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NY Health Exchange Plan: Oscar, Health Republic, Metroplus. Help please?
December 10, 2013 2:42 PM   Subscribe

I would love the knowledge and insights of Mefites on this decision and on my top three contenders for insurance companies and their networks: Oscar, Health Republic, and Metroplus.

Oscar and Health Republic are both new and there doesn't seem to be a ton of info available on them. But I would love anything that you all know or have reason to suspect about them, as well as any personal experience or reviews that you might have of Metroplus.

Any feedback about the doctors and hospitals on the Metroplus network or the Magnacare network, which both Health Republic and Oscar seem to use, would also be great.

I like the connectivity that Oscar seems to promise, organized electronic records, free telephone medical care, and some free primary care. I don't love that the founders seem to be Ivy league tech startup golden boys but don't want to hold it against them too much. I don't like that their plans seem consistently more expensive. I like that you don't need referrals to specialists.

I like the coop-ness of Health Republic, though don't love the expenditure that their advertising blitz seems to represent. I like the free access to a PCP with their PrimarySelect plans, though not sure they're a better value than the EssentialCare plans (unless maybe for the acupuncture?). I like not needing a referral to specialists. I like that they are the cheapest bronze plan for me.

I like the not-for-profit-ness of MetroPlus and the fact that they're more established. I really really like that they have by far the cheapest gold and platinum plans for me. I really don't like that you need referrals to specialists but think I could live with it.

As far as price shopping, this is the spreadsheet that I made to try to compare the plans available to me (in Brooklyn, as a thirty-something). For now, at least, I'm not eligible for subsidies and/but even the relatively more expensive platinum plans would represent a much better deal than the insurance I have now. I'm completely on the fence about which to get - I'm generally pretty healthy. On the other hand if I had access to reasonably priced health care I might use a lot more of it, especially potentially therapy and mental health care. While I've had bare bones insurance, my entire health care has been 1-3 trips to the urgent care clinic for urgently needed (generic) antibiotics.

Part of me wants to get the cheapest bronze and hope for the best, part of me wants to get a platinum and never argue with myself again about whether a health need is really worth spending the money on. On the spectrum I guess I am relatively risk-averse.

All of me is comforted by the fact with a best case absolutely no health care needs year I 'waste' maximum (of the choices I am looking at) about $3000 on the 'wrong' more expensive premium plan, and with a worst case scenario health year, I 'waste' maximum about $3500 on the 'wrong' cheaper premium plan. For now at least that is margin of error I can live with, and though my job is very unstable, I know that if I did lose it I would be eligible to change plans as well.

(All of me is also sad that my gynecologist is only in network for the ridiculously priced United plans which I can't even begin to consider as a realistic option.)

Please, what do you know about these companies? About their networks? How are you thinking through the risk calculations and cost calculations for yourself? How do you think I should think about it for me? Am I missing anything?

Thank you!
posted by Salamandrous to Shopping (6 answers total) 5 users marked this as a favorite
 
I was curious about Oscar, and looked that up. I am definitely not an expert, but the way the plans were structured made it seem like they were really trying to make sure you wouldn't ever want to see a doctor or go to the ER. I approached it asking what would happen if I had to go to the emergency room and I was on this plan (one of the main reasons I have insurance). Well, it seemed like with Oscar I would be liable for a pretty large deductible before I would get any help. I could be reading that wrong, but it seems to say you will have a $0 copay for an ER visit, but you will have to pay the first $6350 (for the default plan I clicked on). And on their plan comparison table, all that seemed hidden below the fold. Basically, as a pretty healthy individual I want to know how much it is going to cost for me to go see a doctor once or twice a year for routine things, and then how much it helps me if I were to get injured and have to go to the ER. If I'm already paying a few hundred every month, and then have to also pay $6350 before my deductible kicks in I will be in pretty rough shape.
posted by This_Will_Be_Good at 3:06 PM on December 10, 2013


One comforting thought is that due to the new guaranteed-issue rules of the ACA, you can change to a different plan next year if you don't like the one you choose this year. You aren't making a lifetime, irrevocable decision. Take your best guess and go for it.

Also, if you really like your current doctor, there's no reason you can't pay for the visit out of pocket.
posted by JackFlash at 4:55 PM on December 10, 2013


Thanks This_Will_Be_Good and JackFlash!

I ended up getting an e-mail response from a non-Mefite who found this thread, and he agreed to let me post our back and forth in case it might be helpful for others.

