Getting insurance: Marketplace vs Off Marketplace (medical, plan, hospital, doctor)

[vagabond48]

1st sorry for the long message.
I am currently overseas and Skype calls to the US are pretty bad so I am hoping I can get some information here. I have researched this on the web but still am not crystal clear about the difference. The reason I am asking this question is because I have read that some people may have been rejected by doctors because of the ACA code on their card. If this is true, in my opinion, this would be totally unethical IF the doctors were being compensated the same amount. Plus why would the insurance put this code if the plan uses the same provider list unless they want to sabotage ACA. On to my question.
My wife needs insurance. We do not qualify for any tax credits so we don't necessarily need to get it from the marketplace. I found a Humana POS plan in our area that will fit her needs. I also found appears to be the same plan plus child dental which we don't need on their website for $2/month more but I wonder if the 2 plans are really identical minus the dental?
It looks like they both have the same National POS Open Access Provider list but will the providers get paid the same fees if the same insurance comes from the marketplace? If they don't, the provider may deny you services.
Are the free preventive health services for adults and women also included in the private insurance plan?
Is there more legal protection if you get the plan through the marketplace?
Thanks for any helpful comments.

[vagabond48]

Sorry but I just found out that my wife who has a green card can only get the Humana plan through the marketplace.
Feel free to comment to help others with similar concerns.

[Qwerty]

The Marketplace is really just a consolidated resource to shop for insurance plans. If you don't qualify for subsidies there really is no reason to buy a plan from the marketplace. I would contact an insurance broker in the area where you will be moving or wherever you live in the US and have the shop plans for you. You don't pay them anything to do that work for you so why not use them.

As far as the ethics of not taking Marketplace plans, doctors have been free to choose which networks in which they want to participate. There is nothing unethical about that. The hearsay about taking marketplace plans mostly comes from people that have not done their homework to research which doctors or facilities are in their new networks. Yes, that network is more limited but that is what you get when you pick an HMO plan to save a couple bucks. It's been that way with HMO's since HMO"s started and has nothing to do with the ACA, Marketplace plans or ethics.

Providers are paid based on the contract they sign with the insurance company and they choose which networks they want to be included in for each company. If the fee structure for Company A is $100 for the marketplace network, $120 for the non-Marketplace plans, that is their choosing.

Personally I would find another company to get insurance through vs the one you mentioned .

[vagabond48]

Qwerty. You misunderstood what I wrote. Let me explain.
I wrote "The reason I am asking this question is because I have read that some people may have been rejected by doctors because of the ACA code on their card. If this is true, in my opinion, this would be totally unethical IF the doctors were being compensated the same amount." I had written that I found the SAME plan with the SAME provider list at both the marketplace and off marketplace, therefore "if" the only reason a denial is based on getting the insurance from the marketplace, then this action is indeed both unethical and against the Hippocratic oath because it would have nothing to do with getting less money or being on a different network. Politics has no place in medicine.

[NSHL10]

Most marketplace plans are high deductible in nature. 85% of marketplace enrollees are getting some sort of subsidy because they can't pay their premiums. Providers are concerned that these customers won't have enough money to pay their deductibles and will "stiff" them.
Not political, not unethical, just a business decision.

[Ariadne22]

Originally Posted by vagabond48

Qwerty. You misunderstood what I wrote. Let me explain.
I wrote "The reason I am asking this question is because I have read that some people may have been rejected by doctors because of the ACA code on their card. If this is true, in my opinion, this would be totally unethical IF the doctors were being compensated the same amount." I had written that I found the SAME plan with the SAME provider list at both the marketplace and off marketplace, therefore "if" the only reason a denial is based on getting the insurance from the marketplace, then this action is indeed both unethical and against the Hippocratic oath because it would have nothing to do with getting less money or being on a different network. Politics has no place in medicine.

She answered your question, here:

Originally Posted by Qwerty

Providers are paid based on the contract they sign with the insurance company and they choose which networks they want to be included in for each company.

If the fee structure for Company A is $100 for the marketplace network, $120 for the non-Marketplace plans, that is their choosing.

ACA plans do have different fee structures. Docs are not being compensated in the same amount.

Further, as NSHL said, the higher deductibles - and often people brand new to insurance who don't understand deductibles or aren't accustomed to paying premiums - can result in no pays for the docs when, because of the deductible, patient must pay out-of-pocket.

