Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul. But consumer advocates warn that companies are still using wiggle room to discourage the sickest – and costliest – patients from enrolling.
Some insurers are excluding well-known cancer centers from the list of providers they cover under a plan; requiring patients to make large, initial payments for HIV medications; or delaying participation in public insurance exchanges created by the overhaul.
Advocates and industry insiders said these practices may dissuade the neediest from signing up and make it likelier that the customers these insurers do serve will be healthier –and less expensive.
Insurers acknowledge that people may see changes in coverage, driven in part by how the overhaul affects insurance. But they said prudent business practices, not discrimination against the sick, are key factors behind some of the trends that have raised concerns.
There are three major ways insurers still might steer sick or expensive patients away from their coverage:
FORM NARROW NETWORKS
Insurers can lower their chances for covering patients with expensive medical conditions like cancer and autism simply by limiting the number of doctors and hospitals in a coverage network. That would send those patients searching for coverage elsewhere because they don’t want to pay expensive, out-of-network rates.
Narrow insurer networks might include only 30 percent or less of a market’s hospitals, as opposed to 70 percent or more for a broader network, according to the consulting firm McKinsey & Co.
These narrow networks have grown more common in recent years, especially in coverage sold on new public health insurance exchanges created by the overhaul.
An Associated Press survey of the nation’s top cancer centers this spring found that patients covered under the health care law could encounter barriers to access in many cases. For instance, MD Anderson Cancer Center said it is included in the networks of less than half of the plans sold on the Houston area’s public insurance exchange.
Aside from excluding patients, narrow networks also can help insurers form a healthy customer base by lowering the cost of coverage. A narrow provider network gives insurers leverage to squeeze better rates out of doctors who want to be included in that network in order to get the insurer’s business.
Better rates lead to lower premiums, and young and healthy people generally shop for insurance based on price.
“They’re the ones that don’t check the provider directory,” said Bob Laszewski, a former insurance executive turned industry consultant.
Insurers said plans with narrow networks are among many coverage choices consumers can make when they shop for insurance, and they are not an attempt to dodge the sick.
Some plans are requiring patients to initially pay 30 percent or more of the bill for drugs that can cost several thousand dollars a month. HIV drugs and multiple sclerosis medications are among them.
Insurers said their plans follow HHS guidelines and cover all medically necessary HIV drugs. They also note that the price patients pay reflects, to some degree, what drugmakers charge for their medications.
But AIDS Institute Deputy Executive Director Carl Schmid said he worries that patient choices will dissolve over time if the high prescription payments spread to other insurers in a market, and “the good plans will become the bad plans.”
ENTER MARKETS CAUTIOUSLY
Another way insurers might land a healthier population is by playing the waiting game.
The nation’s largest health insurer, UnitedHealth Group Inc., will dive into the overhaul’s public insurance exchanges with plans to sell 2015 individual coverage in 24 exchanges. That’s up from only four in 2014.
These exchanges debuted last fall and offer shoppers a chance to compare and buy policies, often with help from an income-based tax credit.
UnitedHealth’s delayed growth could be a savvy way to avoid some of the sickest patients who likely rushed to sign up for insurance in the initial year of the exchanges, said Laszewski, the industry consultant.
That could free UnitedHealth to enter markets and sign up healthier patients after other insurers, most likely nonprofits with deep community roots, have “taken the bullet” the first year, he said.
Health insurers are still figuring out plan options for 2015, so there are no signs yet that other insurers are following UnitedHealth’s example.
UnitedHealth said it had always planned a measured approach. It needed a year to set up provider networks and see how the exchanges worked in their debut before deciding whether to plunge in deeper. Spokesman Tyler Mason said the insurer wasn’t waiting for those competitors to sign up all the sick patients first.
“Philosophically, we’ve always said the marketplaces would evolve over time and that they would be good markets and that reform is needed,” he said.