But Carol didn’t have enough details about the policies to sign up over the phone or on paper. She decided to investigate further, using the website of Independence Blue Cross. I had suggested that she ask about a document called the Summary of Benefits & Coverage, a good consumer disclosure statement; insurers are not required to provide these summary forms, but consumers have the right to receive one if they ask. But what Carol got from Blue Cross was not the official coverage document—it offered some details, but not enough to make a fully informed decision.
Furthermore, the premiums listed on the Blue Cross documents did not match the estimated ones she had seen on HealthCare.gov. Premiums on the website appeared to be as much as $200 lower, and the website had said they might be lower still if she qualified for a subsidy (she’s probably right on the cusp of eligibility). When she asked about the discrepancy, a Blue Cross representative told her the premiums on the government website were wrong. As she recounted the conversation to me, the rep told Carol he could send information for only three plans, but in her case he would make an exception and send eight—including two “platinum” plans and something called the Keystone HMO Silver Proactive. That one mystified her.
The Keystone Proactive model offered a fairly cheap monthly premium of $543, but the amount of coinsurance, deductibles, and copays for hospitals and primary care doctors varied according to “tiers.” For example, if Carol chose a Tier 1 hospital she’d pay $400 per day up to $2,000. If she chose a Tier 2 facility, her out-of-pocket amount would be subject to a deductible and she’d pay $800 a day up to $4,000. And if she chose a Tier 3 hospital she’d have to pay $1,250 each day after satisfying her deductibles. What did these tiers mean, she asked the insurance rep, who told her the tiers identify “cost effectiveness among providers.” What did that mean, she asked again, and the representative advised her not to buy that policy. Why? Because it was too hard to work with the tiers.
Carol asked me what the tiers meant, and I looked further on the insurer’s website. Blue Cross assured customers “all of the doctors and hospitals in our network must meet high quality standards,” but “some are able to offer the same services at lower cost”—and if a patient chooses a provider in Tier 1, they pay the lowest out-of-pocket costs. “You get control over how you spend your health care dollars,” the website advised. More control, maybe, but also another layer of complexity to an already super-complex task. And I had questions about how doctors and hospitals are chosen to be in each tier. Do they look at patient safety records when deciding which hospital goes in which tier? How do we know placement is not based on a financial deal between the insurer and the hospital? What went into the designation of a “Blue Distinction Center” for hospitals? I wanted to know more than that the hospital “meets rigorous quality standards” and “consistently demonstrates positive care results.” Earlier this week I called the communications office at Independence Blue Cross to ask my questions. To date, no one has returned my call.