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Affordable Care Act

Narrow Networks Frustrate Houstonians Shopping For Individual Health Plans

In an individual health market bereft of “out of network” options, Humana has offered a last-minute health plan for 2016.



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Houstonians who purchase their own health insurance have been upset recently over fewer choices and higher prices for 2016.

In the Houston market, major insurance carriers decided they weren't going to offer any PPOs for 2016 – PPOs are Preferred Provider Organizations, the type of insurance that allows you to go out of network.

Most of the remaining plans, a mix of HMOs and EPOs – which use closed networks – did not include prestigious specialty hospitals such as MD Anderson Cancer Center or Texas Children's Hospital in their networks.

"It has been affecting my clients greatly,” said Jo Middleton, an insurance agent in Houston. “It has been a very big challenge trying to navigate: ‘Are the doctors in network?'"

With just a few weeks left before the new year, Humana announced Wednesday it has reversed course and is going to offer a PPO in 2016 for many Texas markets, including Houston.

Midleton says the plan will include MD Anderson, which should reassure some of her clients. On the other hand, it will have a deductible of $6,450, she said.

"This is the one option, the one plan,” Middleton said.

In addition, Middleton says the Humana plan is not available on so-called "Obamacare exchange," where many people can access federal subsidies to help pay the premiums on individual health plans.

It is only available “off exchange,” where consumers will have to pay the full premium price.

Middleton says her clients are getting frustrated with the narrow networks offered within the individual plans.

“What I'm getting is ‘I want to be able to see this cardiologist. I want this pediatrician for my child. I want this hospital in my network. I want this ob/gyn, this PCP (primary care provider),’ and my challenge is trying to find them all within the same plan,” Middleton said. “So it's coming down to you've got to pick and choose who's important, because I likely can't give you all of them in the same network.”

The increasing restrictions in the insurance market have many causes, and some have nothing to do with the Affordable Care Act. Before the the law passed, insurance companies had already been tightening their networks of doctors and hospitals, and raising deductibles and co-pays. In many cases, corporate employers pushed for those changes to keep their health care costs down.

But the 2010 Affordable Care Act also requires insurance companies to issue coverage to all consumers, including those with pre-existing conditions. Other parts of the law mandated the coverage of benefits that some plans had previously excluded, such as mental health and pregnancy. That has increased medical claims and prompted insurance carriers to raise premium prices.

“This has been the biggest mess since the law has passed. This year has been the worst year that I've had to deal with people under 65 helping them with their insurance,” Middleton said.

Premiums vary by age, market location, and type of plan selected. One commonly-used comparison is the average cost of a benchmark “silver plan” on the Obamacare marketplace. In Texas, the premium for that plan rose an average of 5.1 percent from 2015 to 2016. This is actually lower than the national increase of 7.5 percent.

Humana did not respond to a request for comment before deadline.


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