Health insurance isn’t simple, and neither are government regulations. Put the two together and things get confusing fast. Federal regulators took a stab at making things more straightforward for consumers with new rules unveiled in February. Those rules are part of a 530-page, array of changes set for next year and beyond. Here are three specific changes that affect consumers who buy their own health insurance in one of the 38 states using the online federal insurance exchange:
1) Consumers could have increased access to information about the size of insurers’ network of doctors and hospitals.
Most consumers care about two things: the cost of the insurance plan and whether their doctor or hospital is in the insurance plan’s network. New rules require insurers to give consumers 30-days’ notice when a provider is being removed from the network. They must continue to provide coverage for that provider for up to 90 days for patients in active treatment, i.e., those getting chemotherapy or women in the later stages of pregnancy, unless the provider is being dropped for cause.
2) Consumers could be given more warning about “surprise” medical bills from out-of-network providers.
One of the most common complaints from consumers, concerns bills they get from out-of-network providers. These bills hit consumers even when they go to facilities that are in an insurer’s network because not all doctors and other medical staff in those facilities are part of the network. The new rules make a small change, requiring that amounts paid by consumers for ancillary care, such as anesthesiology or radiology, will count toward their annual out-of-pocket maximum. Once a patient hits their out-of-pocket maximum, the insurer is responsible for all in-network medical costs for the rest of the year. The new rule only applies in cases where the insurer hasn’t warned patients, at least 48 hours before the hospitalization or procedure, that they might receive care and bills from out-of-network providers. Consumer advocates say insurers will issue form letters to as many patients as they can to avoid the rule, while insurers complain the rule doesn’t get to the heart of the matter: the high charges they say are set by out-of-network providers.
3) Consumers’ out-of-pocket costs may be more standardized.
This could be the rule’s most substantive change. Regulators are requesting that next year insurers voluntarily offer plans with a standard set of coverage costs, from deductibles to co-payments for drugs and doctor visits.
The goal of these new rules is to make comparison shopping easier. The change also attempts to lessen the cost hurdle that may keep some consumers from enrolling: having to pay hundreds, or thousands of dollars in deductibles before some common services are covered. To engage these consumers, federal regulators created six standard plans that include flat-dollar copayments for urgent care visits, most prescription drugs, primary care, mental health and substance abuse treatment, without the consumer first having to spend money to meet an annual deductible.
Insurers opposed the idea of standardized plans, saying they could possibly stifle innovation, lead to higher premiums while making it less likely that they will be able to create plans that appeal to a broader variety of consumers. In the next open enrollment period, consumers could see standardized plans available in addition to the varied policies currently sold. One plan may have a lower deductible but higher out-of-pocket costs for doctor visits, while another plan could exclude certain office visits from the annual deductible, while a different option does not. Variations like this have provided choice for consumers, but also have made comparing and contrasting plans difficult.