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7 things to know about health insurance post ACA

Recent changes to the ACA have left healthcare carriers, consumers and providers searching for more information. David Reid, founder and CEO of the insurance broker HR software solution EaseCentral, and Michael Levin, cofounder and CEO of the healthcare data services company Vericred, spoke with Becker's ASC Review about what to expect during this year's open enrollment period.

Here's what they had to share:

1. Provider networks are narrowing. PPOs are being pushed out in favor of HMOs, resulting in fewer healthcare plans that offer out-of-network benefits, according to Mr. Levin.

"It's important for consumers and small groups to understand if a plan covers the facilities and physicians that they want to see, especially since provider networks have fewer providers in them than in the past," he says.

2. Drug formularies vary by plan. The degree of coverage for medical drugs varies by carrier, leading to large price variances between plans — as seen in the recent EpiPen controversy.

"The plan design, physician network and drug formulary are all equally important when choosing a plan," Mr. Levin says. "They're three legs of the same stool and no one should be making decisions just based on any one alone."

3. Where you live impacts insurance. While rural areas have suffered from a lack of options as health insurance companies like Aetna and Humana have exited the market, metropolitan areas still have hundreds of plans to choose from.

"There are a lot of densely populated areas, like New York City and Portland, where there are hundreds of options for insurance plans," Mr. Levin says. "However, this year, there are also more states where there's single choice and a lack of competition."

4. Rise of alternative strategies. In the past, consumers tended to purchase low-deductible plans that included a range of healthcare coverage — but as deductibles increase, that may not be in the case.

"These alternative insurance strategies have entered the market, where a consumer might purchase a high-deductible plan, combined with other supplemental policies that subsidize specific services, like sports accidents or alternative medicine," Mr. Reid says.

5. Integrating technology solutions. "The ACA has had a huge impact on small businesses," Mr. Reid says. "One of the things it's done is made things a lot more complicated for them, with more rules and regulations."

As employers and employees have increasingly more information thrown their way, integrating technological solutions to help businesses and individuals keep track of their options will likely take on a more prominent role.

6. Need for transparency. EaseCentral has integrated transparency tools that let users enter information about the services they're seeking and their health insurance plan, to identify the average cost of relevant physicians in their network.

"For the first time, we're seeing the emergence of tools that allow you to know, before you go for a procedure, how much it's going to cost you out of pocket," Mr. Reid says.

7. What's next? Responding to the ACA's shortcomings, without repealing the entire program, may be a focus in the coming year.

As health insurance restrictions become increasingly complicated and established carriers leave the market, there is room for improvement. "We're seeing carriers withdrawing from exchanges around the country, or entering the market as the only option," Mr. Reid says. "You really don't have competitive forces at work anymore, which is not good for the market or the consumer."

However, the ACA has achieved some of its goals, such as lowering the rate of uninsured residents and acknowledging those with preexisting conditions. "A high percentage of folks are getting some level of subsidy," Mr. Levin says. "It has certainly achieved some enviable goals."

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