Will Loss Of Your Doctor Be Next Health Reform Crisis?

bigstock-Scientist-giving-thumbs-down-50932802Could the implementation of health reform’s Affordable Care Act (ACA) get any worse?

  • Major system crashes
  • Inaccurate enrollment data
  • Health plan terminations

There may be another problem lurking in ACA’s future –

The unexpected loss of your doctor as a network provider.

Narrowed Choices

To be fair, this problem is not necessarily rooted in ACA provisions. Although insurance companies would probably argue otherwise.

The villain in this scenario is the high cost of health care. When you think about it, that villain is the source for much of the pain in the U.S. healthcare system.

In an effort to control costs, insurers began pushing the concept of narrow networks.

What are narrow networks?

Narrow networks are a significantly smaller group of physicians and hospitals, contracted as “network providers”.

In theory, health plans limit the choice of network providers to lower costs by contracting with the most efficient, cost-effective health care providers.

What does this mean for you?

If you have been covered by health insurance in the last several years, you are probably familiar with network providers.

  • Generally, you receive a higher benefit level if you receive care from a network provider
  • Your out-of-pocket costs are typically lower when you receive care from a network provider

In the past, most physicians and hospitals contracted with major insurers to deliver health care. With a narrowed network, you run the risk that your physician or preferred hospital does not participate in the narrow network.

Any care you receive from your physician or preferred hospital would be covered at the out-of-network level (or possibly not covered at all).

That means significantly higher out-of-pocket costs for you.

Getting Personal

I live in Idaho, which offers a perfect illustration of what we’re discussing. Lucky me.

There are two major healthcare delivery systems in the Boise area.

  • St Luke’s Health System
  • Saint Alphonsus Health System

We also have very few options for health carriers.

  • Blue Cross of Idaho (10 insurance exchange plans)
  • Select Health (St. Luke’s plan – 18 plans)
  • Pacific Source (12 plans)
  • Bridge Span (Regence Blue Shield of Idaho – 3 plans)

Ads for Blue Cross boast the lowest cost plans in the insurance exchange (marketplace).

Sounds good, until you consider that my primary care physician is associated with St. Luke’s. He is not a network provider for 5 of the 10 Blue Cross plans.

The 5 Blue Cross health plans are an example of a narrow network, which includes Saint Alphonsus providers only.

My Choices

  • Pay higher premiums to keep my primary care physician
  • Find a new primary care physician who is part of the Blue Cross narrow network

If you are like me, I do not find that last option appealing.

Buyer Beware

The idea behind the insurance marketplace was to offer you comparison-shopping for your health insurance.

The debate about its effectiveness is another story.

Like any major purchase, there are factors you need to consider – like a narrow network.

When you find a plan you are interested in ~

  • Confirm that your doctor is in the network
  • Unless you don’t care about changing providers
  • Or paying higher out-of-pocket costs


BX Plan

The screenshot is from my broker’s site. So, healthcare.gov (which I STILL cannot access) or your state’s website may look different.

  • Look for any links that discuss Provider Networks
  • Click on the link – most lead to a provider search screen
  • Enter the details for your doctor to see if he/she is in the network

We like surprises during the holiday season; however, going to your doctor’s office in the New Year and finding out he/she is not part of your plan’s network is not a welcomed surprise.

Buyer beware. May the force be with you.


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Notice of Disclaimer –Cathy Miller is not an attorney or health care provider and cannot provide legal or health care advice. The information provided is for your general background only, and is not intended to constitute legal or health care advice as to your specific circumstances. We recommend you review legislation with legal counsel and visit your physician for health care issues.

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