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.

So how about plans without all those tiers? Carol ruled out HMOs, with their restrictive provider networks, as well as “bronze” plans, which would cover only 60 percent of her medical bills. She looked at something called the Personal Choice PPO Silver, with a premium of $695, but had a hard time figuring out what her total costs would be.
The sheet sent by the Blue Cross rep listed copays of $30 for primary care doctors, $70 for specialists, and $10 for generic drugs. But only some of the details about the plan’s high coinsurance rates were listed on the sheet. Further website research showed she’d have to pay 30 percent after the deductible for outpatient surgery and routine radiology services, for example, if she stayed in the network. The coinsurance would be 50 percent if she went out of network. (As we’ve pointed out, high coinsurance amounts are becoming the norm, and consumers continue to confuse smaller copays with the larger coinsurance costs.)

Carol understood the deductible, though. It was $2,000 in network and, according to the website, a whopping $10,000 if she went out of network. (The reform law’s limits on out-of-pocket spending generally don’t apply to out-of-network expenses.) “That’s crazy,” she said. “By the time I pay that, the year will be up.” She had just met the reality of today’s health insurance market—many policies these days are akin to catastrophic insurance, meaning policyholders pay most of their bills out-of-pocket before insurance kicks in. “I was so turned off by the deductible, I exited out,” she told me.

*****

The process had been exhausting, time-consuming, and confusing—and she wasn’t close to done yet. But at least Carol was making some progress in figuring out which plans didn’t work for her, and avoiding pitfalls by paying close attention to the fine print.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.