Highmark canceling some ACA plans

Nov. 15--As a licensed health insurance agent, Sam Ross was used to seeing changes slipped into customers' plans during open enrollment season.

But he was surprised this month when he opened a letter from Highmark. The 60-year-old Southmont man discovered that his current plan, the Highmark Shared Cost Blue PPO 1000, which was eligible for premium tax credits on the Health Insurance Marketplace, was being discontinued -- and that he automatically would be enrolled in another plan not on the marketplace if he didn't take action before Dec. 15.

A Highmark representative said the company mailed letters to some customers -- though he wouldn't say how many or provide a list of plans being discontinued.

The company is "mapping" some customers on plans that are being discontinued into new plans, he said.

Factoring in the tax credit, the new plan would have cost Ross $481.02 more a month. It didn't come close to offering similar coverage, Ross said.

"It's not even comparable," he said.

"It's vastly inferior."

The new plan to offer family coverage for Ross and his wife, he said, included higher deductibles -- $5,000 more per individual and $10,000 more for family -- thousands higher in maximum out of pocket in-network, triple his current copays for primary care physician visits and 40 percent coinsurance.

Ross said he's shocked that he wasn't at least being rolled into another marketplace plan, where he could have taken advantage of premium tax credits, and he worries that consumers who don't pay attention to notices may find themselves in a financial bind when new policies take effect.

"I get it," he said. "(Highmark is) trying to find their way through a brave new world of healthcare. I don't understand, though, why Highmark wouldn't have automatically put me into an (Affordable Care Act) policy."

'Not sustainable'

Highmark spokesperson Aaron Billger said the company's Affordable Care Act offerings proved far more costly than expected, prompting the company to drop some plans. He said some consumers have been "mapped" into new coverage -- though they're encouraged to compare products.

"Highmark has been forced to modify ACA plan offerings for 2016 to maintain financial viability of the products," he said. "We've been paying more in claims than we are collecting in premiums for ACA products."

As of June 30, the company had lost $318 million on those plans, he said.

"Those losses are not sustainable," he said. "We must charge what the products actually cost to administer. Like any business would, we're making necessary adjustment to the plan offerings to keep them financially viable but to also make it simpler for consumers who are picking plans. We had multiple products with numerous plan options.

"We are just narrowing the plan options."

The company requested average rate increases of 25 to 30 percent for western Pennsylvania rates, Billger said.

The Pennsylvania Insurance Department approved smaller increases. For the six companies that proposed rate hikes above 25 percent, including Highmark, state insurance Commissioner Teresa Miller requested the companies phase in increases over additional years if necessary. The commission approved 19 companies to offer individual health insurance plans under the Affordable Care Act in Pennsylvania for 2016.

Highmark's financial viability was impacted by use of healthcare services, Billger said. Close to 50 percent of Highmark's Affordable Care Act enrollees were new to insurance, he said, and they came with a bevy of expensive health issues.

Those customers had 49 percent more chemotherapy claims than commercial members and a rate of congestive heart failure at 43 percent higher than commercial customers, for example.

"They have far more medical needs than we could have anticipated," Billger said. "The ACA certainly expanded coverage for people. We want to be able to offer products to everyone. Why, we are modifying our plans so they are simpler for consumers to choose and multiple plans in every county."

Automatic enrollment

"Mapping" consumers into new coverage is one step the company took. Affected customers should have received the letters within the past month.

"Many consumers whose plans may have been discontinued are mapped to a similar plan, but consumers need to make sure they feel comfortable," Billger said, adding that the company has provided extended customer service hours.

"They are sometimes automatically enrolled. That's why it's important to shop for the coverage that best meets your health care needs.

"People should call the number in the letter to ask questions about the plan and be sure to go to the federal marketplace to compare plans to make sure that one is best suited to them," Billger said. "We've notified customers of their plan changes so they would have more than enough time to shop for another Highmark plan or another offering in the market."

Dec. 15 is the deadline for Jan. 1 coverage. The marketplace, accessible at Healthcare.gov, lists what's available from Highmark and other regional insurers.

