Health Care

Overhauled will try to ease insurance shopping

The Obama administration plans major changes to this year to make it easier for shoppers to find health insurance plans that include their doctors and to predict their health care costs for the coming year.
The Obama administration plans major changes to this year to make it easier for shoppers to find health insurance plans that include their doctors and to predict their health care costs for the coming year. The Associated Press

The Obama administration plans major changes to this year to make it easier for shoppers to find health insurance plans that include their doctors and to predict their health care costs for the coming year.

With substantial premium increases coming in some states in 2016, administration officials are expecting that many people already in the Affordable Care Act’s networks will have to switch health plans and find new doctors as they scramble for cheaper alternatives. And millions more Americans could be receiving health insurance through health care marketplaces for the first time.

But insurers in many places are offering such a dizzying array of health insurance plans with so many subtle differences that potential buyers have struggled to determine which plan is best for them.

“Normal consumers just cannot assess the dollar consequences of their decisions,” said Robert M. Krughoff, president of the Center for the Study of Services, also known as Consumers’ Checkbook. “Is a $200 deductible with a $10,000 out-of-pocket limit better for my family than a $2,000 deductible and a $4,000 out-of-pocket limit?”

Changes coming to the federal website will include a tool that allows people to estimate their probable out-of-pocket and total costs under different health plans.

Some consumer groups already offer such tools. A more sophisticated version developed by Consumers’ Checkbook is already used in Illinois, and it will be available this fall in Missouri, Minnesota and Washington, D.C.

With the Affordable Care Act’s third annual open enrollment season starting Nov. 1, new features of will allow people to type in the names of their doctors, prescription drugs and preferred hospitals and see which plans cover them, administration officials said.

The effort to ease the consumer experience is driven by the administration’s push to reach the 10.5 million people who Sylvia Mathews Burwell, the secretary of Health and Human Services, says are still uninsured but eligible for marketplace coverage. Though 9.9 million people have received health insurance through the exchanges as of June 30, the law has far to go to reach the 21 million people the Congressional Budget Office estimated in March would be enrolled next year. Federal health officials say that target is too optimistic, but they have yet to announce their own goal.

The new search tools are important for several reasons. Most insurers try to hold down costs by creating networks of selected doctors and hospitals, and patients typically face higher costs if they go outside the network to obtain care.

Until now, people using generally had to visit the website of each insurer to see which doctors and hospitals were in its network and which drugs were on its list of preferred medications. That could be cumbersome and time consuming.

Insurers said the new tools could be helpful, but had not been fully tested. In any event, they said, if consumers have any questions, they should call the doctor’s office and the insurance company to confirm if a particular provider is in its network.

New research shows what is at stake. A study by HealthPocket, a technology company, found that nearly half of health plans sold in the federal insurance marketplace did not provide coverage for services outside the network, so patients bore most of the cost. A separate study by America’s Health Insurance Plans, a trade group for insurers, said that out-of-network providers typically billed patients for amounts far exceeding what Medicare pays for the same services.

Under a new federal rule, insurers must publish their drug lists and doctor directories in a “machine readable” format that allows software developers to manipulate the data for myriad purposes, just as they do with stock quotations and sports scores.

In the last two years, the federal marketplace tended to steer people toward health plans with the lowest premiums, even though such plans often have high out-of-pocket costs so consumers end up spending more.

The changes to will include a cost-comparison tool that allows consumers to estimate their probable out-of-pocket and total costs, including premiums, deductibles and other charges, under different health plans.

To make such estimates, the website will ask consumers if they think their use of medical care in 2016 will be low, medium or high, and the website then will provide an estimate of costs for each plan.

In making these calculations, the government takes account of a person’s age, sex, income and ZIP code. The website will show premiums reduced by the amount of any subsidies that a family may receive in the form of tax credits, but consumers can also see the full price if they want.

Some private groups have even more sophisticated tools. Krughoff’s group, Consumers’ Checkbook, has developed such a tool, based on more than 30 years of experience in providing advice to federal employees on their health insurance options.

The tool, already used in Illinois, will be available this fall to consumers in Minnesota, Missouri and Washington, D.C.

In addition, Enroll America, a nonprofit group trying to expand coverage, has developed a digital tool to help consumers estimate their likely out-of-pocket costs for each plan available in their area. Consumers can also use it to find health plans that cover their drugs and preferred providers.

Enroll America devised the tool with Clear Health Analytics, based in Stamford, Conn. To help estimate costs, they ask if consumers have any of 11 common conditions. The conditions include asthma, back problems, diabetes, heart disease and breast, lung and prostate cancer. Women are asked if they are or plan to become pregnant.

Anne Filipic, the president of Enroll America, said such tools could transform the experience of shopping for insurance.

“In the past,” Filipic said, “people often got stuck trying to pick a plan that was right for them. They found the process overwhelming. If people can find a plan that better meets their needs, they are more likely to stick with it and stay insured.”