It’s open enrollment time through Dec. 15 for individual insurance, and Ingrid Shell just signed up. She just isn’t completely sure what she signed up for.
Shell got conflicting or uncertain answers from representatives of the insurance company and her nearby hospital about whether the hospital would be in her preferred insurer’s network for 2020. In the end, a reliable-sounding woman from the hospital told her the answer was yes, and Shell signed up.
Events this year have underlined a big vulnerability for Georgians buying private insurance individually through the Affordable Care Act. Insurance companies’ networks of covered health care providers such as hospitals and doctors no longer blanket the map. And if a shopper knows that, and hunts for a list of providers the company covers, they can find a list — but it’s not guaranteed.
“She came back and said yes,” the hospital would be in network, Shell recalled. “She said, ‘for now.’ But what does ‘for now’ mean? I don’t know.”
People with insurance through their employers have less of a problem because their networks tend to be larger. Big groups have more leverage to negotiate better plans with insurance companies. For the individual policyholder, though, the narrow networks that increasingly fill policies are becoming a troubling risk.
The stakes are high. Out-of-network medical visits are almost certain to cost the patient more money. Hospital visits for emergencies are always covered, regardless of network, but some insurance companies are cracking down on what they consider to be an emergency. And depending on the policy’s provisions, an out-of-network visit in the Georgia individual market can often leave the policyholder with the entire bill — if the provider will agree to see the patient at all.
A legal obligation
The law says insurers must keep an updated list online. But the list isn’t guaranteed.
“It seems like that should be the case,” said Jason Doss, a lawyer who is fighting the insurance giant Anthem. “But the directory is not the contract.”
Insurance networks these days are far from comprehensive. Of the six Georgia companies offering individual plans on the Affordable Care Act exchange, none have contracts with all of seven major health systems that the AJC asked them about.
One, Oscar Health, had a contract with only one: Wellstar.
Even if Georgia customers know they need to find out who’s in an insurer’s network, the information available to them can end up being faulty.
Sometimes, the lists aren’t updated correctly. Sometimes the list is correct at the time of signup, but insurers later change it for reasons that have nothing to do with the customer.
One such incident here made news. In February, the insurance giant Anthem dropped the Wellstar health system from its network after policyholders were already locked in for the year. Cobb County, home of 750,000 people, has only Wellstar hospitals.
Then a new issue: When open enrollment began this fall for 2020 plans, it looked as if the problem was solved:
Anthem’s network listed Wellstar.
Except it wasn’t true. Anthem says it made a mistake. Now customers who signed up believing Wellstar was in their network need to change by Dec. 15 if they are counting on Wellstar for care.
Anthem’s not the only insurer that has made mistakes or failed to update a network list.
Mark Mixer, CEO of Alliant Health Plans, said there are many reasons lists aren’t instantly accurate: technology, doctors changing addresses, glitches, or health providers pulling out of networks.
Alliant is a nonprofit and Mixer said it’s honest with its customers, but he’s not sure all companies are.
The issue has come up in state legislative discussions. Richard Smith, R-Columbus, chairs the House Insurance Committee and helps write the laws that define insurance contracts. He said he feels for the patients who can’t rely on the provider list they sign up for.
“It should be binding,” Smith said.
He said he has tried for years to get patients out of the middle of the fight between insurers and providers. He’ll again attempt legislation to decrease surprise billing this session. But not a bill that protects the policyholder by making his or her provider list a contract.
A bill like that sounds simple, he said. "But then you'll have all these various groups coming out in opposition to it."
Resorting to the courts
Georgia Department of Insurance officials made clear that insurers are supposed to update their lists. But there’s no obvious penalty if they don’t.
If the list a customer sees at signup ends up different from what gets covered, Scott Sanders, assistant director of the Georgia DOI said, they can file a complaint with the department, which can compel the insurance company to cover the claim.
But does that happen? When Anthem dropped Wellstar, the insurance department was unable to get Anthem to fully restore its coverage of Wellstar.
Federal regulators who run the ACA have the power in extreme circumstances to re-open enrollment for customers to switch plans, but didn’t for the Anthem customers.
In the latest snafu, when the state last month found out about Anthem’s inaccurate provider list for 2020, it issued a press release about the problem. Anthem said it will contact the policyholders to let them know about the error.
DOI said those who signed up can change their 2020 policies before enrollment closes on Dec. 15.
Some Anthem customers affected by the earlier mistake have filed a lawsuit against the company.
Doss, who represents them, thinks he can convince a court that the list those customers saw last year should be considered a contract. But that will take time. Anthem said it did nothing misleading or deceptive.
Meanwhile, patients have delayed care and wound up with bills.
A $170,000 bill
That’s enough to scare Shell, 61, after a serious illness this year. The hospital where she’d like to go if necessary is five minutes from her home.
