Naturopathic physician Sierra Breitbeil recently drew a blood sample from a patient at her Winthrop office.
State exchange offers 31 plans through three companies
There’s good news this year for Okanogan County residents who buy their own health insurance through the state exchange, the only place where people can get subsidies to reduce the cost of coverage:. There are many more options — 31 plans from three companies, compared to five plans from just one company last year, with minimal premium increases.
Unfortunately, all those options can be confusing, making it hard to find the coverage that best suits your needs.
Plans are still classified by three metal colors — bronze, silver and gold — with bronze plans having the lowest monthly premiums but also the highest deductibles and out-of-pocket costs; and gold having higher premiums but lower deductibles and lower out-of-pocket maximums.
This year, there are three types of plans — regular qualified health plans, plus two new types called Cascade and Cascade Select, which must provide identical benefits to help consumers compare. Any insurer that wants to sell insurance through the Washington Health Benefit Exchange must also sell a Cascade plan, said Jeff Lindstrom, a health insurance broker with One Digital Health & Benefits.
All plans sold through the exchange must provide 10 essential benefits, including preventive screenings, mental health care and maternity care. They must cover pre-existing conditions, as required by the Affordable Care Act (Obamacare). People who earn up to 400% of the federal poverty level qualify for subsidies through the exchange.
The Cascade plans were designed to make it easier for consumers to compare, so each plan will provide the exact same benefits, in terms of deductibles, co-pays, and out-of-pocket maximums.
The metal categories set a range for co-pays, deductibles and out-of-pocket costs but, within that, coverage can vary. Some plans may offer some free doctor’s visits, while others may require a co-pay.
Plans differ
One important difference that isn’t always evident up front is that the network of providers and health care facilities is not the same under each plan, Lindstrom said.
“You have to be very careful, as always, with the network. Prices of the plans vary based on that, too,” Lindstrom said. And, unfortunately, it’s not straightforward for the consumer to compare networks. “If you’re a regular consumer, you have no way to tell what the network is,” Lindstrom said.
LifeWise Health Plan of Washington, Ambetter, and Community Health Network of Washington are all selling plans in Okanogan County this year. Deductibles for individuals range from $8,300 for bronze plans to $500 for gold plans, with out-of-pocket maximums from $8,550 to $5,250.
For Methow Valley residents, LifeWise tends to have the best network, particularly for behavioral health care, said Maureen Collins, a certified insurance navigator and client advocate at Room One in Twisp. Ambetter’s network is second-best. No plans pay for an out-of-network provider unless it’s an emergency.
Check out your options
• Visit the state exchange at https://www.wahealthplanfinder.org to browse plans.
• Call Room One at 997-2050 to schedule an appointment with a navigator or get a list of brokers.
• Deadline: Open enrollment runs through Dec. 15 for coverage starting Jan. 1, 2021.
The third type of plan is called Cascade Select. These plans grew out of the state’s effort to create a “public option” to reduce health care costs. After negotiations with providers and insurance companies, the state settled on a reimbursement cap of 160% of what Medicare pays — which, theoretically, would make the plan cheaper, Lindstrom said.
Since that reimbursement rate means a pay cut for doctors, many providers weren’t willing to accept it. As a result, the networks in the Cascade Select plans may be even more limited, Lindstrom said.
In Okanogan County, only Community Health Network is offering Cascade Select plans.
Who’s in the network?
The SmartPlanFinder feature on the state exchange, which is intended to help consumers choose the best plan based on providers, prescription needs and anticipated doctor’s visits, is “notoriously not accurate” when it comes to networks, Lindstrom said.
In some cases, a doctor may be incorrectly listed in the network. At other times, a provider isn’t listed but is actually part of the network, he said.
The comparison tool also requires some savviness to get the desired results. For example, consumers who enter the Twisp ZIP code to research coverage options will not see Three Rivers Hospital in their network. That’s because Three Rivers is in Brewster and is listed under a different zip code, Lindstrom said.
Lindstrom recommends checking with the insurance carrier directly to be sure a provider is in their network.
Comparing a company’s regular plan with its Cascade plan can also be bewildering. One may look like a bargain based on its premium, but reading the fine print may reveal that you have to pay for services that would be free under a different plan, Lindstrom said.
When researching plans on the exchange, Lindstrom recommends sorting them by premium. The default — sorted by the exchange’s recommendation — tends to put the Cascade plans at the top of the list, and they may be more expensive, he said.
Plan nomenclature can also be confusing. LifeWise and Community Health Network name their plans by metal type, but Ambetter offers 16 plans called Balanced Care, Essential Care, and Secure Care and, within those, an array of options differentiated by numbers like 1, 4, 5 and 71. The numbers don’t necessarily correlate with benefits, Lindstrom said.
Consumers can look up metal categories for the Ambetter plans on the exchange’s website. Ambetter is the only company offering vision coverage.
Lindstrom hailed the development of the standardized Cascade plans so that consumers can compare, but “in some cases there is too much choice and, with a poorly designed comparison tool, it can be overwhelming for the consumer,” he said.
Getting help
Navigators can help people apply for coverage on the website and troubleshoot issues, but aren’t allowed to make recommendations, Collins said. Room One in Twisp can recommend brokers to help people understand plan details. “The brokers know the plans in and out,” she said.
Brokers are licensed by the state and insured. A broker who specializes in health insurance will be very familiar with plans and benefits and can make sure your provider is in the network.
Insurance companies compensate brokers when they help a customer select a plan, but the cost is already incorporated into the insurance company rates, whether a consumer uses a broker or not, Lindstrom said.
Insurance companies also sell some plans outside the state exchange, which don’t qualify for subsidies but may present good options for some people.
Open enrollment runs through Dec. 15 for coverage starting Jan. 1, 2021. People who have a qualifying event — such as having a child or losing employer-provided coverage — can buy a policy through the exchange at other times of year. Applications for Apple Health, which provides free or low-cost insurance to low-income people, can be submitted year-round.
