How risky is it not to have coverage at Vanderbilt?

Nashville consumers have two carrier options for individual ACA plans in 2018 — Cigna and Oscar Health — but only Cigna offers coverage at Vanderbilt. Does every consumer need to be covered at the city’s academic medical center?

Realistically, no. Some consumers may have no healthcare needs next year, or only very basic needs that do not require going to Vanderbilt.

But the decision does carry some risk. There are some services that only Vanderbilt provides, and if you choose an Oscar plan without coverage at the hospital, some say that you would be effectively uninsured for that care.

Technically, however, if what you needed was truly only offered at Vanderbilt, you could have some coverage because of a concept referred to as “network adequacy.”

When would network adequacy come into play?

How to navigate choosing health insurance — at work or on your own

What is a network?

An insurance network is the group of doctors and hospitals with whom your insurance company has contracted. The carrier negotiates with the providers, and you typically pay less to visit in-network doctors than out-of-network doctors. 

With some health insurance plans, you may have “out-of-network” coverage. This means that your insurance company will contribute something to the cost of out-of-network care. However, in these situations, your insurance will generally not cover the full cost, and you can be “balance billed” for the rest of the charges. 

Neither Cigna nor Oscar offer out-of-network coverage. This is important, because it means consumers with Oscar Health insurance are not covered, at all, at Vanderbilt facilities. There are two exceptions — in the case of an emergency, and if Oscar’s network was deemed to be inadequate for what you needed.

Is the network adequate? 

So how is it determined whether a network is “adequate”? In general, the analysis centers on whether you can get the care you need from other providers who are in-network in a reasonable amount of time and within a reasonable distance.

If you discovered that there were no pediatricians in-network on a plan that covers your child, or that the only in-network pediatrician was three hours away, you would probably feel like that network was not very adequate. 

That example is pretty over-the-top. More common network adequacy issues occur around very specialized care — like the kind often provided by Vanderbilt. 

For example, Vanderbilt has the city’s only pediatric cardiac ICU. If your child needed that care and Vanderbilt wasn’t in your network, arguably, the network could be deemed to be inadequate. 

“Arguably” is important, because state standards on this issue that apply to marketplace plans are difficult to find. Carriers aren’t required to cover Vanderbilt, even though it provides care that no other facility in the area can provide. This puts consumers in a pretty challenging spot, where their insurance plan might cover the care they need, but not the hospital where they can get it.

Consumers might also experience “gray areas” of network adequacy. 

For example, let’s say you have COPD — chronic obstructive pulmonary disease — and diabetes. Acme Hospital Network has a doctor who is specifically trained in this “comorbidity,” which is a term used for concurring diseases. Beta Hospital Network has multiple physicians who can treat both, but no one trained in treating both at the same time when both are present in a single patient. 

Many consumers would feel like they might get better care from Acme’s doctor who is specially trained in these two conditions, rather than coordinating with multiple Beta doctors. 

But because the Beta network has physicians to treat both those disorders, the insurance company that offers the Beta network might decide that their network is plenty adequate. A consumer could appeal to the insurer and argue that the network is not adequate, and petition for coverage. If granted, that coverage would not necessarily cover the entire cost, but the consumer may at least get some help.

The availability of requesting a network adequacy exception can be a valuable option for healthcare consumers. While there are never any guarantees that one will be granted or that it will cover the entire cost, the fact that it is available should not be forgotten by healthcare consumers when analyzing the options.

Alex Tolbert is the founder of Bernard Health, a company that provides noncommissioned, expert advice on health, Medicare and COBRA insurance and medical bill consulting. To learn more about Bernard Health, visit www.bernardhealth.com.