She wants to remain with the insurance company Ambetter because this year they stood by her. She came down with a rare syndrome and stayed in her hospital, Gwinnett Medical Center, for a week, racking up $180,000 in charges. She paid her $8,000 deductible, and Ambetter paid the rest. Had the hospital not been in network, she fears the entire amount could have been her bill.
When she went to sign up this year on healthcare.gov, she checked networks.
She also knew something important: Gwinnett Medical Center had been bought by Northside and renamed Northside Hospital Gwinnett. She checked Northside, and Northside was not in Ambetter’s network. The insurance company’s website still said her hospital was in network — but listed under the old name, not the new name it got when Northside acquired it. So she started calling.
The person Shell decided to trust was correct, a spokeswoman for Ambetter says: While the Northside system is not in Ambetter’s network, the old Gwinnett hospitals still are. The list just hadn’t updated the names.
She’s pleased she can stick with Ambetter, but frustrated that insurers’ provider lists are not like an ironclad contract.
“If you’re a basic innocent person and healthy you don’t think about it,” said Shell. “You just assume you’ll be insured.
“My friend, she signed up for Anthem. And I told her, be careful, you can’t go to Emory. You won’t be in network. She said, ‘Wow, thank you for telling me, I had no idea.’ How are you supposed to know this stuff?”
KNOW YOUR NETWORK
The AJC asked all six individual insurance providers on Georgia’s ACA exchange about seven healthcare groups: Children’s Healthcare of Atlanta, Emory, Northside, the Gwinnett Medical Center providers now under Northside, Northeast Georgia Health System, Navicent, Piedmont and Wellstar. Here’s who they said is in network for plans that start Jan. 1, 2020.
Alliant Health Plans
- Yes:
Emory
Navicent
Northeast Georgia Health System
Piedmont’s Athens hospital, its Mountainside hospital and their physicians.
Wellstar
- No:
Children’s Healthcare of Atlanta
Northside
The Gwinnett Medical Center providers that are now under Northside
Not Piedmont’s Atlanta hospitals
Ambetter
- Yes:
Emory
The Gwinnett Medical Centers
Piedmont
Wellstar
- No:
Children’s Healthcare of Atlanta
Northside
Northeast Georgia Health System
Navicent
Anthem
- Yes:
CHOA
Emory for transplants but not the rest of Emory
Northside
The Gwinnett Medical Center providers that are now under Northside
Navicent Health Baldwin, but not the rest of Navicent
- No:
Emory, except it is in network for transplants.
Northeast Georgia Health System
Navicent, except Navicent Health Baldwin is in network
Piedmont
Wellstar
CareSource
- Yes:
CHOA (this is not yet listed online with healthcare.gov but CareSource says it will be in network)
Northside
The Gwinnett Medical Center providers that are now under Northside
Piedmont
Wellstar
- No:
Emory
Northeast Georgia Health System
Navicent
Kaiser Permanente
Kaiser Permanente has a unique structure where they employ their own healthcare providers. However, Kaiser has provider contracts with several hospitals. The Kaiser network includes:
CHOA, CHOA Scottish Rite
Emory St Josephs, Emory Midtown, Emory Johns Creek
Gwinnett Medical Center Lawrenceville
Northside, Northside Forsyth
Piedmont, Piedmont Athens, Piedmont Newnan, Piedmont Rockdale
Oscar Health
- Yes:
Wellstar
- No:
Children’s Healthcare of Atlanta
Emory
Northside
The Gwinnett Medical Center providers that are now under Northside
Northeast Georgia Health System
Navicent
Piedmont
KNOW YOUR RIGHTS
How to make sure you get the health insurance network you need signing up for ACA plans on the marketplace.
During signup:
Check your network. When you're signing up for a policy, check to make sure your hospitals, doctors or other providers are in the network of the company you choose. The Healthcare.gov ACA website has an easy check box for this.
Take screenshots. If you really need a provider to be in your network and it's an important piece of why you chose a plan, take a screenshot from your computer to document that you saw it on the insurer's network list.
Switch if you need. You can switch policies until open enrollment closes at the end of Dec. 15.
After policies start:
Talk to your insurer. If you believe you've been denied coverage for a provider visit that was in network, make that case to the insurance provider. Keep records of who you talk to and when.
Going to the state. If that doesn't work, you can file a complaint with the state Department of Insurance. They will investigate the complaint and decide if it looks like you're right. Then they can talk to the insurer and try to broker a deal or solve the problem.
State DOI:
https://www.oci.ga.gov/ConsumerService/HealthInsurance.aspx
Consumer Services Division
2 Martin Luther King, Jr. Drive
West Tower, Suite 716
Atlanta, Georgia 30334
Telephone: 404-656-2070
Toll Free: 800-656-2298
Between 8 a.m. and 7 p.m.
Source: Georgia DOI
ACA: SIGN UP SMART
Open enrollment for the Affordable Care Act’s individual market ends Dec. 15. Customers have until then to choose or switch plans.
You can learn your plan’s network of hospitals and other care providers by checking for them under the plan on healthcare.gov.
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