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Limits of Maine Plans on ACA Marketplace Frustrate Consumers
11/08/2013   Reported By: Patty B. Wight

A primary goal of the Affordable Care Act is to increase access to health care. But some insurance plans in the new online marketplace restrict where a patient can receive insurance-covered care. In Maine, of the two insurance companies that offer products in the marketplace, only one provides out-of-network coverage that extends beyond Maine's borders - at an added cost. Patty Wight reports.

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ACA's Maine Plans Frustrate Consumers Listen

Lisa Turner

At Laughing Stock Farm in Freeport, farmers Ralph and Lisa Turner (right) purchase health insurance on the individual market. Currently, they pay about $7,000 a year in premiums and a $15,000 per-person deductible.

So when Lisa Turner first checked out plans on the new online marketplace under the Affordable Care Act, she was thrilled. "Especially if you get subsidies, it's wonderful," she says. "And the deductibles are lower, and it looked wonderful."

But as she continued shopping, her enthusiasm turned sour. It started when she called Anthem - one of the insurance companies that provides plans on the new marketplace. Turner says when she asked what kind of coverage they offered if she saw a doctor outside of their network - which excludes six Maine hospitals - the answer was "nothing." No out-of-network coverage.

"Which is, like, no one does that," Turner says. "I've had insurance for a long time, and I've never heard anyone say, 'There's no coverage out of plan.'"

So, Turner asked what would happen if she was out of state and needed medical attention.

"They said, 'Well, if it's an emergency, it's covered.' And the next obvious question is, well what about all the people that all of us know with cancer that end up going to Boston? Not covered," Turner says. "I mean, how many people do you know that have had cancer that didn't end up going out of state? And the whole point of the insurance is catastrophic coverage. It's to not lose your house if something horrible happens. And they've got nothing."

According to an email from Anthem spokesman Chris Dugan, the company does not provide out-of-network coverage for its southern Maine plans, but they do for northern Maine plans. Dugan said he would need to verify the differences.

But the Maine Bureau of Insurance offered more information. In an email, a spokesperson says Anthem's out-of-network coverage for plans in northern Maine only extend to the state's borders.

Limiting coverage, says Mitchell Stein of Consumers for Affordable Health Care, is a circumstance that predates the Affordable Care Act, and it's a reflection of how the insurance system works.

"In a perfect world, you would be able to access the appropriate providers and they would be part of a network," Stein says. "But there are trade-offs. If you look at plans that have no, or less, out-of-network benefits, it's an attempt to keep the premium cost down."

Stein says even if a marketplace insurance plan only includes Maine providers, it still provides care - and at an affordable cost. Seeking care out of network, he says, is a choice.

"The idea behind insurance is to provide you with protection," he says. "It's not necessarily to provide you with everything you could possibly want."

But the other insurance provider offering products on the state marketplace - Maine Community Health Options - has a network that includes all Maine hospitals, as well as providers across all 50 states.

CEO Kevin Lewis opens the company's Web site on his laptop, and searches under "Find a Provider Outside of Maine."

"And there, a person can enter in either a zip code, or a state or a facility itself," he says. "So Dana Farber might be a good example."

Up pops a list of providers from Dana Farber, a cancer treatment center in Boston. Lewis says Maine Community Health Options is constantly expanding its list of in-network providers. They do offer out-of-network coverage on all plans, but "there is a higher deductible and co-insurance for out of network providers," he says.

There is a cap on how much a patient will will have to shell out on their own - about $13,000 for an individual and $25,000 for a family. But that's separate from the cap on in-network providers, which is about $6,000 for an individual and $13,000 for a family. So, there's still the potential to wrack up tens of thousands of dollars in health care costs.

The Maine Bureau of Insurance urges those purchasing plans on the marketplace to shop around, noting that there are additional plans sold off the marketplace. The bureau also suggests getting assistance from a trusted source, and to contact the bureau for more information.

Photo:  Patty Wight


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