Why Obamacare May Not Let You Go Out of Network

Thursday, May 08, 2014

For people with health insurance plans they bought on the New York State Affordable Care Act exchange, doctor choice can be limited and none of the plans offer out-of-network coverage. WNYC reporter Fred Mogul explains that while these narrow networks might keep costs down, some customers aren't happy with the doctors they can choose from. And, New York State just announced it still won't require out of network coverage next year. Elisabeth Benjamin, Vice President of Health Initiatives at Community Service Society and co-founder of Healthcare for All New York, also weighs in.


Elisabeth Benjamin and Fred Mogul

Comments [39]

Lili_NYC from NYC


Let's say that you need the care of a specific doctor or group to save your life. You've purchased insurance out-of-pocket for years. You live in NYC and now can only purchase an Obamacare plan which costs more than your former policy. You don't have enough money to pay out of pocket to save your life and you don't qualify for SSI because you are still well enough to work in some capacity. You read the news and you see the jump in health insurance executives pay. You hope to live long enough to give your children a solid start in life. This is a true story. Stop being a mouthpiece for the insurance industry and wake up to the fact that Obamacare is a legally enforced two-tier system that harms and contributes to the untimely death of many. Until I am allowed to see out-of-network doctors, it is useless to me. Show some backbone and work to remediate this situation.

Jun. 30 2014 03:30 PM
anabanana from Sunnyside, NY

I am just now experiencing the Obamacare dance, where I think, "Yay! I finally have health coverage!" I was so excited when I signed up for Healthfirst in February, and gladly forked over my money. I envisioned getting some long-standing medical issues addressed at my preferred hospital, in Manhattan. I received a card, which assigned me some random doctor in Queens, despite that I called and asked them to assign the primary care doctor I already see, in a Manhattan clinic that widely accepts Healthfirst. I refused to see the assigned doctor, and also learned, when I went for tests at Beth Israel, that the specialist there said they 'didn't take Obamacare, only other Healthfirst plans.' A kind staffer helped me, and I was seen, and given my much needed tests. Now that I am likely facing major surgery, I wonder if that will be covered? I can't help but notice that the top hospitals accept, at most, only a few plans, if any, from the exchange. If this isn't 2-tiered medical care, I don't know what is.

May. 23 2014 08:30 PM

Thank you so much for covering this very important story. It is extremely important for consumers to have choices when it comes to their health coverage, and it's only now that people are discovering that the in network choices are very limited and, except in a region in Western NY, there's no out of network choices. Many consumers, who are paying more for the ACA health insurance plans, feel like they've been duped when they learn how limited the plans are and that they were forced to join the ACA plans. If consumers are willing to pay for plans with out of network coverage, they should be allowed to have them. I believe NYS is considering this for 2016. However, as consumers we need to be vigilant that, if there are out of network plans in the future, that the insurance cos. don't make the deductibles so high that it's like having no insurance at all. We need our State politicians to advocate on consumers' behalf and consumers must demand to be allowed to have choice. Please follow up on this important story, and thanks again for covering it.

May. 09 2014 09:56 PM
Bonnie from NYC

I’m so glad you’re covering the shrinking of choice of doctors. I do hope you’ll cover the fact that individual policies off the exchanges in NYS are no longer offering out of network coverage. In order to discourage people from buying policies off the exchange, somehow, by fiat, it was decided that NO individual policies in NYS would offer out of network benefits. The insurance companies are delighted to cooperate with this, as it’s cheaper for them. And I suspect that before long, this will apply to employer based plans as well. Added to this is the growing trend of increasing deductibles and copays astronomically, so that plans that offer a choice of providers become unaffordable.
I see this as part of the fact that the ACA has been structured with the interests of the insurance companies as primary. United Healthcare is one of the richest corporations in the country, and the insurance lobby is larger than the defense industry lobby, according to my understanding. The issue of costcutting is a red herring unless you consider the enormous amount of money that goes to insurance company bureaucracies and profits. If the insurance companies were more regulated, or if we had a single healthcare insurance plan, I think we would be able to afford to insure everyone without diminishing the quality of care of those who are already insured. No need to divide the classes on this issue.

