Some New Yorkers can choose from more than a hundred health insurance products offered by more than a dozen insurers participating in the state-run health insurance exchange, depending on where they live, but theyre hard-pressed to find anything other than the HMO-style plans that dominate the landscape.
There are a few exceptions in the far western part of the Empire State and Albany area, Kaiser Health News recently reported, noting that residents who seek out-of-network care for anything other than emergency care are generally going to be responsible for the entire bill.
Its a highly unusual arrangement. The same article noted a McKinsey & Co. study that found just 1% of Americans who were eligible for HIX coverage in 2015 were confined to an HMO option, while 4% could choose between an HMO or exclusive provider organization.
Roughly 75% of New Yorkers who purchase coverage through the individual marketplace have incomes at or below 400% of the federal poverty level, according to a NY State of Health (NYSOH) spokesperson. She says network plans are more affordable and have far more predictable out-of-pocket costs when consumers access services.
Sabrina Corlette, project director at Georgetown Universitys Center on Health Insurance Reforms, believes a state requirement that plans with out-of-network benefits sold outside the HIX marketplace also must be sold inside the NYSOH discouraged PPO offerings.
Consequently, most insurers decided not to sell PPOs than have their hand forced with their cautious demeanor also a reaction to a history of tight regulation of the states health insurance market. They were worried about adverse selection, so they only offered HMO-style plans, Corlette told Kaiser Health News.
New York regulators also have taken steps to raise the level of consumer protections amid a dearth of other delivery mechanisms for health insurance. Consumers who want out-of-network benefits run the risk of balance billing by providers who refuse to accept the insurers rate. With this in mind, New York passed a law in 2014 to prevent surprise out-of-network bills by improving adequacy standards for plans networks and, thus, reducing a need for out-of-network care.
If the health plan does not have a network provider that meets the patients needs, the plan must approve a referral to an out-of-network provider and the consumer will be responsible for only the amount of in-network cost sharing, says the NYSOH spokesperson. With these protections in place, we believe that health plans with robust, high-quality health provider networks are the best option for consumers.
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