With only five weeks remaining for Long Island individuals to replace their cancelling health insurance policies on 1/1/14, the pressure is on for people to make a decision on a new plan via the NY Exchange website. However, as shoppers continue to work with licensed insurance brokers in determining if their existing doctors & hospitals are participating in the new exchange plan provider networks, they are coming to the realization that most of the competitively priced plans that are available are not being accepted by a good portion of their providers.

After having a telephone conversation with a reliable source (who wished to remain anonymous), this office has learned that not one health insurance plan being offered on the NY Exchange website will be accepted by Stony Brook Hospital (SBH). “The reimbursement rates just aren’t there”, the source has said. This presents a major problem for Suffolk County individuals who require elective procedures being conducted at this facility. “We will continue to be working with existing provider networks. However at this time, unless the new on-exchange provider networks increase their reimbursement rates, we do not plan to participate in them”, the source went on to say. Unfortunately, the majority of existing provider networks accepted by SBH is only obtainable through employer-sponsored plans.

Individuals wanting to have access to Stony Brook Hospital will need to secure a new plan outside of the NY Exchange website via broker-assisted paper applications. But even in the off-exchange individual market, very few plan choices are available that will give people access to this facility. Moreover, premium subsidy assistance is only available to individuals who enroll in on-exchange health plans, making these off-exchange individual coverage options very difficult to obtain due to their high price tags.

Given the Affordable Care Act’s new minimum Essential Health Benefits requirements for all health plans (which drives up costs), the only way to keep health insurance prices “affordable” is by scaling down their provider networks, and/or lower their reimbursement rates to providers. This represents the majority of the on-exchange plans unfortunately. All carriers (old and new) offering on-exchange health insurance plans on Long Island have reacted to this by creating new “narrow” provider networks. For example, individuals losing their Healthy NY coverage written through Empire currently have the Empire “HMO” network. Under ObamaCare, Empire will be offering their new “Pathway X” network, which has significantly less providers than the incumbent “HMO” network. Oxford has also created a new “Compass” network, which has about 85% of the providers available in their existing “Liberty HMO” network. The list goes on…

Because off-exchange individual health policies are not subject to the same cost controls as on-exchange individual health policies as mandated by the Affordable Care Act (ACA), carriers (if they wish) can choose to write off-exchange plans using larger provider networks, and which pay higher reimbursement rates to providers. An example of this is United HealthCare/Oxford, which is offering an off-exchange individual health plan utilizing the “Liberty HMO” network…the same network that is available to small and large employers on Long Island, and which provides SBH access to its subscribers. The Platinum-level single rate price tag: $965 per month, which carries a $2000 deductible, plus 10% coinsurance. At the other end of the spectrum, the Bronze-level single rate price tag is $590 per month, which carries a $3000 deductible, and 50% coinsurance. Child-only rates are also available. The rate card below shows all available medal grades for this UHC/Oxford plan.

United HealthCare Oxford – Individual Off Exchange Health Plan Options

As demand for specific providers increases over time, hopefully ACA regulations will change where more expansive provider networks will become available on-exchange. Until then, the only way for LI individuals to gain access will be through limited, off-exchange plan options. For more information or enrollment assistance with UHC/Oxford individual products in downstate New York, contact an insurance broker.