May. 09 2014 06:25 PM
Paula from Manhattan

The assumption made by Elisabeth Benjamin is that the insurers themselves have an accurate list of which providers are in network at any give time. I was recently told by a United Healthcare representative that there was no in-network mammogram provider in Manhattan and that I'd need to go to Queens. (I live on the Upper East Side.) I did find one--by literally going through the phone book, dialing and asking. But how can I efficiently navigate this if the insurer doesn't know?
Additionally, the requirement that changes in network be made public within 15 days is pretty meaningless. Why not require that networks at least offer the same providers within a given calendar year? How can one coordinate care in an ever changing system?

May. 09 2014 09:34 AM
JerseyJazz from Bergen County, NJ

None of these issues comes as a surprise to someone like me who has self-paid for health insurance as a freelancer or small business owners for 30 years. I go back to the days of HIP-NJ, which went bankrupt--remember them? To keep premiums down, I've had to accept in-network-only coverage and greatly reduced RX benefits for many years. Sounds like we have more in-hetwork choices in NJ, though, despite not having our own state exchange.

A related major issue, one that I'd love to see The Brian Lehrer Show address, is small business insurance. That federal exchange was postponed for a year and is still in limbo. And please include NJ as well as NY in your coverage--you have plenty of fans here in the Garden State.

May. 08 2014 08:58 PM
The Polemicist from Manhattan

All of these problems result from the fact that Obamacare is a program of, by, and for the private health insurance industry. Its main purpose is to save and subsidize the private health insurance industry by forcing everyone to buy private (NOT "government") health insurance, and pouring public money into for-profit private insurance companies. This was a deal made by Obama with the insurance companies, and he prevented Democrats in congress from presenting or considering the only real alternative -- single-payer, universal coverage. Obamacare is fraud on progressives and on the people. See detailed analysis at "Who’s the Boss?
The Obamacare Deception

May. 08 2014 07:22 PM
Camille Cosco from Westchester

Couldn't listen this AM - listened just now - guests provided very accurate information as did the two complaining callers. I am a health insurance broker and can attest that the difficulty with networks is and has been for me an enormously stressful issue. And it will take a considerable amount of time to resolve. For my part - I have never in the past two decades felt unsure of what I was offering a client, but I do feel that now and it's very unsettling.

I read all the comments posted as well - more unsettling - the amount of misinformation and misunderstanding among your listeners/commenters. Not just unsettling - very disturbing.

May. 08 2014 06:29 PM
Regina from Centerport, NY

I was on the phone this morning with NY State of Health trying to get arrange for coverage before my husband's coverage runs out on 5/31 (He left his job on 5/1).

Believe it or not, there is no way to do this through the NYS Health Exchange site BEFORE our coverage expires.

I will need to go on the site on 6/1 and then choose a plan. In order to have coverage from 6/1, I will have to appeal and have our coverage backdated.

It's just mind-boggling how the architect of this site did not put some forward thinking in the programming so that a responsible person can have seamless coverage.

May. 08 2014 12:40 PM

"only true free market competition"

Are you serious? Please don't tell me that you think capitalism solves everything. The hand of supply & demand is not fool-proof. Or, tell me the maximum you'd pay not to die, or not to have your child die. There is no limit when it comes to death, so capitalism does not function in this marketplace. If it did, we would have solved this problem decades ago. For capitalism to work there has to be a top limit that someone would pay for the product. That's what drives prices down. When it comes to not dying, there is no limit. Such a thoughtless solution.

May. 08 2014 11:51 AM
rj from prospect hts

The idea that the free market will improve this is beyond ludicrous. Whether it's the doctors or hospitals, which had money and political power in the past or the insurance and drug companies now, profit will be the decider in health care when it's allowed. Profit doesn't discriminate when *quality of care* is what is being sought. All providers should be on the same playing field--comparable rates--without the obstructionist, profit-driven intermediaries such as insurance companies.

May. 08 2014 11:49 AM
rj from prospect hts

Providers are taking non-obamacare plans and *not* obamacare plans from the same companies.

May. 08 2014 11:42 AM
Sue Fine from New Jersey

I'm a 61 year old cancer survivor living in North Jersey with my self- employed husband. I worked in Manhattan for 24 years, most recently insured by Blue Cross. I got laid off Jan 30, 2014. Comparing Cobra to Obamacare we are electing to stay in Cobra as long as possible. We are me, my husband and stepdaughter who is 20 and living in Washington State. Since my stepdaughter is out of state and it seems the plans are mostly state based, we can't carry her on the same plan in terms of network, doctor availability. Without her, we don't qualify for a subsidy and would be paying $2,000 a month for insurance for just me and my husband. Plus we are in New Jersey so it's not clear I could continue to see my Oncology doctors in Obamacare. With Cobra we can stay with Blue Cross for all of family for 18 months for over $1,200 a month. After that, we are very concerned about what will happen.

