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Health Plan Summaries to include Balance Billing?

In a December 2, 2011 piece for LifeHealthPro, Allison Bell writes about the new standardized health plan guides that are required under PPACA. Most of the article is about the delays in the process of developing the Summary of Benefits and Coverage (SBC) mandates and the industry response to these. Ms. Bell states that:

“The concept is popular even with many Republicans who hate PPACA. Analysts at the Henry J. Kaiser Family Foundation, Menlo Park, N.J. recently surveyed Democrats and Republicans about PPACA and found when they asked about major PPACA provisions that the concept of requiring health insurers to provide standardized, easy-to-understand plan summaries had the support of 76% of the Republicans they polled.”

That said, there are still questions about what should go in the SBC and whether all plans and markets would be subject to the requirement. Ms. Bell reports that regulators want consumers to be able to use SBCs to compare plan provisions such as deductibles and co-payments as well as to compare the total out-of-pocket costs for some specific conditions. She also reports that consumer representatives note that there are many consumer complaints regarding the practice of balance billing.

This is something that I have had some recent experience with as a consumer’s advocate. Regular readers of this blog may know that my father is being treated for ALL – Acute Lymphocytic Leukemia. In working through all the insurance issues associated with his care and treatment, I have seen a different side of health insurance than I had previously. Up until my father’s diagnosis, I had made routine use of my own insurance. I provide health insurance for my full-time employees, and have asked for little contribution from them towards that coverage. So I have watched the premiums climb, as have all employers. Every year I have gone through a process of comparing plans to try and figure out the most cost-effective coverage for my business, my employees and my own family.

But until my father’s illness, I did not factor in the possibility of balance billing. I simply was not aware of balance billing. Perhaps I should have been, but the health insurance that we do here is limited – just to the kinds of policies that life insurance companies issue. We don’t represent health insurers; we represent life companies who also write some limited lines of health coverage. So when I was pouring over all the tables of co-pays and deductibles for the health insurance I was buying for my employees, and myself the truth is I didn’t know about balance billing. I didn’t know that out-of pocket caps weren’t really caps from the consumer’s perspective. They are only limits on what the insurer requires an insured to pay, but that doesn’t mean the out-of-network provider isn’t going to bill the insured directly for the difference – the balance – between what the insurer pays them and the full price of the service. There are no limits on that potential liability.

On this, I think the consumer representatives in this discussion have a strong argument that the SBCs are the place to explain and provide examples of how balance billing might operate if a patient receives out-of-network care. The example they suggest is one where there is an in-network ER visit when the ER physician is out-of-network. In my father’s situation, it was the hospital that was out-of-network and the physicians who were in-network, though they only had privileges at the out-of-network hospital. My father ended up having to change physicians so he would be admitted to a different hospital. He has gotten excellent care all along, but many of his treatment decisions have been based on balance billing exposure and none of us even knew it existed until he got sick.

If balance billing isn’t included in the SBC, is there another way consumers can be made aware of this issue?