Curmudgeon's Corner

cur-mud-geon: anyone who hates hypocrisy and pretense and has the temerity to say so; anyone with the habit of pointing out unpleasant facts in an engaging and humorous manner

Narrow Network ACA Health Plans

Quality of Life, Politics, Healthcare, People Making A Difference

Narrow networks were part of the process health plans used in order to get providers to agree to join their networks at the lowest reimbursement rates possible.  The narrower the network, the more patients would be seen, and the more money would be earned.

That ‘solution’ for the health plans has begun to be seen at the point of service when the covered person learns his or her favorite provider is not available in the new network.  That is unnerving for most of us if we have had a provider relationship that has extended over the years.

I recall my years in the health maintenance organization (HMO) business when there were turf wars between the HMOs as each fought for market share.  That was a very similar situation as compared to the narrow network plans that are part of the Affordable Care Act (ACA).  Providers were more amenable to deeper discounts if they felt they were being given “most favored” exposure in the network.

Similarly, provider groups today are diligently trying to stake out their claims to greater market share.  The Accountable Care Organizations (ACOs) have done the same thing.  In those cases, the health care network has formed their own ACOs borrowing the old HMO approach but driving market share nonetheless.

This is all “insider’ talk that doesn’t change the anguish of not seeing your provider of many years in the network you’re now forced to use, but it might help you to understand how and why this occurred.

These narrow networks were not, unfortunately, made known to the buyers in order for them to make other choices.  In fact, the exchange site didn’t even have the capacity to let this information be seen.  Some were smart enough to select a plan, and then call the local insurer about network availability before they actually enrolled.  But, there are many more people who never gave thought to that and who now find themselves saddled with a network that has not one of their regular doctors included.  Now it is too late to change plans until the next annual open enrollment period.

One way in which some were able to avoid this was to rely on regular insurance brokers who represented more than a single insurer.  Through those agents they were able to verify the composition of the provider networks before making a choice.  As a matter of fact, those agents wouldn’t have sold a plan unless and until they knew that person’s or family’s physicians were available to them in their about- to-be new plan.

If you are among those unfortunate people who learned about narrow networks the hard way, be sure you use a recognized local agent or broker next time the open enrollment period is about to be available.  Unfortunately many “navigators” or “assistors” were people who had no prior insurance agency background.  This is but one of the disappointments of the ACA so far in this first year of its actual existence.

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