May. 08 2014 11:42 AM

only true free market competition will put pressure on the providers and force them to lower their costs to remain in business. Additionally, Ron Ron Paul wanted to change the tax code to allow individual Americans to fully deduct all health care costs from their taxes.

Through these measures and the elimination of government-sponsored health care monopolies a much larger number of people will be able to finally access affordable health care, either by paying for medical insurance or by covering their medical expenses, which are now much lower, out of their own pocket.

May. 08 2014 11:41 AM
MikeInBk from Clinton Hill

This is what happens when medical care is a for-profit venture.

May. 08 2014 11:41 AM
Nancy Cadet from Fort Greene

Kudos to the speakers who are well informed and working hard for the public good. It's true, absolutely true, that employer provided plans have restrictions and that it is very hard to find medical specialists,phys therapists , or even decent family practices , that accept our insurance,. The same goes for dental insurance. The reimbursement levels are so low, and most medical doctors are into profit making. Or, if they genuinely care, they are overwhelmed by paperwork for multiple insurance plans.

May. 08 2014 11:41 AM
k brown from NYC

It is true that many, many people have been rejected by care providers,like Mt. Sinai--like 4 close friends..(& what you are now exactly talking about) and specific doctors even though originally being listed. All then bought a much more expensive Obamacare plan.

Unfortunately your guest is not exactly telling the truth but rather spinning pro Obamacare...she even quoted at beginning of segment that people were paying prior to Obamacare $1,000 to $1,500 per month for one person...which is not even a proper average......
Please try to get another more accurate guest on this subject...

May. 08 2014 11:41 AM

30,000 pages of Obamacare regulations can't improve anything.
A better approach would be:
Ron Paul Healthcare
A. Provides all Americans with a tax credit for 100% of health care expenses. The tax credit is fully refundable against both income and payroll taxes;
B. Allows individuals to roll over unused amounts in cafeteria plans and Flexible Savings Accounts (FSA);
C. Provides a tax credit for premiums for high-deductible insurance policies connected with a Health Savings Accounts (HSAs) and allows seniors to use funds in HSAs to pay for medigap policies;
D. Repeals the 7.5% threshold for the deduction of medical expenses, thus making all medical expenses tax deductible.

This bill also creates a competitive market in heath insurance. It achieves this goal by exercising Congress’s authority under the Commerce Clause to allow individuals to purchase health insurance across state lines. The near-monopoly position many health insurers have in many states and the high prices and inefficiencies that result, is a direct result of state laws limiting people’s ability to buy health insurance that meets their needs, instead of a health insurance plan that meets what state legislators, special interests, and health insurance lobbyists think they should have. Ending this ban will create a truly competitive marketplace in health insurance and give insurance companies more incentive to offer quality insurance at affordable prices.

The Private Option Health Care Act also provides an effective means of ensuring that people harmed during medical treatment receive fair compensation while reducing the burden of costly malpractice litigation on the health care system. The bill achieves this goal by providing a tax credit for negative outcomes insurance purchased before medical treatment. The insurance will provide compensation for any negative outcomes of the medical treatment. Patients can receive this insurance without having to go through lengthy litigation and without having to give away a large portion of their awards to trial lawyers.

Finally, the Private Option Health Care Act also lowers the prices of prescription drugs by reducing barriers to the importation of Food and Drug Administration (FDA)-approved pharmaceuticals. Under my bill, anyone wishing to import a drug simply submits an application to the FDA, which then must approve the drug unless the FDA finds the drug is either not approved for use in the United States or is adulterated or misbranded. This process will make safe and available imported medicines affordable to millions of Americans. Letting the free market work is the best means of lowering the cost of prescription drugs.

May. 08 2014 11:40 AM
Amy from Manhattan

I was told the 1st orthopedist I went to for my hip took my new health insurance, but when I called to make a follow-up app't., they said he didn't. The insurance co. still said he was in their network. I called the dr's. ofc. again, & they said he used to take their coverage but had dropped them--the change just hadn't been entered in their system yet.

May. 08 2014 11:40 AM
Truth & BEauty from Brooklyn

My husband and I signed up for Obamacare and got a really affordable policy with vision and dental coverage. We pay less together than I paid on my own before we were married.

