Set Up for Failure

I've figured out why the Marketplace Health Plan I initially bought was so cheap. In most cases, they'll be able to collect the premiums without actually paying any claims. Here's how it works: This policy has some "not so fine print" which indicates that if you go to a specialist without a referral, you will pay a higher co-pay. Typically $40 more. (That's $40 the insurance company doesn't have to pay!) If you go to an out-of-network specialist (or any other doctor or facility) you will be responsible for the ENTIRE bill. And furthermore, it will NOT apply toward your deductible. (There's a whole lot of stuff the insurance company doesn't have to pay!!)

To be forewarned is to be forearmed - or so they say. When I went to my in-network primary care doctor, I expected him to refer me to a specialist that was in the network. But that's not what happened. And if I hadn't spent the two days prior to my appointment researching all the doctors (turns out there were two) in my network, I would have accepted that referral and gone happily on my way only to go into shock when I found out I would be responsible for the entire bill - which could be sizable considering that I've seen an orthopedic surgeon, had x-rays, I'm waiting on an MRI and may have arthroscopic surgery on my knee. 

Fortunately for me, I've been around the block a time or two with insurance companies. By the time you're over 60, you pretty much know most of the tricks they use to keep from paying your claim. I WILL navigate these shark-infested waters because I understand that I have to use a network facility and that the doctor must make a referral beforehand. Lots of phone calls and staying on top of people. But it will save me money in the long run.

But what of those poor souls who are finding themselves insured for the first time? I think they'll go along to their primary care doctor and get referred to an out-of-network doctor or facility. They won't understand exactly what happened that caused them to be responsible for the bill rather than the insurance company. It's like letting the insurance company off on a technicality. Then the general consensus will be that "this Obamacare is a load of crap". And in this particular instance - that would be a correct assessment. But the blame should be resting squarely on the shoulders of the insurance companies who chose to implement those plans in that way.

I'm fortunate that I found out about the deficiencies of this plan early while it's still open enrollment. I got my insurance agent to put me in a different plan - one that has more provider options and doesn't require referrals. (Yes, I pay almost twice as much for it, but I think it's going to be well worth it.)