By Guy Furay
The combination of these two words is JARRING. GRATING. UNNERVING. And it can make your blood boil just thinking about it.
My name is Guy Furay and I love INSURANCE. I get the opportunity to help people with something really important---something that really matters. I’ve spent my entire career in the health insurance field and I can truly say I love what I do. I help people every day.
Insurance is an absolutely critical product. It can and should be a great safety net---protecting our entire financial lives from the impact of an unforeseen illness.
INSURANCE really matters. It’s like an umbrella that protects us from the heavy rains when they come as they do.
But what happens when an insurance plan fails to cover us? What happens then???
If you live in Greenville County and you buy your own individual or family health insurance, you may be about to find out that answer. Have you ever heard of the Latin phrase “Caveat Emptor?” It means “Buyer Beware.”
What do I mean by all this?
In 2021, there will be a new competitor named Molina Healthcare. That’s great! We always welcome competition in the market. However, it appears that Molina Healthcare did not believe it was necessary to develop a network of hospitals or physicians for people who buy their product to use. That’s right…you read that right. Customers who buy a Molina product do NOT have access to either Bon Secours St. Francis or Prisma Health. So, they would be buying a health insurance product and literally could not be able to use that product in Greenville County.
Insurance departments EXIST for this very reason: To protect consumers and make sure that any and all insurance sold in the state of South Carolina meets appropriate standards. Please read an important memo from the South Carolina Department of Insurance:
Reflecting the critical importance of this issue, the South Carolina Department of Insurance issued this memo to all insurers in South Carolina as recently as January 2020, and you will notice that these notices refer to Appendix C: Network Adequacy Standards.
As you can see, the importance of network adequacy is very important.
1. The issuer must have a network of providers, including primary care physicians, hospitals and specialists. The network of providers must meet any additional standards set forth in § 1311 (c)(l) of the ACA as further defined in 45 CFR Section 156.230.
2. There must be a network within a reasonable distance of each geographical area to be served. An area is a county. The issuer of a network plan shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers to the business and personal residence of enrollees.
You might be thinking---well that’s no problem---I just won’t buy a Molina product. I’ll just keep my BlueCross BlueShield of South Carolina product or my Bright Health product and I will be fine. Right?
The problem with that is based on how the government handles the health insurance under the Affordable Care Act. Many people receive something called a “subsidy” or an “APTC.” This is an amount that the government provides you to reduce the costs of health insurance for you. This is where the “Affordable” part of the Affordable Care Act is realized. The subsidies are based on the lowest cost silver product in any given market. Remember, a market is segmented by County. So, because Molina Healthcare offers a product in Greenville County with literally no network in Greenville County, their rates are very low.
This means that the subsidies are dramatically lowered for everyone else. So, if you buy your health insurance for yourself and your family and you want to buy a product that actually allows you to use a doctor or a hospital in Greenville County, you need to buckle up and brace for impact as your insurance premiums will go up dramatically. This is because of the presence of Molina Healthcare who didn’t feel it was necessary to develop a network in one of the largest counties in SC and the failure of the South Carolina Department of Insurance to prevent the plan from being sold in Greenville County until the insurance company demonstrated that they have an adequate network for these consumers.
Do you think it’s fair that you need to pay more for your insurance because of all of this???
No, of course not!
It’s just not right!
But----there is HOPE.
I believe that there is hope contained in a statement referenced in the Appendix C. Here is that relevant statement. It is found under the Section Provider Network Adequacy Guidelines.
5. The Department reserves the right to withdraw approval of any network plan if based on actual practice, it becomes apparent that a network does not meet community standards of care.
6. The Department reserves the right to determine a network to be inadequate where the standards have been met at a minimum, but the network does not appear to be reasonable based on community practices, or the complaints are sufficient in number and severity to warrant an adverse determination.
So my question to you is this:
Should we make the state of South Carolina and its Department of Insurance and all insurance companies offering product in the state to actually follow the rules developed by the state?
If your answer is yes, please help me develop “complaints (that) are sufficient in number and severity to warrant an adverse determination.”
Make your voice heard Greenville County!!!!
South Carolina Department of Insurance
Director: Raymond G Farmer
Deputy Director Diane Cooper
South Carolina Governor's Office
Guy Furay is owner of The Insurance Source in downtown Greer. Furay has been in health insurance for more than 25 years and is an expert on the Affordable Care Act. Furay and The Insurance Source have received numerous recognitions throughout the years for their achievements within health insurance. For more information, visit www.insure-u.com.