GARNETT — It’s worth remembering, as the sign-up deadline for the Affordable Care Act’s health insurance marketplace draws near, that the exchange-based plan with the most inviting price may not be the best choice for the consumer, and may not include her local clinic or hospital or her primary care physician. KEILEN’S HUSBAND recently traded in his job as an over the road trucker for full-time employment as a sheet metal worker at Adamson Bros. Heating & Cooling, in Ottawa. The couple lost their health insurance in the bargain. Casting about for new coverage late last month, the Keilens contacted a local insurance agent for advice. The agent determined the couple was eligible for federal subsidies through the health exchange, a boon which would reduce their projected monthly premium from, according to Joyce, an unmanageable $1,000 to a steep, but ultimately affordable, $638. KEILEN IS A SLIM woman with deferent manners who, on the day we met, waited for me on her porch swing in heavy coat and gloves. She wore sunglasses and sneakers and thin blue tracksuit bottoms, which, when she is seated, reveal the arthritic bulges in both knees.
Even with the best counsel, the baffling rules laid out by the health insurance industry are enough to make the eyes water. And it’s a confusion only further inflamed — as it was for Joyce Keilen, 64 — when the insurance company itself trips over its own data.
Kansans looking to purchase health insurance on the exchange are limited to two carriers: Blue Cross Blue Shield or Coventry Health Care, Inc., a subsidiary of Aetna.
The Keilens consulted a Coventry broker, who was able to find the pair a “PPO Exchange” policy that seemed, at the time, to meet the couple’s requirements.
The most urgent of which was, for Joyce more than her husband, proximity. Her ailments — bouts of vertigo and advanced arthritis in her knees — make long car journeys difficult.
She and her husband and three dogs live in a small clapboard house four minutes’ drive from their home clinic, the Family Care Center of Garnett, which is a part of Anderson County Hospital, which is itself operated by Saint Luke’s Health Systems, in Kansas City. The couple purchased the policy with the expectation of continuing their care at this location.
A couple of weeks later, though, card in hand, Joyce arrived at the clinic’s front desk, where she was told her new insurance would not be accepted. Saint Luke’s does not participate in Coventry’s exchange network.
In a statement to the Register, Saint Luke’s explained its position: “[We] negotiate in good faith with many insurance carriers, some of whom provide products on the Healthcare Exchange, to provide fair reimbursement for the quality care we deliver.” And then went on to recommend Blue Cross and Blue Shields’s Kansas Solutions Exchange, whose reimbursements to Saint Luke’s are presumably deemed fairer than Coventry’s.
“They are hurting a little,” she said. “See, I double up. I take a pain pill, then I take arthritis pills on top of that, to kind of boost it. It’s not a strong pain pill, because I’ve got a weak stomach.”
Keilen removed her gloves and retrieved from one of the pockets of her green duffel coat her new Coventry insurance card, marked “PPO Exchange.”
“This is all they gave me. They simply said, at the clinic, that the doctors there don’t take it. And then at the hospital — the lady asked somebody else and she comes back and she says ‘We don’t accept this,’ so I said ‘Basically, we’re paying out every month for an insurance that is crap, and she said ‘Yes.’”
The problem, though, is not with the policy itself. CoventryOne — the designation given to Coventry’s marketplace policies — appears to serve most of its members well. And, if Keilen felt comfortable driving even 30 minutes — to Iola or Ottawa, say, both of whose largest hospitals and clinics participate in Coventry’s marketplace programs — then she, too, could receive the expected medical coverage.
Many insurance policies, whether purchased on the exchange or off, impose narrow network restraints on its members. It might be argued, in Keilen’s case, that having to drive 30 minutes is a mild sacrifice for the benefit of her reduced premium.
The problem, though, concerns Keilen’s expectations at the point of purchase, and the clarity of the information provided to her during the process.
According to a McKinsey & Co. survey from June of last year, “26 percent of those who indicated they had enrolled in an ACA plan were unaware of the network type they had selected.”
In Keilen’s case, however, the insurance company didn’t make it any easier. Coventry’s website, as of this article’s date, incorrectly lists Dr. Janell Jones of the Family Care Center — the Keilen’s home clinic — as accepting the company’s “PPO Exchange” policy. Multiple phone calls from the Register to Coventry’s member representatives — using Keilen’s member ID — yielded the same result. Even the Keilen’s Coventry broker, prior to helping the couple select a policy, claimed to have found the Garnett clinic listed among the participating providers.
In May, KSHB-TV, in Kansas City, reported a similar mix-up in which a pregnant couple selected a Coventry PPO Exchange policy on the basis of an online provider list in which the carrier had incorrectly listed the couple’s Saint Luke’s doctor as being in-network.
Coventry is looking into the matter in Garnett and has promised to contact the Register with its official response.
In related news, Gov. Brownback was in Garnett on Saturday, with jumbo, ribbon-cutting scissors, for the opening ceremony of the new 70,000 square foot Anderson County Hospital, which is scheduled to open its doors in earnest on Jan. 29.
The Keilens, meanwhile, are busy pursuing one of the Blue Cross exchange policies recommended by Saint Luke’s.
Open enrollment for the 2015 healthcare marketplace ends Feb. 15. Those wary of completing the forms on their own can contact a free, trained consultant. In Allen County, Navigators are located at the office of Thrive Allen County, 620-365-8128.
Tricky insurance rules plague area couple