That said, NONE of my doctors is in the provider book, so I either go to new doctors or pay out-of-network. Of course, when the exchange opens again, we can switch insurers, if we want. And, of course, all the policies from all the insurers cover emergency care and that doesn't matter where you are at the time - including overseas.

Even though we are pretty healthy, it is nice to have this safety net under us, and I can, of course, resume regular mammograms and other preventive care, which is the best way to go.

May. 08 2014 11:39 AM
ARB From Brooklyn from Brooklyn


I have always had private insurance... and was told that my policy with Emblem was ended and I explored Obama Care and chose a plan with access to to the many great Hospitals in the plan. But that has begun irrelevant, as many of the "best" hospitals have NO Doctors that work at those hospitals. None!

May. 08 2014 11:38 AM
ss brooklyn from brooklyn

I had been a patient at Sloan Kettering for 3 years through Healthy NY via Aetna. When I was forced to switch insurance companies because of the new system I called the Sloan K to see which provider I should select, and Blue Cross Blue Shield was suggested. After I enrolled, it turned out that Sloan Kettering ONLY accepts BCBS from non Obama care patients! In other words, only high payments BCBS patients can continue their work at Sloan K. I can no longer see my oncologist at that hospital.

May. 08 2014 11:37 AM
Ron from Manhattan

When I first got my Affordable Healtcare card from Metroplus Healtcare, my chosen provider, it indicated that my automatically assigned doctor was in Harlem Hospital, a bit of a distance to travel from the upper eastside, especially when actually sick, and I found the doctor very difficult to even contact and make an appointment. I called the Metroplus Healthcare customer service, which took quite a while connect with, but once we connected, they were very helpful in helping me find a primary care physician walking distance from my apartment. While the doctor is not affiliated with one of the fancy, reputable hospitals, he is quite good and has a similar pholosphy on healthcare and pharmaceuticals that I do. Basically, while the road is a bit rocky, I believe this system is working, and most importantly, affordable.

May. 08 2014 11:37 AM
rj from prospect hts

A provider I checked for in January was on the State of Health site for my plan. I scheduled an appt, and was told that they don't take the insurance I signed up for. I checked again a week ago and the provider is still listed. I called the state of health helpline and they said the insurance plan has to update them; I called the plan and they said that the docs have to update them. I gave up--I've already spent months and months figuring this out, as I'm a sole provider and the state of health website is disastrously incompetent for us--it is clueless about what we need to figure out our eligibility, much less the plans.

May. 08 2014 11:36 AM

I'm told the Medicare HMO groups are similarly breaching their contracts. A friend called all the listed specialists in her Long Island area. All said they were not in the program.
I recommended she sue for breach of contract in Small Claims Court.

May. 08 2014 11:36 AM
Brock from Manhattan

The Left can force you to take a less quality plan for more than you paid before just so they can subsidize their base and buy more voters. So now the Left feels slighted because they can't force doctors to buy into their pathetic political utopia? Serves them right, told you so, ha ha...and all that.

May. 08 2014 11:35 AM
Stacy from New York

I carefully researched all my doctors/specialists as I have several doctors I need to see annually to maintain my health. Now that I am on the exchange program, I'm finding out that doctors can just suddenly drop out of the program. I cannot express how infuriating this is. Not sure what to do now.

Our healthcare system is so dysfunctional!!!!

May. 08 2014 11:35 AM
eric from par slope

please follow up with your guest as to which two networks have over 100 hospitals in their network?

May. 08 2014 11:32 AM
June from Westchester

My self-employed husband and I spend almost 25K on Health Insurance a year - high deductible etc. and we were thrilled at the prospect of Obamacare. BUT none of our physicians offices could guarantee us that they were taking any of that coverage and none of my son's many therapists are covered as they are all out of network. NY state has sold it's citizens up the river and once again the Insurance Industrial Complex wins.

May. 08 2014 11:31 AM
Jason W from Manhattan

We purchased the United HealthCare Platinum plan for our daughter which includes pediatric dental. After months of UHC's dental group's system not recognizing her as having coverage we finally were able to get a list of in-network pediatric dentists. How many many dentists are in network in Manhattan? ONE! That is not a limited set of choices, that is NO choice. Also the plan is listed as an EPO on the NY State of Health site, but once you get the documents it is an HMO plan -- and those are two very different things.