Seth:

Here's some initial research I've done, there's so little out there, it's a shame local journalists have not done more to help us out with this.

Btw, I'm looking just at Silver plans because my income is so low these days that I get solid support at this level only.

Oscar and Health Republic have both licensed the Magnacare health network for all their offered services. So they are both essentially Magnacare, with a few variations I have not yet figured out. And the rest I think comes down to their costs, organizational structure and leadership.

I'm signed up with an insurance agent here in NYC and she called the top contenders for me to test their customer service: Empire Blue Shield / Blue Cross, Oscar and Health Republic. Oscar and Heath Republic both had people on the line quickly and seeming to be knowledgeable. I think Empire is bigger, broader…but interestingly NYU Langone Medical Center for example did not include them from among the ones they'll accept from NY State of Health Exchange.

Health Republic is born out of the Freelancer's Union health services, and they set up these custom offices around Brooklyn and NYC I think, which I believe is why they offer the differently named "Magnacare Extra" network. My guess is that this is a merger of Freelancer's Union facilities and whatever Magnacare doctors, hospitals and facilities they licensed.

As for Oscar, I'm not sure how their version of Magnacare is different, beyond missing whatever "extra" Health Republic has. My guess is it's mostly about their actual doctors and facilities more than dealing with them direct, which is what Oscar and Health Republic will have to handle.

Though having two layers may cause issues…and these two are new in the game. In considering the two, I lean towards Health Republic over Oscar, because they are a nonprofit co-op, with 51% of their executives culled from people who are members using the same plan(s). There's thus vested interest to make the plans work well and be affordable, also not profit unduly in fleecing its members.

The Freelancer's Union has been looking out for working individuals left out of the system for a long time, in some ways a smaller scale of what Obamacare is trying to implement across a wider swath of Americans nationwide.

All these nice things said, their earlier plans years back, via HIP and whatnot, always seemed so low quality but still expensive that I never signed up. I hope this was all they could muster at the time with the resources on-hand, and that Health Republic represents a new phase and level of offerings possible. And maybe they're more words than action, it's hard to know without diving deeper.

Oscar is both fascinating and scary. From what I read, it's run by about 30 thirty-somethings in Soho, who don't have much experience in health care but do have plenty of data, IT, VC and general social/class connections. It's for-profit, backed by VC, so they're going to demand big payback which will be on backs of the customers to provide. Maybe this will keep things streamlined though. So far as I read, there's no management in their 40s; statistically startups with this young of management fail for lack of vision / experience.

Oscar has this 24/7 doctor on call, initially it sounds great, but I agree with that poster saying there's something fishy. Is it just a way to keep people from going to doctors in person? That is, if they are all about having their service seem human and like going to the family doctor, why not also guarantee one can see their own doctor or a selected alternate within a day or two, along with the 24/7 phone doctor on call? That would be more believable and sincere in terms of trying to humanize healthcare.

My guess is they've read the stats, that there won't be enough doctors for all the incoming patients for Obamacare, so they're trying to market these phone doctors as way to reduce total office visits.

I'm curious about the management teams running the ship at Oscar and Health Republic, i.e. age range and experience background, also any links to what sets them apart. Also FYI, I saw this blog entry that was interesting and honest:

http://magnacare.typepad.com/blog/2013/10/thoughts-on-obamacare.html

Personally I think more young people will sign up once they make it less difficult to sign up, and better options are provided.

Salamandrous:

I actually have been on the Freelancer's Union insurance for the last couple of months. I agree with you that it's not a great value. Their Freelancer's Medical Facility seems awesome and is great for minor health needs, but the out of pocket maximum is insanely high (18k). I actually didn't think the Freelancer's Medical facilities would be available on the Health Republic plans. If I'm wrong about that it would actually make it much more attractive. I will see if I can get that information. (Update: I asked on their Facebook page, no response yet. I guess the 'extra' is their discounts for acupuncturists et al though.)

I saw only poor reviews of Magnacare online but they seemed to pertain less to the network and more to the benefits (and I guess online there's always the bias towards the negative), so hopefully that won't be too bad.

I like your reflections on Oscar. I kind of love the doctor on call because I hate taking the time and trouble to actually go to the doctor, and the general hassle of the logistics of arranging and coordinating healthcare that it seems like their services could help with, but even in a best case scenario health year where I could get away with that kind of medical care, their rates are not competitive to Health Republic and the total annual cost for a bad year (premiums + out of pocket maximum) are meaningfully higher. It's interesting what you said too about the lack of more experienced directors. I haven't tried to call them but they responded to my question on their Facebook page pretty promptly.

