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3 ways insurers can still avoid covering the sick

By Tom Murphy

Associated Press

Published: Wednesday, Aug. 27 2014 9:00 a.m. MDT

Updated: Wednesday, Aug. 27 2014 11:33 a.m. MDT

In this Sept. 5, 2013 file photo, an infusion drug to treat cancer is administered to a patient via intravenous drip at a cancer center hospital in Durham, N.C. Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul, but patient advocates still see wiggle room for companies to avoid covering the sickest and costliest patients. An Associated Press survey in 2014 found that some of the nation's top cancer centers were excluded from the networks of insurance plans sold on state exchanges.

Gerry Broome, File, Associated Press

Enlarge photo»

Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul, but there's still wiggle room for them to discourage the sickest and costliest patients from enrolling.

Insurance companies can exclude some well-known cancer hospitals or certain individual specialists who treat pricey conditions from the list of providers they cover under a plan. They can dissuade HIV patients from signing up for coverage by requiring heavy initial payments of the bill for their prescriptions. They also might simply wait for competitors to jump into a market first and take all the risky patients who were hungry for coverage.

Consumer advocates and industry insiders warn that insurers are using tactics like these to limit their coverage of the sick, which can make it difficult for the people who need insurance the most to find the right plan. Narrow provider networks, in particular, have become more common, especially in coverage sold on new public health insurance exchanges created by the overhaul.

"It's the same insurance companies that are up to the same strategies: Take in as much premium as possible and pay out as little as possible," said Jerry Flanagan, an attorney with the advocacy group Consumer Watchdog.

Insurers acknowledge that people may see changes in their plans. But they say prudent business practices, not discrimination against the sick, are the key factors behind the trends that have raised concerns. They also point out that if customers find a plan they don't like, they generally have plenty of additional options to choose from both on and off the exchanges.

They also note that the overhaul takes several steps to discourage them from avoiding costly patients. The law prevents them from marketing or designing a plan that would discourage someone from applying based on their health. It also calls for insurers to chip into a pool that compensates competitors who wind up with a more expensive patient population. That lowers their incentive for discouraging the sick from enrolling.

"Health plans now guarantee coverage for individuals and families regardless of health status," said Clare Krusing, a spokeswoman for the trade association America's Health Insurance Plans, or AHIP.

There are three major ways insurers still might shape healthier patient populations:

— FORM NARROW NETWORKS

Insurers can lower their chances for covering patients with expensive medical conditions like cancer and autism simply by limiting the number of doctors and hospitals in a coverage network. That would send those patients searching for coverage elsewhere because they don't want to pay expensive, out-of-network rates.

Narrow insurer networks might include only 30 percent or less of a market's hospitals, as opposed to 70 percent or more for a broader network, according to the consulting firm McKinsey & Co.

An Associated Press survey of the nation's top cancer centers this spring found that patients covered under the health care law could encounter barriers to access in many cases. For instance, MD Anderson Cancer Center said it is included in the networks of less than half of the plans sold on the Houston area's public insurance exchange.

Aside from excluding patients, narrow networks also can help insurers form a healthy customer base by lowering the cost of coverage. A narrow provider network gives insurers leverage to squeeze better rates out of doctors who want to be included in that network in order to get the insurer's business.

Better rates lead to lower premiums, and young and healthy people generally shop for insurance based on price.

"They're the ones that don't check the provider directory," said Bob Laszewski, a former insurance executive turned industry consultant.

Insurers say plans with narrow networks are among many coverage choices consumers can make when they shop for insurance, and they are not an attempt to dodge the sick.

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