<p>But aren’t all plans, on and off the exchange, metal level plans? Doctors are accepting gold plans off the exchange but not on the exchange? Why would they care?</p>
<p>You’ll have to ask the doctors that question. All I know for sure is that many of our local doctors are not accepting anything less than the platinum plan. So, we searched for a better option off of the exhange and found it. </p>
<p>[Obamacare:</a> Fewer options for many - CNN.com](<a href=“http://www.cnn.com/2013/10/29/health/obamacare-doctors-limited/]Obamacare:”>http://www.cnn.com/2013/10/29/health/obamacare-doctors-limited/)</p>
<p>We are in a similar situation as the town in this article. Why buy a plan that isn’t going to work for our area? The small business plans offered in our area on the NY marketplace are useless to us. That’s why we looked elsewhere.</p>
<p>Cardinal Fang–check the list of providers and see if your doctors accept the specific plan listed on the marketplace. If they do, you’re in luck. It’s not the case where we live.</p>
<p>I am skeptical about NYSmile’s claims, but if a doctor is willing to accept a platinum plan but not gold, silver, bronze – there is only one possible reason, and it has nothing to do with insurance reimbursement rates. That doctor is essentially shopping for rich patients, or at least trying to avoid any sort of direct billing of the patient. An individual platinum plan is a terrible deal for the patient, because of the cost of the premiums. I can see doctors being wary of patients with a high deductible Bronze plan, as it might be harder to collect payments from patients who are unlikely to meet their deductibles – but the copay plans will always pay the doctors for outpatient services, at whatever the negotiated rate is. But high deductible / HSA plans have been around for years now, and I think many more affluent people have opted for those plans because of the tax benefits that come with the HSA – so using the deductible amount as a pre-screen doesn’t make much financial sense either.</p>
<p>But whatever you bought has a metal level. It has to. That’s the law. So either you bought a platinum plan off-exchange, or doctors are accepting plans that aren’t platinum.</p>
<p>We bought a plan not offered on the exchange. It’s not BC/BS or any of the other options available to small businesses on the exchange. It’s a plan that has also recently been purchased by the biggest bank in our area for its employees (this bank has quite a few branches too so they have many employees). Reasonable copays, lower deductible than the exchange, bigger provider network, and cheaper cost. </p>
<p>It’s fine to be skeptical of my claims, but it is the way things are working here—Small community with limited providers—thus, one needs to be very careful when choosing a plan. For people near a city with availability to more doctors, I’m sure the plans on the exchange will work. For people in the boonies with a 2 hour drive to the closest city and limited number of local providers, the plans on the exchange may not work. They don’t work for us.</p>
<p>We wanted to keep our current primary care doctors and specialists. We wanted reasonable co-pays for visits and prescriptions as well as reasonable deductible. We also preferred a plan that didn’t require referrals to see specialists (although this wasn’t a deal breaker). We couldn’t get it on the plans offered for small business in our area on the exchange. We found it off of the exchange.</p>
<p>All plans, on exchange and off exchange, have metal levels. That is the law. Thus, either you bought platinum, or the doctors on your plan accepted something that is less than platinum.</p>
<p>We bought a gold level of a plan not offered on the NY marketplace for small businesses in our area. Yes, it’s less than platinum, but it is accepted by our physicians and hospital. This isn’t to say that all gold plans are accepted. This particular plan at the gold level is accepted (this is a gold plan from a company that is not offered on the exchange for small businesses in our area).</p>
<p>Nysmile, your assertions would be more convincing if you would post some links to pages at medical facilities or provider lists showing the “platinum” only plan policies. Otherwise, it sounds like one of those internet rumors spread among people who don’t understand what the metal distinctions are all about – the metal levels do NOT reflect a difference in reimbursement rates, they reflect a difference in co-insurance rates. All of the plans have to cover the same essential benefits. It is possible that some plans might also provide additional benefits coverage beyond the minimum required, but that wouldn’t typically be connected to metal level designation.</p>
<p>That is a different issue than the fact that group coverage tends to be better than individual coverage, so it is quite plausible that your agent found a plan for you that is better than the SHOP plans. But that has nothing to do with metal designation.</p>
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I had actually asked BCBS-mi about this specifically --three tiers up, not just the regular customer service folks – and I was assured unequivocally that the network of my current employer plan vs. individual plan were identical and the payment rates the same on the provider end so that my silver-HSA plan would not be medically ghetto-ized.</p>
<p>Now, I’m willing to accept that assurance from an insurance company is like asking a fox to guard the hen-house, but I believe this information from the private plan or agent is in error. I suppose I will find out directly in February :)</p>
<p>I’m not going to post links which include the names of our doctors. I’m telling you that they are not listed as providers for the gold and lower tiers of bc/bs and others offered on the ny marketace small business options in our area. Thus, the options available on the ny marketplace listed for small businesses (which are limited options) are not useful to us. The provider networks and hospital networks are too limited for this area. They would work for people living an hour and half or so drive west from where we live, but not here. I’m talking about the options available for small businesses on the marketplace. This info is not only from our agent. I’ve seen the list of providers directly on the marketplace site. The plans offered (again, to small businesses in our local area) do not fit with the availability of local providers. I refuse to have to change doctors or drive an hour away to go a primary care doctor. We found a plan not on the ny marketplace that is a better fit for care in our area. It’s cheaper for our business, the local doctors accept it, the local hospital accepts it, the deductible is less, and co pays are reasonable. We did not blindly take our brokers advice. We had done the research well before stepping into his office.</p>
