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Obamacare Clusterfuck: HHS wants insurers to cover out of network docs as in-network...for a little while

Oh dear Gawd

WASHINGTON -- The Obama administration wants health insurers that offer plans under the Affordable Care Act to cover out-of-network drugs and doctor visits at in-network rates into the new year to help patients transition to their new plans.

Specifically, the Department of Health and Human Services (HHS) is "strongly encouraging" insurers to treat out-of-network providers as in-network if the provider was listed in a plan's network on the date a consumer enrolled.

The timeframe would be determined by the each insurer, an HHS spokesperson told MedPage Today, but "generally we encourage insurers to do this for the beginning months of coverage."

23 things:

  1. Is this about scamming people into believing they have better coverage than they do? Because...election? Because...silence the protest that will make its way into the media and continue to color the perception of this law?
  2. Obviously the administration doesn't understand insurance. Providers who do not have contracts with insurers have no obligation whatsoever to accept insurance reimbursements as final payments. Exchange reimbursements are typically much lower than customary charges, making it likely that providers will balance bill.
  3. (Update) So what do these people do once they're locked into this intentionally misleading structure and need to see the same docs later in the year?

I am all for insurance paying out as much as possible. But this only increases the probability that people will suffer from surprise balance bills.

The administration gets more stupid by the day.

Average: 5 (3 votes)


Rainbow Girl's picture
Submitted by Rainbow Girl on

Everything you said. Plus, note this cute limitation to Obama's new (real-world ineffective) "suggestion":

"Private Insurance Companies, please cover out of network doctor as if in-network " ... if the provider was listed in a plan's network on the date a consumer enrolled."

Is Obama unaware that Insurance Companies have created brand spanking new "networks" for their Obama Exchange TM plans? For any private plan that Ins Cos created specially for Obama's Exchange, there's as likely as not a Special Network TM for that plan. (I saw this while researching New York State plans and being funnelled into an indecipherable labyrinth of drop-down menus of different networks applying to different plans.)

So the whole idea of a provider that was "in network" when a person enrolled is -- in such cases -- a total chimera.

Not to mention how apparently thousands of doctors don't know -- even now -- whether they were in a network.

And not to mention how exactly would one establish that Dr. Jones was in-network when I enrolled in Policy X given that the insurance company websites loudly caveat their network provider lists with: information subject to change and may be inaccurate, please call provider to confirm. Insurance Companies will be able to force policy-holders to bear the burden of proof that a provider was in-network when they enrolled but not at time of treatment in circumstances where the only "objective" evidence of who was in the Insurance Company's network is an Insurance Company directory that specifically calls itself "inaccurate" or "incomplete."

Nice move.

Submitted by Dromaius on

It's to try and circumvent the "if you like your doctor you can keep your doctor lie". It's all about getting past 2014. They don't care about the implications of what they're suggesting. They just want to make the headline. Marketing supersedes reality.

The Administration is trying to help! But the evil insurance companies won't let them....That is what the Obots will tell you. And this proposal is great for arguing at the "holiday" table this year.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Here is a screenshot of how New York State's ACA Marketplace Exchange ("New York State of Health") provides information about provider networks. Yes, a list of eleventy insurance company's websites, where you then have to go hunting and gathering for information that's hard to find and then nearly impossible to collate and -- drum roll -- "subject to change."

A disgrace as well as a con -- insurance companies sure as he** didn't want people finding out they were going to be shelling out big bucks for anorexic networks with none of their providers, and a handful of community clinics of "doctors groups" with sketchy credentials.

Submitted by lambert on

1) Given the data fuckups, that date is going to be wrong for some people;

2) How do people prove what was up on the website when they enrolled? Do they get some sort of evidence when they press submit? Do they take a screen dump? Use the Wayback machine?

3) What the fuck does "the beginning months of coverage" mean? Would it be too much to ask for a date or a number of months?

Submitted by Dromaius on

Like I've said, this is all cover. It's to circumvent the "if you like your doctor you can keep them" lie. It's exactly analogous to Obama's renig on the cancellation of "substandard" policies. Of course, the practicalities of doing this are insurmountable. Who cares? The Obots can argue that the administration tried.

They are trying to keep "Dr. PR" from ditching their own political network ;-).

Submitted by lambert on

The other thing this is like is an initial low APR% for credit card buyers. Then, bang!

And you can bet the Obots are going to forget to mention that the price balloons.

Rainbow Girl's picture
Submitted by Rainbow Girl on

QED the nomenclature for plan classes: "Platinum," "Gold," "Silver," "Bronze."

The business-product DNA of ObamaCare Exchange Policies IS credit cards.

And after just one year, at renewal time, gawd knows sky will be the limit on ballooning the premiums, copays, deductibles, out of pocket max's (whatever *those* are), and revising shrinking the networks. Just like credit cards, that can change up your terms at will, when they feel like it.