May. 08 2014 11:30 AM
mar from New York

I would like to hear a discussion on health insurance and how it works differently on other countries and why. I am a citizen in Spain and I have no problems whatsoever going to doctors or getting any medical assistance. It's always easy, accessible and free. I guess we pay for it in taxes, but it's money that you don't see and you don't miss. It gives you peace of mind and it's something you never have to worry about
Since I am living here, I pay amazing amounts of $$ per month to medical insurances and it is still a problem anytime I go to the doctor, either I have to pay co-pays or there is always some kind of added expense. In addition, it is always a tremendous inconvenience to call your policies whenever you need something straightened out.
Why is there such a difference and how is it possible?

May. 08 2014 11:29 AM
Sharilyn from Brooklyn NY

before ACA, I paid $707 per month and had decent out of network coverage. Now I pay $642 per month for a plan which is basically an HMO with NO out-of-network coverage. Have had to change every single doctor I use.

I'd have kept the original plan, but the insurance company no longer offers it and is all but forcing individual buyers to go onto ACA/exchange plans.

Even my insurance broker was surprised at how limited my new United Healthcare coverage is now.

May. 08 2014 11:27 AM
rj from prospect hts

I was meticulous in checking for my many providers, as I am diabetic and will not give up people who keep me alive. I was paying ~$17,000 year in premiums, deductible, copay, etc. Because one of my important providers is not taking insurance, and others I still have to make decisions on out-of-network care or not (apparently there are no gyns taking insurance), my costs will be about the same per year. Much lower premiums but critical providers not taking it have blown that.

So, as usual, the insurance companies win.

May. 08 2014 11:27 AM
Brock from Manhattan

Why are the subsidized complaining? Do Food Stamp recipients complain? Section 8 dependents?

May. 08 2014 11:26 AM

If you're in the program, maybe you shouldn't be allowed to go outside its network, but is this the same with Gold, Silver or Platinum plans?

May. 08 2014 11:26 AM
Melissa from Brooklyn

The limited networks and no out of network coverage leaves families exposed to significant financial risk or neglecting potentially serious health conditions. I did not think this was a goal of Obama Care.

May. 08 2014 11:25 AM
Joseph Bell from Downtown

Imposition of HMOs-- that's what is at issue here is not new. Shrinking networks is not a phenomenon limited to ACA plans alone. This is part of an overall trend that has been underway for years.

May. 08 2014 11:23 AM
Kim murdock from Manhattan

Very excited when I signed up for my Blue Cross platinum plan in December. Then came weeks of frustration. Hard to even get an acknowledgement that I had enrolled. I finally got a card,at the very end ofJanuary, together with a bill for January and and February. Of course without a card I had no way of using my supposed benefits, but I was still expected to pay for that month. Blue Cross was forced to send out partial refund checks at least, and I knew I was not alone in my experience
But now begins weeks of frustration. I begin a careful search for a good primary care physician, one essential criterion being that she accepts Blue Cross. How hard is that, this is a gigantic insurance company with a presence in every state.

That was when I discovered -- slowly, because no one wants to tell you -- that my form of Blue Cross is on a black list. The "platinum guided access" name stamps it as purchased through the Health Exchange, and guess what? No one is accepting patients whose plan was bought from the exchange. I worked for 3 weeks with one doctor's office to get Blue Cross to accept her as my primary, they first said she had no provider number. We finally got a number for her, but the number would not compute. Her office manager said to me, "I don't understand it, we take all kinds of Blue Cross.....except of course Obama Care." This is a literal quote!

Next stop is this it my longtime gynecologist. I selected Blue Cross after confirming that he accepts it. The day before my appointment his office calls to tell me that they do not accept plans purchased from the exchange. On the visit they also tell me that no hospital in Manhattan accepts exchange plans. OK, I am paying $620 a month for a plan no one takes!

On the only plus side, my wonderful doctor tells me he will not charge me for the visit, and that he believes that this problem is temporary, that doctors and hospitals want to participate, but that the parties have to negotiate better reimbursement rates. He thinks this time next year things will have shaken out. I hope. But that probably means that all the policies will be much more expensive.

I add one final complaint, they assigned me a primary care doctor without ever informing me.

May. 08 2014 11:22 AM
Grant MD

It appears the insurance companies have limited the number of specialists on their ACA plans. (Rumor has it to their lowest reimbursed specialists.) Eighty percent of the specialists I used and referred to are now not part of the health plans.
I see patients paying much more money out of pocket for less health care coverage. Meanwhile primary care reimbursement is less.
Seems the insurance companies have all the power and money.

May. 08 2014 10:48 AM

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