Lowcountry residents shopping for a new health insurance plan with coverage starting Jan. 1 may be forced to choose between their preferred insurance company and their preferred doctor or hospital.
That's because individual plans purchased through the new federal health insurance marketplace, and even some plans bought outside the marketplace, will have fewer in-network providers than many patients are accustomed to.
“Who you can go to will change dramatically, and a lot of people don't realize that,” said Colin Smoak, a Charleston benefits consultant. “A lot of people have developed relationships with physicians or a hospital and may have to forgo that relationship.”
Here's an example — neither Medical University Hospital nor Roper St. Francis Healthcare are included in the provider networks for new individual policies offered by BlueCross BlueShield of South Carolina, the largest private insurer in the state.
For most South Carolinians, this isn't a problem. The majority of residents, who already have insurance, are covered by large or small group plans offered through work and won't lose access to their doctor or hospital, said S.C. Department of Insurance Director Ray Farmer.
“Generally, the employer plans that are in place now will remain basically the same as they are, but they could change in the future,” Farmer said.
The immediate changes will affect those residents who aren't insured through work and need to purchase health coverage to avoid a $95 penalty mandated under the federal Affordable Care Act.
For example, Lowcountry residents who want to buy an individual insurance policy and would like full access to the Roper St. Francis Healthcare network of doctors and hospitals need to pick a plan offered by Coventry Health Care of the Carolinas, or be willing to pay higher out-of-pocket costs.
Coventry, which is owned by Aetna, is the only health insurance company that Roper St. Francis Healthcare chose to partner with for these new individual policies.
“We did not come to terms with any of those other companies,” said Bret Johnson, senior vice president and chief financial officer at Roper St. Francis Healthcare.
“One of the reasons government is shut down today is there is still a battle going on about health care reform,” he said. “There is a lot of caution both among providers and insurance companies until the horizon becomes a bit more clear.”
Medicare patients and patients covered by group plans with current access to the Roper St. Francis Healthcare network have not been affected by these negotiations and can continue to see their regular providers next year.
Four insurance companies — Coventry, BlueCross BlueShield of South Carolina, Blue Choice and Consumer's Choice Health Plan — are offering 52 plans for South Carolinians to purchase through the federal insurance marketplace, which launched Oct. 1. Eight companies are offering individual plans outside the marketplace.
A flawed website and higher-than-expected web traffic have made it very difficult for nearly everyone trying to sign on to healthcare.gov for the past two weeks.
Jim Herritage, 64, of Mount Pleasant, tried using the website to pick a policy but decided to seek help from an insurance agent after unsuccessful attempts to create an account and log on.
Herritage, an energy consultant, and his wife, Nancy, make too much to qualify for government subsidies to help pay for a plan, so avoiding healthcare.gov and using an agent instead was an easy choice. Individuals who earn between 100 percent and 400 percent of the federal poverty level will qualify for a government subsidy to offset the cost of insurance, but they must enroll through healthcare.gov to take advantage of that assistance.
“I think what we'll end up doing is purchasing a BlueCross BlueShield plan ... because if something happens, we obviously need that coverage,” Herritage said.
But the plan Herritage wants to purchase won't cover benefits provided by many of the doctors his family already sees.
“Nancy's OB-GYN and dermatologist and our primary care physicians, we'll just have to pay them ourselves,” he said. “The big wakeup call is when people realize this is a very, very thin network.”
Consumer's Choice Health Plan offers policies that include benefits provided by Trident Medical Center, Summerville Medical Center, Medical University Hospital and East Cooper Medical Center.
Individuals plans sold by BlueCross BlueShield of South Carolina and Blue Choice include access to the Trident Health hospitals and East Cooper Medical Center.
Every plan will not offer benefits at every facility, and consumers are advised to pay attention to their preferred policy's details.
“More than likely, the doctors associated with the hospital are in the network, but they need to check,” said Consumer's Choice spokeswoman Adrian Grimes.
Farmer said his agency recommends that residents review the plan's benefits, review its provider network, shop for the best price and then choose a policy.
“This is a whole new ball game that the plans and the networks are changing,” he said.
Insurance companies can no longer minimize their risk by denying coverage to patients with pre-existing conditions or charging women more than men for insurance. The Affordable Care Act rewrote some of these old rules.
Insurance companies are adjusting to federal law by narrowing their provider networks, Smoak said. “That's their only control point.”
Reach Lauren Sausser at 937-5598.