Health

Kentuckians in more than half of all counties who buy insurance through HealthCare.gov next year will have a much more limited choice of doctors and hospitals.

That’s because the only insurer left in Kentucky offering exchange plans in all 120 counties — Anthem Blue Cross Blue Shield — will only offer an HMO plan in 74 of those counties starting Jan. 1.

An HMO plan means cheaper coverage in exchange for fewer doctors to choose from. Enrollees will only be able to go to an in-network doctor, which means the provider has agreed to be paid less in exchange for seeing a larger number of patients. Going to a doctor outside the network would mean none of the cost is covered.

“HMOs were created many years ago, but there were 30 choices. So if you couldn’t get into the network [with your provider], you just chose another type of plan,”said Jude Thompson, and insurance broker in Louisville. “We don’t have that. Choice is gone. We have Anthem, and we have Anthem.”

A spokesperson for Anthem said the move was in response to changes in the “health care environment.” United Healthcare, Baptist Health Plans and Aetna have pulled out of the market in Kentucky, citing the inability to make money.

“With the recent changes in the health care environment, Anthem has responded with new products offered through Kentucky’s Health Benefit Exchange and will offer PPO plans in 46 counties, and HMO plans in 74 counties,” said Mark Robinson, public relations director with Anthem.

Humana is only offering exchange plans in Jefferson County, and CareSource will offer plans in some counties. [Story continues below graphic]


Large swaths of the state will be affected — the entirety of Eastern Kentucky and counties surrounding Louisville, Lexington, Owensboro, Bowling Green and Paducah. More than 85,000 people had exchange coverage this year in Kentucky.

Rural areas will be most affected by the reduced choices. For instance, in the Eastern Kentucky city of Louisa — population 2,482 — the Three Rivers Medical Center won’t be in the Anthem HMO network. Instead, exchange enrollees would have to drive 31 miles north to Kings Daughters Medical Center to go to the hospital.

“It’s unfortunate to see they’re leaving the Kentucky market with so few options,” said Emily Beauregard, executive director of the advocacy group Kentucky Voices for Help.

Joel Thompson, an insurance broker in Ceredo, West Virginia, on the border with Ohio and Kentucky, estimates he has 60 clients enrolled in exchange plans. A majority of these are from Kentucky, and a little less than half picked an HMO plan last year because it was cheaper.

But he said he had several clients who specifically asked for a plan with their doctor in-network and so had to splurge on a broader-network plan that was more expensive. That won’t be an option this year.

“There are a number of people that have providers that they swear by, cardiologists and other very specialized physicians that are not HMO. And they’re really going to be hurting this year,” Thompson said. “And that’ll be devastating for a lot of people.”

30 Miles or 30 Minutes

Kentuckians who are enrolled in HMO exchange coverage will still be able to access emergency care at their local hospital, but they’ll otherwise not have insurance cover out-of-network medical providers.

The state also has an “Any Willing Provider” law that lets any doctor or hospital join an insurance plan if they accept the payment rate on the table.

But because these plans on principal pay a low rate, it might not be in the interest of a hospital to be in-network.

Jude Thompson, president and partner at health insurance brokerage Agency One in Louisville, said having an HMO-only network can work if providers are taking new patients.

A 2015 survey of 1,257 primary care physicians by the Kaiser Family Foundation found 14 percent of doctors weren’t taking new patients. Pair that with a more limited network with more patients being sent to providers.

“Here would be the issue: If a physician practice is already at 100 percent, they don’t have to accept new patients,” Thompson said. “That’ll be the domino effect.”

The choices left were not the intention when the Affordable Care Act was approved by Congress in 2010. There were supposed to be a lot of options, according to the theory supporting the law.

The Kentucky Department of Insurance enforces regulations regarding network adequacy, which say an enrollee must be able to access a hospital and primary care within 30 miles or 30 minutes of the person’s home or work.

“They want people to have access to a plan, and if that’s the only option, they obviously want that to be available, especially when there is a law requiring insurance,” said Nancy Galvagni, senior vice president of the Kentucky Hospital Association. “What are people supposed to do if there’s no plan offered and you’re under a law that says you have to be insured? I’m sure it’s a balancing act for the Department of Insurance.”

 

Lisa Gillespie is WFPL's Health and Innovation Reporter.