qotd: Changing provider networks when enrollment periods are closed

The Columbus Dispatch
February 10, 2016
InHealth customers mad about late notice dropping OhioHealth
By Ben Sutherly

Some central Ohio consumers say a Westerville-based health insurer
intended to keep quiet about its plan to drop OhioHealth hospitals and
doctors from its provider network until it was too late for many of its
enrollees to change their health plan.

In those complaints, the consumers, who mostly live in Franklin or
Delaware counties, expressed frustration over InHealth Mutual's
last-minute notice to consumers about its plan to drop most OhioHealth
providers as of March 1.

Many consumers said they were not notified of InHealth's plan to narrow
its provider network until last week, though some received robocalls on
Jan. 30, the day before the deadline to sign up for health insurance
through the federally run health-insurance marketplace.

During the first half of January, InHealth's leaders decided to drop
OhioHealth from the provider network. An official with the Ohio
Department of Insurance said that InHealth contacted the department late
on Jan. 15, triggering a required 15-day review period during which
department officials review documents to ensure that insurance companies
clearly explain provider-network changes to consumers.

However, an official with the Ohio Department of Insurance said nothing
stops insurers from starting the notification process during the 15-day
review period.

Ohioans who buy coverage through healthcare.gov <http://healthcare.gov>
typically cannot sign up for a different plan after the open-enrollment
period ends. There are some exceptions that allow for a special
enrollment period; among them, the loss of a job, a move or the birth of
a child. But an eleventh-hour change in an insurance company's provider
network isn't one of them.

The federal government will not create a special enrollment period for
people affected by InHealth's decision, said Andy Slavitt, acting
administrator for the Centers for Medicare & Medicaid Services, in a
conference call last week.

http://www.dispatch.com/content/stories/local/2016/02/09/Consumers-upset-about-insurer-dropping-hospitals.html

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Comment by Don McCanne

One of the more important considerations in selecting plans offered
through the healthcare.gov <http://healthcare.gov> insurance exchanges
is whether or not an individual's physicians and hospitals are included
in the provider networks selected by the insurer. Although this is
supposed to place more control into the hands of the health care
consumer, in fact, the insurer is free to change the provider network at
any time, yet the patient is prohibited from changing insurers outside
of the open enrollment period. Patients lose their providers and can't
do anything about it until open enrollment for the next year.

The Affordable Care Act does allow special enrollment periods for
unavoidable circumstances wherein a person loses their coverage, but CMS
is reducing these special enrollments to prevent patients from
supposedly gaming the system. Apparently it is acceptable for insurers
to game the system through bait and switch of their provider networks,
but Andy Slavitt, the acting CMS administrator, stated that he will not
open up enrollment for these victims of bait and switch.

Really, is cracking down on special enrollment periods to the detriment
of the patient the type of incremental change we can expect going
forward? Great for the insurers, terrible for the patients.

What is wrong here? It is that the model of health care financing that
has been foisted on us is one that is designed to take good care of the
insurers while treating patients as a necessary nuisance since insurers
otherwise would not have a business without them.

Yesterday the citizens of New Hampshire had something to say about a
government that takes good care of the wealthy but makes middle- and
low-income individuals second class citizens. We have a crying need for
a single payer national health program, so it has to be up to us to
select politicians who will bring it to us. Most of those currently in
office are not going to do it.


/Physicians for a National Health Program (PNHP) is a nonpartisan
educational organization. It neither supports nor opposes any candidates
for public office./