Community clinics now face insurance haggles

Posted: February 10, 2014

Community health centers never put much effort into the kind of high-pressure haggling over insurance company contracts that many hospitals and large medical practices engage in. With maybe 10 percent of patients covered by commercial plans, it didn't matter.

Suddenly, it does.

Some of their uninsured patients are now eligible to buy subsidized commercial coverage on the marketplace set up by Obamacare. The most popular new plan in Southeastern Pennsylvania puts providers in tiers that set copays and deductibles.

Formerly uninsured patients may now find copays are unaffordable at the health center where they have received care on a sliding scale for years.

Particularly galling to health centers, the tier assignments are based on costs - not their costs, but those of nearby hospitals.

"For Blue Cross, the most expensive thing is inpatient admissions," said Susan Post, executive director of the Esperanza Health Center. Temple University Hospital is the nearest, and doctors at the clinic have affiliations that allow them a role in their patients' in-hospital care. They generally have sent patients to Temple.

But Temple is costly. Independence Blue Cross' Keystone HMO Silver Proactive plan put the hospital and the clinic in Tier 3, with the highest out-of-pocket costs.

After Esperanza pleaded its case, IBC "gave us a waiver for a year," Post said, putting the center in Tier 1 while it works to send patients to cheaper hospitals such as Einstein and Hahnemann.

IBC spokeswoman Ruth Stoolman said half the region's health centers are now Tier 1, with the rest split between Tiers 2 and 3.

Other centers said they, too, had sought reconsideration, some successfully. The city, which runs eight clinics, said the insurer changed some but would not alter its two centers in West Philadelphia because no Tier 1 hospital was nearby.

Most of the big teaching hospitals are Tier 3; all children's hospitals are Tier 2.

On paper, the differences in patients' out-of-pocket costs are large. A primary care visit copay is $20 for Tier 1, $35 for Tier 2, and $50 for Tier 3. Inpatients pay $400 a day at Tier 1 hospitals, $800 at Tier 2, $1,250 at Tier 3.

But silver plans like HMO Proactive are popular mainly because, besides premium subsidies, they offer discounts on copays and deductibles for people with incomes between 100 percent and 250 percent of the poverty level.

An individual with an income of $15,000 (131 percent of poverty) in the Silver Proactive plan would pay $5 for a primary care visit at a Tier 1 provider, $10 for Tier 2, and $15 for Tier 3, Stoolman said - each about one-quarter to one-third of the full copay.

Thomas Vincz, a spokesman for Horizon Blue Cross Blue Shield of New Jersey, the largest insurer in South Jersey, said its Advance EPO plans assign tiers to hospitals but not health centers.

215-854-2617 @DonSapatkin

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