Submitted by Dromaius on

The other good one is that the administration is extending the high risk pool -- for January only. Soooo, you start meeting that deductible for a month (assuming you're a cancer patient or some other person with loads of medical bills), and then you have to switch to an Obamacare plan and start all over again.

As my grandmother used to say, "they're trying to get you ten ways from Sunday".

It's sick. As far as I'm concerned, Worst. President. Ever.

Rainbow Girl's picture
Submitted by Rainbow Girl on

That is a huge WTF about forcing people to shoulder extra deductibles under the guise of a "helping hand." That's pure mafia shit. It's boiler room territory. It's at least ten rungs below used car sales.

Your grandmother sounds like a great gal. And I have always loved that expression, though I've heard it phrased with "Ten Ways From Monday" instead of "Sunday."

Submitted by Dromaius on

BTW, from my link above, the first death spiral.

The Pre-Existing Condition Insurance Program, or PCIP, was always intended as a temporary bridge for the uninsured that would sunset in 2014, when the health law requires insurance plans to accept all customers, including those with costly medical conditions.

The program covered just over 104,000 Americans as of last summer. While enrollment was lower than projected, those who did sign up had higher-than-expected medical costs, and, in February, the PCIP program stopped accepting new enrollees.

In other words, Death spiral 1.0.....Will we feel shocked at all when subsidies go the way of the PCIP dodo bird because "higher-than-expected premiums?"

Submitted by lambert on

"help patients homebuyers transition to their new plans home" with a low initial rate, that later balloons to a much higher rate. The scam was that by then they'd have flipped the house to a bigger fool by the time the balloon payment kicked in. Of course, you can't do that with your body, unless you get a second or third job to cover the ObamaCare balloon payments.

Alexa's picture
Submitted by Alexa on

is true of "premium rates."

HHS can ask insurers to "justify rate increases."

But, IIRC, they have no actual power to stop insurers from raising rates.

Sounds as though this new "gimmick" is more of the same!

Alexa's picture
Submitted by Alexa on

if anytime has the time and/or inclination to pursue it. (I can't, because just found out that our availability of "in-network providers" means that we'll have to stay out-of-state for many more months--or I would volunteer to pursue this topic.)

Remember all the hyperventilating by Dem politicians, over medical research dollars being denied due to the sequester?

That would be an excellent point, but what does it matter for the "average Joe" if your policy denies access to providers and/or life-saving drugs.

Our group health plan, starting in 2014, is narrowed to very few Tier 4 drugs.

And it is this very category of drugs that are saving many lives, today. That is, if you're among the "privileged" few who can access them.

I will try to write a comment on one of the Kennedy daughter's "aggressive" treatment plan, including "designer drugs," which allowed her to live quite longer than an average individual with the same illness.

(Not that I begrudge her the excellent treatment that she received. I don't. But receipt of quality care should not depend upon the size of one's pocketbook, IMO.)

Anyway, the topic of "designer drugs" would be a hot one, I believe!

Submitted by Dromaius on

And remember, our Congress remains among those privileged few. Even if they have to enroll in shit Exchange plans, they can afford the out of pocket costs for the designer drugs.

So designer drugs are still critical to them!

Submitted by Dromaius on

Two ways I'll cut a tiny, slight pass:

Tier 4 drugs are rarely covered in any great way by anyone. And sometimes, that's actually a good thing. My FIL is on name brand statins for which the generic brand is proven just as effective, but he has federal insurance, so the doctors constantly use him as guinea pig.

Designer and last-hope drugs are a can of worms in themselves. Take Avastin for instance....please (in the Rodney Dangerfield sense ;-) ).

Submitted by Dromaius on

One total falsehood about Obamacare is that it covers "preventive care". It covers very limited preventive care, such as flu shots.

Physical exams, mammograms and the like are NOT preventive care. They are screenings. When the screenings find something which is treated early, THAT is preventive care. But of course, early treatment to prevent or subvert disease is NOT covered as preventive care under Obamacare.

Colonoscopy does do limited preventive care via removing polyps. The rest of the screening "exams" -- NOT preventive care! And "free" screening without subsequently funding treatment is IMHO heartless.

quixote's picture
Submitted by quixote on

California made a big boast about how they'd have easily searchable doctor lists so you could see which plans included your physicians.

Last I checked about a week ago, it's just the same as what you describe for NY: go visit the InsCo and look through their endless lists. They have pdfs for the individual companies which you can download to make it "easy." :eyeroll:

Submitted by Dromaius on

It would be a great service to consumers if the Exchanges created a spreadsheet listing which doctors were covered by which plans. It is doable because most plans have the same network for gold, silver, bronze. Of course, doing so would uncover the radically thin networks offered, which is why they would never do it.