That's great that the broker actually did that legwork for you, that didn't even occur to me. I have used the Empire BCBS online chat, they were prompt and generally helpful, but not necessarily super well informed. Also I don't know whether you noticed but there are real differences between their plans as described on the Exchange site and on their own site. For example, whether a hospitalization is just $1000 after deductible, or $1000 + 20% after deductible; and conflicting information over whether a plan is HSA eligible or not. I asked the chat representative about it and she said she would have to refer it to their New York plan coordinator person and get back to me (she seemed to be based in Ohio). That kind of sloppiness... doesn't inspire confidence. They're also more expensive. I do have a colleague who signed up with them basically on the strength of the name alone and the assumption that they would have the better network (as you said, I haven't seen that borne out yet).

Right now I'm actually leaning towards the Gold or even Platinum MetroPlus plan. It's more up front but seems like it'll feel like actually having healthcare I can just use and not need to start emptying my bank account by the thousands for. It's so much cheaper than the others at that price level and it feels like almost the closest thing to actual socialized care, probably since that's more or less what they've been doing, for the HHC, for many lower income New Yorkers. I just don't know about their network though, sadly also because that's the population they've been primarily serving, that I suspect often doesn't get the best hospitals/specialists/etc. MetroPlus did respond to my metafilter post by tweeting me, which was interesting. Neither of other companies I mentioned have responded to it at all, which is also interesting.

I so much agree with you that some local journalist needs to get on this. It's kind of shocking to me that it hasn't happened. Also they just added dental plans to the site and apparently everyone who already enrolled might be out of luck for that?

That blog post you sent was depressing. I hope he's not correct. At least in my office (where we all fairly well paid but very insecure) temps without healthcare, it seems to be 'working.' The more risk averse among us who have been buying individual insurance are pleased with the value of the plans and are switching (except for one who had her insurance through an association and was basically sounding just like the people in this NYT article - she had been paying a lot but really valued the out of network benefits that she's losing now and the cost savings wasn't worth losing that to her. But the less risk averse who have been going for years without health insurance, most of them will be buying health insurance (though dragging their feet until March). Even though the penalty is relatively low this year, they seem to feel that if they're paying anything, they'd rather pay more and get insurance than pay less to the government and get nothing.

Which silver plan are you thinking of? MetroPlus definitely seems like the best value. There are all these little differences though that make it harder to compare. HR covers acupuncture, chiropractor, and infertility but limits outpatient mental health/therapy visits to 30 per year. MetroPlus has unlimited mental health visits, and covers chiropractor but not acupuncture or infertility. Both of them have lifetime limits on rehabilitation and habilitation visits, which I think covers physical therapy - 60 per lifetime! Oscar has no limits on rehabilitation and habilitation. It's really a mess to compare.
posted by Salamandrous at 4:56 AM on December 16, 2013


I also found a pretty in depth discussion of some of these plans and issues on Dagblog.
posted by Salamandrous at 6:31 AM on December 18, 2013


A couple of more bits and pieces:

Salamandrous:

I asked Health Republic on their FB page whether they'd give access to the Freelancer's Medical Homes, and the answer was no. They also said they're not related to FU. That's not quite right - even on the official Health Exchange site they're listed as Freelancer's Union DBA Health Republic. I understand that there are probably legal/financial walls in place but it still all feels a bit cagey and coy.
...
I feel like the MetroPlus will feel the most like having real health care (I'm Canadian originally...) where I can just go to the doctor and take care of myself and not weigh the costs each time. It also fits with my values, being a nonprofit, municipal partnership model. I like the fact that they've been around for a long time and I can't seem to find any serious complaints about them (though this could be due to the fact that they serve an under-served, under-reported on, under-cared about, and maybe under-internet-complaining demographic) I like the Health Republic coop thing and I understand that they've had to do a marketing blitz, but I don't like the caginess about the relationship with Freelancers, the fact that Freelancers is maintaining their Freelancers Medical at the same time as offering the HR plans (implies a lack of confidence in the latter or a willingness to gouge on the former, imo), and their limits on mental health treatment. But that said, I like a lot about them - the discounts for nontraditional treatments, the inclusion of treatment for infertility (which would definitely be a strong factor, as a 34 year old woman, if I were thinking about trying to have kids next year), definitely like the EPO aspect of not needing referrals to specialists, and I wish they would say more about the tech and access benefits they will give. So I'm not 100% decided. I think you've persuaded me though that I would pick HR over Oscar even if the costs were the same. I do see the appeal though, just in case they really could make health care logistics easy and transparent!

