwood or Indianapolis, according to the Affordable Care website.
Enrolling in an Anthem plan could make health care less affordable if a patient chooses to stay with an out-of-network doctor.
But that situation will not necessarily be permanent. Health care providers and insurance companies renegotiate contracts regularly.
In 2012, Bloomington’s largest multispecialty group, Premier Healthcare, stopped participating in Indiana University’s Anthem insurance network. It left thousands of employees without an in-network physician, but Anthem and Premier Healthcare reached an agreement after five months.
“We’re not wanting to have anybody feel like this is terrible, this health care thing,” Paul Johnson said. “I have my own opinions about it, but we just want people to be informed.”