Obamacare Plans Illuminate High Cost of Going 'Out of Network'

Editor's note: This post is part of the ongoing Ask Emily column, a project of the nonprofit CHCF Center for Health Reporting. Reporter Emily Bazar answers consumer questions about Obamacare. In this issue, Bazar takes a look at the potential costs of visiting an out-of-network doctor or other provider. This is an issue anyone with health insurance should pay attention to.

Q: I learned today that the health “insurance” I purchased for my family through Covered California does not have ANY maximum out-of-pocket cost on out-of-network providers. … How is that even possible? Our family is now faced with potentially infinite costs that could wipe us out.

A: Let’s start with a quick refresher.

An out-of-pocket maximum is the most you would pay during the term of your health policy (usually one year) before your insurance begins paying 100 percent of covered medical services.

Deductibles, co-pays and other costs generally count toward your out-of-pocket maximum. Your monthly premiums don’t.

This year, Obamacare capped out-of-pocket maximums at $6,350 for an individual policy and $12,700 for a family policy.

Maureen Burke of Berkeley, who submitted the question above, settled on a Blue Shield EPO (Exclusive Provider Organization) family plan from Covered California with a $12,700 out-of-pocket maximum.

It wasn’t until recently that Burke realized that those much-publicized out-of-pocket maximums –-including hers –- only apply to services obtained from medical providers IN the plan’s network.

So what about providers who are not in network? Were limits set on those costs?

In her case, to her shock, no.

As it turns out, insurers get to decide the dollar limits –- if any –- for themselves.

“The out-of-network, out-of-pocket costs for each plan would be at the plans’ discretion,” says Covered California spokesman Roy Kennedy. “You would need to inquire with the individual plans on what their policy is for out-of-network costs.”

What’s the big deal, you may be wondering. Burke and others should just stay in their networks, right?

Challenge in Determining If A Doctor is "In Network"

In this new health insurance environment, that’s easier said that done.

As many of you know, insurers have created “narrow networks” for many of their new plans. In plain terms, that means they have whittled down the number of participating doctors and hospitals. The providers agree to charge insurers lower fees in return for higher volumes of patients.

But for consumers, staying in network has become more difficult because there are fewer providers serving more patients.

(Good luck confirming whether your doctor and hospital are in network. Misinformation and inaccuracies have plagued the network lists since the beginning.)

Burke poses a hypothetical: What if she needs surgery? She’ll make sure her doctor and hospital are in network. But, she notes, they won’t be the only ones providing services.

“One can’t know during surgery whether the assistant surgeon, the radiologist, the anesthesiologist, etc., are in network or not,” she says.

This doesn’t apply just to Covered California plans. Priscilla Myrick, also of Berkeley, bought an Anthem Blue Cross PPO (Preferred Provider Organization) family plan on the private market.

Earlier this year, she visited the cardiologist she used to see through her previous Anthem plan and had a mammogram and bone density test at an imaging center that used to be in network.

Then she opened her mailbox and found bills totaling more than $1,500.

Myrick started digging. She learned that her cardiologist and imaging center are no longer in her network, which sent her bills skyrocketing.

Then she discovered that Anthem would assume all costs for covered services outside its network only after she had paid $30,000 out of her own pocket.

Myrick is a retired certified public accountant. “I know how to look at numbers,” she says.

But that one had not been apparent when she shopped around for plans. “How was anyone supposed to know this?” she asks.

Myrick has since cancelled a follow-up procedure ordered by the cardiologist because “I couldn’t find out how much it was going to cost,” she says.

(Find Myrick’s complaint letter to the Covered California board here.)

Darrel Ng, an Anthem spokesman, says out-of-pocket maximums for out-of-network providers range from $10,000 to $18,000 for the company’s individual plans and $20,000 to $36,000 for family plans on the private market. On Covered California, they range from $10,000 to $15,000 for individuals, he says, and from $20,000 to $30,000 for families.

He urges consumers to do their homework before getting care, if possible, to ensure their providers are in network.

“We would encourage them to contact the hospital and find out whether all the different parts of the medical system they’ll be touching are in their network and ask, if possible, that in-network providers be used,” Ng says.

Once again, easier said than done. How will the hospital know which radiologist or pathologist or fill-in-the-blank-ologist will be working at the time of your surgery one month from now?

“Who would answer those questions? The receptionist at the hospital?” Burke asks. “It’s impossible.”

I tend to agree.

Here’s my advice:  Find out what your limit is for out-of-network providers.

And hope like heck that you don’t need them.

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