"We know there's a lot of competition," Billger said. "Some health insurers have elected to leave markets. We have multiple plans available in all 62 Pennsylvania counties we serve."

Broad impact

At Your Health Insurance Shop, a Benefits Network company, more than 80 percent of clients with individual insurance in the Somerset area will be impacted by the changes being made by Highmark, according to Benefits Network President and CEO David Straight. Benefits Network was notified on Oct. 27 that Highmark will be dropping a number of plans, going from about 25 plans down to eight or 10.

"The most popular plan designs are being discontinued, so it is important that clients watch their mail and take action," Straight said.

The Highmark changes have caused some confusion in the marketplace this year, Benefits Network marketing Vice President Susan K. McKee said.

"Since open enrollment began on Nov. 1, we have consulted with a record number of Highmark clients," she said. "We are making every attempt to explain why the changes were made and to help them re-enroll in a plan that more closely matches what they purchased initially and that is eligible for tax credits and subsidies, if applicable."

While Highmark had the most sweeping changes, other carriers like UPMC Health Plan, United Health Care, Aetna/Coventry and others also have made plan modifications, according to the company.

As for Ross, he shopped the marketplace -- and found that a UnitedHealthcare Gold Compass 1000-1 was most similar to his current coverage and premium. He worries that others won't take the time to compare, though, he said.

"I do know from firsthand experience there are people who put that stuff aside and then they're caught by surprise," he said. "You do get a lot of mailings."

UPMC's portfolio

While all major insurers filed for rate increase approvals, including UPMC Health Plan, UPMC representatives said the company's was the lowest increase -- at 9.9 percent -- according to John Mills, UPMC Health Plan consumer products senior director.

The company also is offering the silver marketplace plan -- and it is not discontinuing any plans, Mills said.

"Our portfolio is the same as it was in 2015," he said.

For Cambria and Somerset counties, the company is offering eight individual plans in its Premium Network: one platinum, one gold, four silver, one bronze and one catastrophic.

As for increased costs from an influx of customers through the marketplace, Mills said those numbers still are being evaluated.

"We don't really have a good idea yet of all the new membership who came in in January (2015)," he said. "We'll have a better idea next year."

Customers may have benefit changes, he said.

"Every individual plan has to fit within the actuarial values of bronze, silver, gold and platinum," he said. "Because they adjust the actuarial value, the calculation changes every year.

"There were a couple plans to make minor adjustments to.

"Otherwise, our portfolio is the same as in 2015."

Aside from considering cost and networks, Mills said, more consumers also may want to consider value-added benefits.

Another change this year to the healthcare.gov website, he said, should allow consumers to more quickly assess whether their doctors are in a network.

Comparing options

To help locals understand changes or compare current coverage with other options, Conemaugh Health System offers free sessions with one of five Certified Healthcare Access Associate financial counselors.

Rita Jones, one of the system's counselors, said she expects more people will be looking for plans on the marketplace.

"This year is going to be the year we'll see a lot more people than we have before," she said.

"That first year, folks weren't believing it. Last year, it was starting to be absorbed. This year, it's becoming a reality. I've seen a lot more patients who already have coverage through health care reform than prior."

The system's counselors are to provide objective help, she said.

"We're there for the consumer as far as not pushing one insurance company or the other," she said.

"We just want to help you be more informed as to what each has to offer. It is so confusing.

"We'd love to help those who aren't sure."

One of the most important measures, Jones said, is to carefully review renewal information.

"We usually hear after the fact, 'I didn't know that (change) was part of this,' " she said.

"Please, make the time to look at your paperwork, at least biggest parts -- deductibles, copays, what will be covered. There have been patients who said, 'When I initially got coverage, they took care of this. Now, I don't have the coverage.' Unfortunately, that happens because they assume it's the same as last year."

Kecia Bal is a reporter for The Tribune-Democrat. Follow her on Twitter @KeciaBKay.

Kecia Bal is a reporter for The Tribune-Democrat. Follow her on Twitter at @KeciaBKay

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