And, with the grace period allowed for premium payment, doc has no guarantee policy is actually in force at the time of service. If service takes place within that grace period and premium isn't paid, doc isn't paid by the insurance company either - even if service is 'free' to the patient.

Many docs are limiting the number of ACA patients they will see to avoid these hassles.

[toofache32]

I'm trying to understand why someone would think ACA plans would reimburse the same as non-ACA plans.

[Qwerty]

Originally Posted by vagabond48

Qwerty. You misunderstood what I wrote. Let me explain.
I wrote "The reason I am asking this question is because I have read that some people may have been rejected by doctors because of the ACA code on their card. If this is true, in my opinion, this would be totally unethical IF the doctors were being compensated the same amount." I had written that I found the SAME plan with the SAME provider list at both the marketplace and off marketplace, therefore "if" the only reason a denial is based on getting the insurance from the marketplace, then this action is indeed both unethical and against the Hippocratic oath because it would have nothing to do with getting less money or being on a different network. Politics has no place in medicine.

No, the issue is you don't understand how insurance networks work.

Take United Health, for example. https://www.providerlookuponline.com...o7/Search.aspx

This is a list of their current networks for individual plans only--doesn't include group plans. Say a doctor contracts with United Health, they give him a list of these networks and he says he wants to be in these networks:

UnitedHealthcare Choice
UnitedHealthcare Choice HMO/Choice Plus HMO
UnitedHealthcare Choice Plus
UnitedHealthcare Choice Plus with Harvard Pilgrim
UnitedHealthcare Choice with Harvard Pilgrim

Now, the doctor takes United Health, but not ALL of United Health networks. So, on the doctor's website he lists he participates in United Health. A patient, not doing their homework, has say their Compass Plan, goes to that doctor and presents their card only to be told that they are not in their network. That patient takes that to be "rejecting" their Marketplace plan, but its not because it's a Marketplace plan, it's because the dr isn't in that network, or 20 other UH networks. There is a thread going on this board right now where a patient is accumulating huge medical bills because he did not check his network before going to a hospital. That is not the insurance companies fault, nor is it unethical or against the Hippocratic oath. It's a failure on the user side, period.

Compare that to a company like Cigna, who, for non-marketplace plans has ONE network, Open Access Plus. If you sign up for a non-Marketplace plan with Cigna, any provider that accepts Cigna will accept your plan, easy, done. Now, Cigna has a few local networks (Marketplace plans): Plan Names:
myCigna Copay Assure Gold
myCigna Copay Assure Silver
myCigna Health Flex 1250
myCigna Health Flex 1500
myCigna Health Flex 2750
myCigna Health Flex 5000
myCigna Health Flex 5000 Bronze
myCigna Health Savings 3400
myCigna Health Savings 6100

So, you need to look at your card and see what network you are in, then you can look up providers. You should also ALWAYS ask your provider to verify their network status BEFORE your appointment.

The networks are about controlling costs. A smaller network, say an HMO, has limited doctors in a specific geographic region. The usual and customary charges for those doctors/procedures are pretty well defined and predictable so those plans can be offered at a lower cost, which is why most Marketplace plans are HMO's. Expand your network nationally to a PPO, for example, and your costs are not as predictable and are higher. The benefit for paying more, however, is you don't need referrals and you can go to whatever doctor you want. If you stay in network, your costs are lower, but they have out of network coverage as well. Individual HMO plans only have out of network coverage for emergency care, heart attacks, etc. and then only then until the patient is stable and can be transferred to an in-network facility. The Marketplace plans are pretty much what people would experience in the US if we went to a single payer plan, very limited networks, no real choice of doctors/facilities, etc., much like you see today with Medical Advantage plans, and even Medicare in most cases.


Now, if you found the same plan both on and off the Marketplace, that is remarkable. The Marketplace plan is probably listed on the insurance company website, but when you go sign up for that plan, it will take you to the Marketplace website.

[toofache32]

Originally Posted by vagabond48

Qwerty. You misunderstood what I wrote. Let me explain.
I wrote "The reason I am asking this question is because I have read that some people may have been rejected by doctors because of the ACA code on their card. If this is true, in my opinion, this would be totally unethical IF the doctors were being compensated the same amount." I had written that I found the SAME plan with the SAME provider list at both the marketplace and off marketplace, therefore "if" the only reason a denial is based on getting the insurance from the marketplace, then this action is indeed both unethical and against the Hippocratic oath because it would have nothing to do with getting less money or being on a different network. Politics has no place in medicine.

Who told you that doctors are compensated the same amount?? Where did you get this info?