There is a quiet buzz emerging from some Commonwealth Care members and member advocates about Commonwealth Care members being locked into specific health plans. (As a general rule, upon enrollment and subsequent eligibility redetermination, Commonwealth Care members have 60 days to change health plans, and then remain members of their plan for one year.)
Certainly, the concept of a lock-in is not unique to the Commonwealth Care program; an annual lock-in is the norm for every person involved in employer-sponsored insurance. The imperative of the lock-in is to create a stable population with reasonable plan tenure. This is a fundamental concept of insurance and affords continuity of engagement with a health plan’s services.
Behind the buzz about the lock-in lurks a larger issue.
While price is obviously a factor in plan choice for premium-paying Commonwealth Care members, the debate around the lock-in rests solely with fully subsidized members. That’s because these “eligibles” are the only ones subject to “auto-assignment” to a plan, assuming they do not choose a plan within 14 days of enrollment.
So, what’s the underlying issue? All Commonwealth Care plans are mandated to offer the same benefits package, which is a product akin to Medicaid — very robust, very comprehensive. The issue lies in the pockets of providers choosing not to do business with all participating Commonwealth Care health plans in their areas. Interestingly, in these pockets are health centers and hospitals that have traditionally been considered part of the safety net health system, with strong missions to care for underserved populations.
The Massachusetts commercial market seems not to have experienced similar issues around what might be characterized as market exclusivity or semi-exclusivity. The vast majority of Massachusetts providers and hospitals participate with the majority of commercial carriers, including Tufts Health Plan, Harvard Pilgrim Health Care, Blue Cross Blue Shield. Although commercial business represents a very small percentage of safety net providers’ payer mix, there still has been a willingness to openly participate with all interested commercial health plans. Presumably, this approach assists them in ensuring that their doors are open to all members of their communities. In the experience of Network Health, this unwillingness to contract with MCOs has not been driven by an articulated, legitimate business reason, such as a lack of competitive rates or poor member satisfaction.
Let’s take a real scenario to illustrate the implications to this issue: A provider chooses not to contract with MCO X. Patients present for care to this provider, and they are enrolled with MCO X — the same MCO that the provider declined to contract with. As a result, the provider complains that the member is experiencing access-to-care issues and needs a longer opt-out period! You don’t need to be vascular surgeon to deduce that the real issue may not be the lock-in, but rather an issue of providers engaged in selective contracting. Unfortunately, this tactic unfairly places members at the center of the issue.
So what’s the cure? Extending or eliminating the lock-in period will not solve the problem. No, the answer is providers engaging in contracting opportunities with health plans offering state-subsidized insurance in a manner that is comparable to the way they engage the commercial health plan market.
Ultimately, we hope that MCO enrollment for Commonwealth Care is driven by meaningful factors like monthly costs and health plan quality. Limiting access to markets runs counter to some of the core principles behind health care reform; it is only through fair and open contracting that health care reform can flourish and true member choice can be assured.
Christina Severin is executive director of Network Health, a health plan with more than 116,000 low- and moderate-income members with state-subsidized health insurance across Massachusetts.
Another issue with the lock-in is the interplay between the deductible/OOP limits and the calendar. According to one of the plans I contacted (but not all of them, apparently), they calculate the deductible and OOP limits on a calendar year basis, while the lock-in goes from the anniversary date. So for everyone who joins initially on July 1, they will always have a July 1 anniversary date, with apparently no way to change that. But their deductibles will be on a different schedule. So for the first six months, they’re subject to a full annual deductible, and if they ever change plans in mid-year, they’ll be subject to a double deductible – one for the first six months and one for the last six months.
I don’t know if I’m getting incorrect information, but that’s what one of the plans told me on the phone. I’m choosing to go with another plan where they told me that their deductible follows the same plan year as the joining date.
How sad, tragic really, if the author of this post is a good hearted caring individual. Because she has clearly BOUGHT IN to the horribly harmful and wasteful concept of treating health care as a “market” driven commdodity instead of as the essential human service that it is.
Can’t you see that this approach is FAILING US ALL??!!!!! It’s a huge rip-off financially, it results in huge numbers of people without insurance or with crappy insurance, and it drives quality of care into the toilet.
You ask “So what’s the cure?”.
A very good question, but again, tragically, you miss the boat with your answer, which was:
“Extending or eliminating the lock-in period will not solve the problem. No, the answer is providers engaging in contracting opportunities with health plans offering state-subsidized insurance in a manner that is comparable to the way they engage the commercial health plan market.”
JUST LISTEN TO YOURSELF AND THE GOBBLDYGOOK YOU ARE SPEWING – YOU”RE NOT TALKING ABOUT HEALTH OR HEALTHCARE!!:
“The Massachusetts commercial market seems not to have experienced similar issues around what might be characterized as market exclusivity or semi-exclusivity. The vast majority of Massachusetts providers and hospitals participate with the majority of commercial carriers, including Tufts Health Plan, Harvard Pilgrim Health Care, Blue Cross Blue Shield. Although commercial business represents a very small percentage of safety net providers’ payer mix, there still has been a willingness to openly participate with all interested commercial health plans. Presumably, this approach assists them in ensuring that their doors are open to all members of their communities. In the experience of Network Health, this unwillingness to contract with MCOs has not been driven by an articulated, legitimate business reason, such as a lack of competitive rates or poor member satisfaction.
Let’s take a real scenario to illustrate the implications to this issue: A provider chooses not to contract with MCO X. Patients present for care to this provider, and they are enrolled with MCO X — the same MCO that the provider declined to contract with. As a result, the provider complains that the member is experiencing access-to-care issues and needs a longer opt-out period! You don’t need to be vascular surgeon to deduce that the real issue may not be the lock-in, but rather an issue of providers engaged in selective contracting. Unfortunately, this tactic unfairly places members at the center of the issue.
So what’s the cure?”
—-
THE ONLY REAL LASTING CURE IS IN EXCISING THE CORPORATE PROFITEERING (practiced by both for-profits and by many large “non-profits”) OUT OF OUR HEALTHCARE SYSTEM. WITHOUT FURTHER DELAY.
Please visit http://www.SickoCure.org to learn more about “The Cure” and to get involved, and visit http://www.Sicko-movie.com to share your story.
Help us to launch the Massachusetts Citizens’ Revolt to the greed-driven Mass. Mandated Insurance faux reform law. Be a part of enacting a lasting and effective cure – Healthcare for People, Not For Profits at http://www.DefendHealth.org
Thank you. Ann, RN
The Commonwealth Care lock-in has definitely created access problems for some patients. It is hard to believe the problem lies with providers perversely unwilling to join the networks of some CommCare plans but not others.
It seems far more likely that some hospitals have not joined some plans because they are offering lower reimbursement rates & that without these local hospitals in the network, local providers who have referral relationships with local hospitals can’t join the network either.
The 4 plans are charging the Connector very different amounts to provide the same level of benefits. Default enrollments go to the plans charging the Connector the lowest rates.Presumably one reason some plans are charging the Connector less is because they are paying network providers less.
In other words, it’s aout the money & patients are caught in the middle.
For patients, some protection should lie in the Connector’s contract with the plans. Unfortunately, the contract includes only the most minimal requirements for provider networks. For example, plan networks are required to have only one hospital per county.
The long term solutions to all this may be a single payer system, but in the short term a lock-in policy that allows patients more flexibility to switch plans and network capacity requirements that better reflect prevailing standards would help a lot.