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Comparing doctors in Obamacare plans requires ‘a computer for a brain’
Posted: 11:00 a.m. Saturday, Feb. 22, 2014

For about $270 a month, a 35-year-old Palm Beach County resident can buy one health insurance plan that gets him access to seven ear nose and throat practices in the county or another plan where the closest ENTs are in Port St. Lucie or Miami. One plan gives him the choice of 60 psychiatrists in the county. Another insurer offers a dozen, one/fifth the choice.
Critics have warned that Obamacare has forced health insurance carriers to tighten their doctor networks to afford the benefits that must be provided by the sweeping healthcare law. While some insurers are offering bare bones networks, others provide the same range of doctors available to their clients on plans outside of the new marketplace.

Special Section: Affordable Care Act news, photos, video, documents
The trick for consumers is figuring out which plans are which. The Palm Beach Post set out to determine whether Obamacare recipients were getting inferior provider networks. Instead it found that consumers would have to undertake something akin to doctoral level research to make an educated comparison of doctor networks in the 132 plans available in the county.

“You need to have computer for a brain,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, who has, in fact, tried to analyze doctor networks in Obamacare plans.

While the Affordable Care Act spun off specific regulations about exactly what must be covered, the Obama administration allowed states or outside accrediting bodies to certify that a carrier had an adequate network of doctors to provide those services. In some circumstances, carriers could essentially self-certify they were providing an adequate network, Pollitz said.

Next year, Americans will have more assurance that their plan is one they can actually use.

The Department of Health and Human Services will require insurance carriers to submit their doctor network for approval before an insurer is permitted to sell an Obamacare plan in the federal marketplace for 2015.

“Hopefully this is a kind of growing pain thing, but that’s probably not a lot of comfort for people who are shopping in this open enrolment period and would like to select a plan with a decent network,” Pollitz said.

The marketplace, also known as an exchange, brings into direct competition insurers that previously sold individual policies. It also offers consumers the kind of group buying power found in large employer plans.

One of the key benefits of a marketplace structure is that all the information is in one place, allowing consumers to compare and shop, said W. Bruce Vogel, Ph.D, an associate professor at University of Florida’s Department of Health Outcomes and Policy.

“If the exchange doesn’t give good, complete comparative information across plans, it’s failing one of its fundamental tests,” he said.

Comparison shopping has become significantly easier than when the Obamacare exchange opened on Oct.1. At that time, technical problems and unexpected traffic slowed the site to a halt.

Weeks of round-the-clock repair and added capacity have greatly improved the speed of the site. New tools allow Americans to window shop for plans without creating an account or accessing part of the website that previously became overloaded.

One new feature lets users to input their county of residence and some key personal data, such as age and number of people being insured. Out pops up the full list of plan options. Users can hit the “details” button for each plan and find “provider directory” as a choice. That’s where things become more complicated.

In Palm Beach County, there are 132 plans, making broad comparisons tedious and time-consuming. Once a shopper zeros in on a desired premium or deductible, comparing plans still requires significant legwork.

For each plan, users are redirected to a provider search hosted by the insurance company. Some are user-friendly. Others are not.

Take the provider network for plans offered by Molina. It links to a page called provider search but most of the page is blank with no drop down menus to choose a state, county or type of doctor.

A call to Molina yielded directions to a different website with a working search function, adding another step if shoppers want to see Molina’s network.

CoventryOne’s search tool was similarly frustrating. It linked to a page with a dropdown menu offering Florida as a choice. While the insurer sells products in Palm Beach County, the doctor search tool didn’t include Palm Beach, leaving county residents no way to search for local doctors.

Cigna’s search tool only lists one kind of medical plan, but the name “LocalPlus” does not match any of the plans on the marketplace.

To find out which doctors are in-network for FloridaBlue, the user has to find the correct network name from more than 30 choices. The names do not precisely match the plan name.