<p>I don’t know how else to explain our situation other than it’s similar to the situation described in Concord within the article I posted earlier.</p>
<p>I believe you, nysmile. </p>
<p>I was trying to understand exactly why the plan you bought wasn’t offered on the exchange. It shouldn’t cost the insurer any more to offer a plan on the exchange, because on-exchange or off-exchange, the insurance policy is offering the same thing: insurance, for money. Nor do I think that providers would be swayed in their decision to participate in a plan by whether it was offered on the exchange or not.</p>
<p>Insurers are trying to drive down prices of plans they offer on the exchange, because they believe buyers on the exchange are particularly price conscious-- this is what the article about Concord says. It’s not, in general, that plans on the exchange are worse for the same money than plans off the exchange; why would they be? It’s that plans on the exchange tend to have smaller networks in order to be cheaper. And then the in-network doctors might be inconveniently far away, or not include a favorite doctor.</p>
<p>Anyway, it’s good that you found a plan that suits your needs. You obviously took great care to find something that works for your employees. Good for you.</p>
<p>So my d went to an urgent care center that was stated in network bc/bs plan. They took blood and sent it out. However they apparently sent it to out of network lab ( d had no idea).</p>
<p>So we get a bill for $400. We went online, looked at the in network providers and there was the lab. So she called. They reduced bill to $45 and sent her a list of labs in network.</p>
<p>So what the heck. I guess as she transitions to her silver bc/bs plan we will call and have them email up to date lists. </p>
<p>It has been a battle to try and educate a sick kid on the ins and outs of health insurance games and plans. </p>
<p>I can’t wait until this is off my plate and in her hands. Until she pays ALL her health costs
I still have skin in the game and it makes for big arguments.</p>
<p>So my point is: looks like asking for up to date lists in a dated email will be the best way to stay up with it. </p>
<p>Ughhhhhh…</p>
<p>Nysmile - without mentioning your doctors etc, can you point to an online reference to your plan if one exists on the vendor site?</p>
<p>Doesn’t the law say one needs a minimum set of requirements with tiers? So what stops an insurance company from modifying it to meet customer needs after they have covered the basic tenets of the law?</p>
<p>It sounds like SMK has not been on the exchange but nysmile is claiming it is on their plan. How does one customize it? I would assume they negotiated a deal outside of the standard plan that is an add on to a standard one.</p>
<p>On a side note, many medical students in UT Houston and Baylor take a year off and do MPH after third year of medicine to enhance their credentials. Someone I know got into Harvard and JHU but stayed back in the same school because they don’t issue hospital credentials in other universities and he wanted to be able to keep access to the clinics and patients.</p>
<p>The business about going to an in-network provider, and then having that provider silently involve out-of-network providers at increased expense to the patient, is already a problem pre-ACA and is going to get worse with the narrower networks. And it needs to be fixed.</p>
<p>The argument for networks is cost savings: If the consumer picks the provider with the smaller negotiated price, then they should get rewarded by cheaper in-network costs. This is “skin in the game.” But if the consumer isn’t involved in the decision (because eg the doctor sent the blood sample to an out-of-network lab, or the in-network hospital had an out-of-network hospitalist) then the consumer shouldn’t be punished by having to pay ridiculously high rack rates. That’s just the out-of-network providers price gouging.</p>
<p>I say the provider should have to eat the difference. That is, if I go to a hospital that is in my network, admitted by an in-network doctor, and then the hospital assigns an out-of-network hospitalist, they can make up the difference between the in-network and out-of-network costs. I shouldn’t be responsible for decisions I don’t and can’t make.</p>
<p>Some doctors are already contracted with insurance companies and may not agree to be included in the new ACA plans. Why is that confusing? We already know that many doctors in many states do not want to participate in the exchanges just as many doctors in many states don’t take Medicaid.</p>
<p>It’s confusing because that’s not the way provider groups negotiate. They negotiate on the basis of reimbursement, not where the person bought the insurance.</p>
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<p>That is something that states should fix so that reimbursement rates do not vary much. It would go a long way in equalizing health care in the states, as opposed to exacerbating the tiers.</p>
<p>It really doesn’t matter to me why doctors choose not to participate. It’s their choice. It’s more important for me to find a plan that does include our local doctors and hospital. We found the plan outside of the exchange and it fits our needs as well as the needs of our employees. It’s called Magnacare and it’s not offered on the exchange. Very competitive pricing and very good coverage. It has a big network of providers giving us plenty of choices. Most importantly, our doctors and specialists accept it.</p>
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<p>Unlike Medicaid rates, reimbursement rates on exchange plans, just like reimbursement rates on off-exchange plans, are negotiated between insurer and provider. It’s not obvious to me why having the state step in would be beneficial.</p>