New York Will Keep Affordable Care Act Health Plans Restricted

By ANEMONA HARTOCOLLIS
APRIL 25, 2014 - New York Times

New York State health officials said on Friday that they would not require out-of-network coverage on Affordable Care Act health plans next year, a decision likely to disappoint customers who have complained that they can no longer use their favorite doctors and hospitals.

Restricting consumers to a fixed network of doctors and hospitals, called in-network coverage, helps keep costs down, and for the first year, none of the 16 insurance companies in New Yorkfs exchange deviated from that model.

Advocates for consumers had lobbied hard for out-of-network coverage, saying that some patients needed more choices, particularly since the networks are being kept small to further reduce costs. Under the current in-network system, someone who lives part of the year out of state, or a student at a college out of state, are not covered while they are away, except for emergency care.

The limitation affects people who buy individual or family coverage on the health exchanges, not those insured through employers, who often have the option of seeing out-of-network doctors if they pay higher fees. More than 350,000 people have signed up with private insurers on New Yorkfs health exchange, making it one of the most successful exchanges in the country.

State officials said they feared that requiring an out-of-network option would make it difficult for four health exchange plans with roots in the Medicaid system to compete. Those plans, like Metroplus, run by New York Cityfs public hospital system, operate through fixed networks, offer some of the most affordable coverage and have been among the most popular.

gThe disruption of losing them might be as bad as the benefits of gaining the out-of-network in some ways,h said Mark Scherzer, a lawyer and consumer advocate, on Friday. The decision, he said, was disappointing, gbut not surprising.h

The State Health Department, which runs the exchange, said it was gstrongly encouragingh some insurers to offer out-of-network coverage voluntarily. The department also cited laws in the new state budget that provide protections for consumers who go out of network. But Mr. Scherzer said that while the laws would help patients who need a specialist outside their network, they would not help consumers who just preferred to have a different doctor than those available.