For instance, BlueSelect Everyday Health, BlueSelect Everyday Health Plus and BlueSelect Essential have slightly different names. None of those full names is an option. The key is to notice they are all part of the BlueSelect network, which is a choice on the dropdown menu.

Once shoppers master the tools to search the plans provided under Obamacare, they will find staggering differences between doctor networks with similar premiums, deductibles and out-of-pocket maximums.

Take plans that cost between $270 and $290 a month for a 35-year-old who is not getting a government subsidy and thus paying the full premium.

A BlueSelect plan features 164 primary care docs or practices compared with 33 in the Ambetter network. BlueSelect has seven ear, nose and throat options. Ambetter lists zero in the county. Ambetter has a single doctor listed in Palm Beach County under obstetrics and gynecology. BlueSelect has 102.

Among plans offered by the same carriers, differences can be vast. Compared with BlueSelect’s 164 primary care doctors, Florida Blue’s BlueOptions plan offers 1,042 primary care doctors. To BlueSelect’s 102 OB/Gyns are 317 in BlueOptions.

All of the FloridaBlue provider networks in Palm Beach County existed before the new marketplace opened. That means that customers of FloridaBlue marketplace plans are getting access to the same doctor networks as consumers who buy insurance outside the exchange. Ambetter’s network is specific to the marketplace.

Shoppers who rarely visit a doctor may think it’s fine to select a plan without many specialists.

But Pollitz urges consumers to dig deeper.

“If you don’t know you’re going to have a heart attack this August, it may not occur to you to check the cardiologist network,” Pollitz said.

Numbers alone can be misleading, said Todd Blum, chief executive officer of Ear Nose and Throat Associates of South Florida, a practice of 30 ENTs that serves Palm Beach County.

Making an educated choice requires research beyond a few clicks, he said.

Having the option of a handful of doctors may seem like enough. Look closer, Blum suggests. Some specialties may be staffed by doctors who spend most their week outside the area and travel to Palm Beach County once a week or less.

He urges consumers to call the provider’s office and get answers to the following questions.

Are they participating in the network in which they are listed?

How long is the wait to get an appointment?

How often does the doctor practice in the location listed in the directory?

Is the doctor taking new patients?

Comparing the networks can be a time-consuming trial. But it isn’t enough, Blum said.

“When you’re shopping for insurance, you need to investigate the doctors listed in the panels,” he said.

Below are two comparisons of provider networks in plans with similar premiums and coverage. Numbers of doctors may include single doctors or practices listed as separate entities.
BlueSelect Essential (HSA) 1452

Monthly premium:$261

Deductible: $6,250/yr

Out-of-pocket: $6,250/yr

Primary care physicians: 164


Allergy: 18

Ear, nose and throat: 7

Obstetrics and gynecology: 102

Pediatrics: 32

Psychiatry: 59

Ambetter Bronze 3

Monthly premium: $272/mo

Deductible :$6,000/yr

Out-of-pocket maximum : $6,350/yr

Primary care physicians: 33


Allergy: 2

Ear, nose and throat: 0 in Palm Beach County, nearest is Port St. Lucie or Miami

Obstetrics/Gynecology: 1

Pediatrics: 1

Psychiatry: 1

Aetna Premier 2000 PD

Monthly premium: $354/mo

Deductible: $2,000/yr

Out-of-pocket maximum: $4,500/yr

Primary care physicians: 79


Allergy: 19

Ear nose and throat: 31

Obstetrics/Gynecology 130

Pediatrics: not listed as a single specialty

Psychiatry: 48

BlueOptions Everyday Health 1420

Monthly premium: $370/mo

Deductible : $2,500/yr

Out-of-pocket Maximum:$6,250/yr

Primary Care physicians: 1042


Allergy: 40

Ear nose and throat: 111

Obstetrics/Gynecology: 317

Pediatrics: 265

Psychiatry: 85

Source: Palm Beach Post research

Key Obamacare dates

March 31 enrollment ends for 2014.

Nov. 15: proposed open enrollment date for 2015 plans

Jan 15: proposed end for 2015 open enrollment

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