If you have a MODA individual health insurance plan, and continue seeing your Providence-affiliated physician or getting care at Providence Hood River Memorial Hospital in 2017, prepare to pay more for your share of the care.
A lot more.
“In dollars and cents, it’s going to be enormous,” says Karissa Way Hamm, individual and Medicare accounts manager with the BCI Group in Hood River.
MODA’s Hood River customers area are looking at a major bump in out-of-pocket costs next year, because MODA has dropped Providence Health & Services providers from its in-network coverage.
Providence operates the only hospital in Hood River County, plus five clinics in Hood River and one in White Salmon, according to its web site.
BCI Group is the largest broker for individual health insurance coverage in Hood River.
Way Hamm says the pending changes affect only individual coverage, not group plans. According to its news release, “the network changes will affect residents seeking individual health insurance under the age of 65, but it will not affect those covered by Medicare or employer sponsored markets.”
She said BCI Group had close to 100 people with MODA last year, but some have already changed plans as MODA has bumped up premiums in an effort to balance its books.
According to spokesman Jonathan Nichols of Moda, the insurer has 679 members in Hood River County.
MODA offered attractively low premiums as the the Affordable Care Act kicked in during 2014. Way Hamm says the company at one point had more than 80 percent of the individual marketplace in Oregon.
High usage by new customers and the federal government’s decision not to cover some of those costs drove MODA into a financial tailspin last year, all covered in great detail at The Lund Report, which covers Oregon health care news.
Providence Medical Group-Hood River includes more than two dozen primary care providers and specialists. According to a media release from BCI Group, Providence Hood River Memorial Hospital “receives more than 1,604 admissions and 8,765 emergency department visits annually.”
Those MODA customers face two options to avoid a steep bump in co-pays, deductibles and balance billing for charges beyond what in-network providers have agreed by contract to waive.
They can change to another insurance company. Two options are available in Hood River County, one owned and operated by Providence, the other by Regence.
Or they can find a physician affiliated with Mid-Columbia Medical Center or its partner care provider, OHSU.
In a media release posted to its website this fall after filing plans with the state, MODA noted that its 13 service areas (one of which is Hood River) “will have access to care through nine health systems: Asante, Bay Area, Columbia Memorial, Mid-Columbia, OHSU, Portland Adventist, Salem Health, Tuality and Willamette Valley. All plans will be available both on and off the health insurance marketplace.”
Conspicuous by its absence from that media release was any mention of Providence. So, why no more Providence?
“This comes about because of our decision to focus exclusively on partnerships with those health systems that commit to working with us on coordinated and integrated approaches to patient care,” Nicholas said.
“Our 2017 network features select health systems — including Mid-Columbia and Advenist — that are eager to partner in this approach. What exactly does this mean? The network’s innovative population-specific initiatives include cooperation on data aggregation, sharing analytics processes and best practices, and evidence-based coordinated care interventions, all designed to help guide people to the right care in the right place at the right time.”
Way Hamm of BCI Group says she is concerned that MODA customers may not be aware of the pending changes, even though notice has been sent directly to those buyers. Health insurance is a complex beast, but Way Hamm says the industry has been boosting network coverage and shifting costs to out-of-network care.
“The benefit of going to an in-network provider is that they’ve signed a contract to accept the insurance company’s payment as payment in full,” she says.
Bills reflect that agreement by listing a total charge, then the discounted amount covered by the insurer.
“If they go to an out-of-network provider, they haven’t signed a contract to accept insurance payment as payment in full. You’ll pay your out of pocket costs, plus an additional amount beyond what the insurance covers.”
For illustration, she says non-network customers of MODA who choose to use Providence providers will pay the full amount for every office visit, not just the $20 co-pay, until they meet the deductible.
The deductible will double.
And the big hit could come with a bill for the balance of charges waived for network providers.
She offered a comparison of premiums next year for the three insurers offering individual plans in Hood River County. These premiums reflect coverage for a non-smoking couple 40 years old with two children, buying a standard silver plan. Benefits are the same with each company.
- Moda – $1,218 per month
- Providence Health Plan – $1,064
- Regence Blue Cross Blue Shield – $1,411
- Bridgespan (operated by Regence, for tax credits under the ACA) – $1,467
“I would like it if everyone made an informed decision, that if they choose to stay with MODA, they know what they’re doing,” Way Hamm says.
The clock is ticking on the annual open enrollment period.
Dec. 15 is the deadline for a new insurance policy that will take effect by Jan. 1. If people miss that deadline, their current coverage would continue into January.
They still can change policies for 2017 if they make the change by Jan. 31.
If they change by Jan. 15, the new policy would take effect Feb. 1.
If they change between Jan. 15 and Jan. 31, the new policy would take effect on March 1.