Molina Dodges Rules on Marketplace Coverage

Update: Check out related article: State’s Health Insurance Marketplace Toxic to Entrepreneurs, Self-Employed.

I consulted an insurance agent last month to assist me in selecting a marketplace plan for 2019. Since I’d had my brain surgery, radiation and continuing care at Swedish Hospital, she recommended Molina health insurance. Swedish was in network with Molina.

So, she was surprised when I told her that Molina left Swedish off its list of anesthesiology providers. Swedish was too. The hospital’s media department said it was, “glad you brought this to our attention.” But it still hasn’t updated its webpage:

Why would it? The primary enrollment period is over. Most patients can’t change their plans til 2020.

As I understand it, Molina provided materials and training to regional insurance agents to help them stay informed about its marketplace. And, on page twenty of this 2018 presentation entitled “Marketplace Hospitals by County”, Molina lists “Swedish Medical Center” and “Swedish/Issaquah Hospital” as in network.

The agents then spread this information in the act of recruiting customers to Molina.

Technically, Molina disclosed that Swedish anesthesiology was uncovered through omission of the hospital from its provider list .pdf. This is the kind of business innovation that makes Molina’s stock nearly indistinguishable from Amazon’s.

The company’s Director of Public Relations, Laura Murray, refused to speak to me. But after ten days, she emailed calling the anesthesiology gap, “balance billing”:

Molina Healthcare is committed to paying providers accurately and appropriately according to the terms of every member’s coverage. We recognize that balance billing is an industry-wide problem, and Molina continues to support legislative initiatives that provide guidance for providers and health plans around balance billing that serve to protect consumers from balance billing surprises. We look forward to continuing to work with the legislature and regulators to develop a solution to this problem in Washington.

Laura Murray, Director of Public Relations, Molina Healthcare

But once Molina trained insurance agents that Swedish is in network, it’s not balance billing, it’s technically surprise billing. Anesthesiology isn’t occasionally uncovered at Swedish when an out of network specialist is the only one available, it’s always out of network. Surprise!

After another week, Murray emailed that Molina covers anesthesiology at Swedish for approved surgeries:

Molina Healthcare’s Marketplace plans do provide anesthesiology coverage at Swedish for approved surgical services, and we will continue to do so.

Laura Murray, Director of Public Relations, Molina Healthcare

But Swedish confirmed to me that its anesthesiology provider is out of network with Molina. There is no out of network coverage on any of Washington’s four oligopolist marketplace plans.

While Ms. Murray says Molina covers anesthesiology out of the goodness of its heart, she refused to answer my request for specifics, such as what percent is covered? Her silence indicates that Molina provides only the dollar amounts it chooses to for your Swedish anesthesiology. The amount is outside the regulation of the Washington State insurance commission.

In fact, Molina’s tiny gesture breaks the structure of the marketplace, as its four EPO plans provide zero out of network coverage.

Maybe Molina would be willing to pay a small amount for me to stay with my doctor of nine years or my long term counselor. Sadly, not.

Washington’s marketplace health insurance system is badly broken. It probably has something to do with our laissez faire, corporatist democrats and the industry’s fifty registered state lobbyists.

You can read more about it here: State’s Health Insurance Marketplace Toxic to Entrepreneurs, Self-Employed.

What’s clear is that the regulated protections promised by the ACA and overseen by the legislature and the Office of Insurance Commission (OIC) have been dodged here. Molina misled insurance agents whose job it is to inform customers about their offerings and who get paid a fee for every recruit. Swedish misled patients by not disclosing the anesthesiology gap on its Molina page.

If you’re a Molina customer who isn’t covered in full for anesthesiology at Swedish Hospital:

  1. Ask Swedish to pay the difference
  2. File a complaint at OIC
  3. Consult a local attorney, perhaps one who specializes in class action cases
  4. Primary your corporatist, privatist, for profit, health insurer/Microsoft/Amazon/Boeing-friendly legislator for 2020. See Run for Something.

The OIC is asking the legislature to reconsider its 2017 surprise billing regulation. The industry appreciates the legislature’s willingness to debate small incremental reforms which take several years rather than providing a meaningful public plan.

Related Links

Posted by Jeff Reifman

Jeff is a technology consultant based in the Pacific Northwest. Check out Portland Wild, a visual map-driven guide to Portland's public art, its Heritage Trees and its Little Free Libraries.

Leave a reply

Your email address will not be published. Required fields are marked *