PPACA Marketplace Update:
 
 Important information about keeping your doctor
 
   

Friends, 

  

  

The Patient Protection and Affordable Care Act (PPACA) has changed the health insurance marketplace dramatically over the past three years.  Many of us have seen, heard, and read much debate on the topic of "if you like your doctor, you can keep your doctor".  We would like to take this opportunity to expand upon the political rhetoric surrounding this topic and provide you with the facts based on what we have seen during this open enrollment period. 

 
How are physicians/hospitals/providers and networks associated?
 
Prior to 1/1/14, physicians and providers generally associated with "a network" - for example:  the BCBSM PPO Network.  If you had a group or individual health insurance plan that provided you access to this network you would receive medical treatment from the physicians and providers who associate with it.  This would result in substantial "in network" provider discounts based on the type of medical treatment you require.

What is the difference between a PPO plan and an HMO plan?

  

Preferred Provider Organization (PPO) plans allow you to seek medical treatment within the network without the requirement of obtaining a "referral" from your Primary Care Physician.  This allows more flexibility and control for the insurance customer to choose which provider they wish to receive treatment from.  You may also seek medical treatment outside of your designated network but your benefits will likely be reduced.  Because of this increased flexibility and control, PPO plans are generally more expensive than their HMO counterparts.

Health Maintenance Organizations (HMO) plans require that you first seek medical treatment from a Primary Care Physician (PCP) which you have designated with your insurance carrier.  Your PCP will determine whether he/she can treat you successfully - if not, they will provide you with a "referral" to see a specialist within your HMO plan network.  Because a medical doctor is controlling the treatment process, HMO plans are generally less expensive than their PPO counterparts.

How has the PPACA impacted access to physicians and providers?

  

Since 1/1/14, we are seeing some changes in how providers are participating with health insurance networks.  As we previously stated, prior to 1/1/14 physicians and providers generally associated with the health insurance network.  Since 1/1/14, we are seeing that providers are actually associating with specific health insurance "plans" rather than the overall health insurance network.  

For example - you select a PPO plan:
  • You go into the Health Insurance Marketplace and select a BCBSM PPO Silver Premier plan
  • Prior to 1/1/14 - if your physician was associated with the BCBSM PPO network, you would be able to receive treatment from your physician on an "in network" basis
  • After 1/1/14 - your physician would have to be associated with the BCBSM PPO network and agree to accept the BCBSM PPO Silver Premier plan that you have selected. 
    • if your physician is associated with the BCBSM PPO network and accepts the BCBSM PPO Silver Premier plan you are good to go!
    • if your physician is associated with the BCBSM PPO network and does not accept the BCBSM PPO Silver Premier plan you may be subjected to "out of network" costs 
For example - you select a HMO plan:
  • You go into the Health Insurance Marketplace and select a BCN (Blue Care Network) HMO Silver Preferred plan
  • Prior to 1/1/14 - if your physician was associated with the BCN HMO network, you would be able to receive treatment from your physician on an "in network" basis
  • After 1/1/14 - your physician would have to be associated with the BCN HMO network and agree to accept the BCN HMO Silver Preferred plan that you have selected. 
    • if your physician is associated with the BCN HMO network and accepts the BCN PPO Silver Preferred plan you are good to go!
    • if your physician is associated with the BCN HMO network and does not accept the BCN HMO Silver Preferred plan your treatment will likely not be covered by your insurance.
  • Furthermore, we have worked with clients whose physicians were part of the BCN HMO network and accepted their health insurance plan.  The issue is that the Primary Care Physician (PCP) refers the client to a specialist that does not accept the health insurance plan!

So what can you do to ensure your provider accepts your plan and get the best coverage?

  

When we bind insurance for our clients we provide them with a confirmation containing web links to search for providers that accept your plan.  The need to ensure that your providers accept the health insurance plan you have selected is now more important than ever!  If you have an HMO plan, it is important to ensure that any physician you are referred to also accepts the health insurance plan you have selected.  

If you have trouble searching the web for a provider you can always contact the provider's office directly and inquire further.  Taking these extra steps will save time and money when it comes to using your health insurance plan.  As always, you may contact your Altruis Benefit Advisor for assistance with these tasks as well - we are always here to help you!

 



 
 

 

We will continue to keep you informed about the nuances of the Marketplace as we experience them.  If you have any questions or concerns about these processes please contact Altruis Benefit Consulting at 877.442.5878 or [email protected]

 


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877.442.5878 | www.altruisbenefit.com | [email protected]

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