nb I later decided against MP mainly based on the paucity of their provider list, only five hospitals in Brooklyn, etc, and also on needing referrals. I still think they're a good value

Seth:

'Also - doing a bit more digging I found that certain insurers don't require referrals from a PCP to see a specialist (which is usually just a feature of PPO plans). The silver plans that don't require a referral to see a specialist are: Oscar, Health Republic, Fidelis, MVP. In terms of a differentiator, that is important. Freedom to go to a specialist without first getting a referral from your PCP is a good advantage (I was on a high level PPO plan for years and I loved that freedom)...

Interesting one re: these plans need to hit certain amount of paid members or they will fail:
http://insights.som.yale.edu/insights/what-are-your-options-health-insurance-exchanges-1

Probably why we're seeing the advertising blitz…they can't be competitive w/o X amount of enrollees. I think btw that Health Republic's Magnacare Extra is because they licensed double the providers and hospitals!!

Health Republic, with a network of 70,000 providers and more than 135 hospitals statewide

Oscar has network of 35,000 doctors and 72 hospitals.

http://www.therepublic.com/view/story/bf771b22ec6341a082acecdf45495331/NY--Health-Overhaul-Insurers

This is a huge difference. I saw Oscar is assuming it will run losses for 2 years and the have profits in year 3, also they had to put up the $45 million that the Act requires to back up claims and whatnot, while Health Republic, as a co-op nonprofit, received $38 million or so in support from the government (not sure if for this or other costs).

See this article comparing, and this quote re: Health Republic:

"The nonprofit plan, available throughout the state, has a network of 130 hospitals and more than 70,000 physicians, and offers the lowest premiums of the three newcomers. "We not only have the lowest rates," said Debra Friedman, Health Republic's chief executive, "we have the largest network." The plan, like Oscar, also offers 24/7 phone access to medical advice."

http://www.crainsnewyork.com/article/20131110/HEALTH_CARE/311109996

The good news is that both NYU Langone Hospital and Memorial Sloan-Kettering are both in-network for Health Republic and Oscar. Also New York Methodist in BK though seems Brooklyn hospitals are not as good as Manhattan these days.

I'm looking at providers now but just the sheet numbers difference alone has me back in Health Republic boat, also on the co-op model vs VC backed...

I'm planning to confirm selection of the following tonight I think, but wanted to send all this your way, in case you have input/thoughts:

Health Republic : EssentialCare Silver Plan
Healthplex Adult Smiles Dental
...

For Healthplex, I just looked up one dentist in east village who got good reviews, i.e. to make at least one was ok.

I figured that for just 2 cleanings a year, it's about $100, and then they have $360 max (after 10 visits, no more $36 copay required). So max out of pocket is $500ish and if just normal care, it's $100 per year. I did not look up any other plans…did you? If so, lmk…I have not had dental for 2 years so figure some work will be needed.

Lmk on emergency care abroad for HR! I'm interested to know same. Also, did you see that HR has 24/7 medical help line? That surprised me, I wonder what sort of people are on it though. Not that I think the MDs are high end on Oscar…I'd rather have a pro nurse practitioner than crap MD, as they seem more humble on average.

Getting closer, looking forward to pick and see…luckily can change through til March and in meanwhile will experience and hear of experiences, read reviews, etc.

...

Salamandrous:

Explanation of Magnacare Extra from the Health Republic site

"Health Republic Insurance of New York relies on MagnaCare for the foundation of its network. The MagnaCare network has been reviewed and approved by the New York State Department of Health to offer sufficient coverage in the counties we serve. It includes many of the state’s key hospitals. In addition to MagnaCare, Health Republic is contracting with community health centers and accountable care organizations, especially those with the infrastructure to support population management. Thus, we call our network “MagnaCare Extra.”"

Seth's Broker:

Re: Health Republic silver plan vs. Oscar silver plan - the differences likely won't be game-changing. We can all thank the Affordable Care Act for that. Any plan you choose: 1) has to cover all the essential health benefits (defined by law), 2) has to present standardized info so you can compare them apples to apples (I've attached the required benefits summaries for the Health Republic and Oscar silver plans), 3) has to provide an adequate network of providers and 4) has to conform to the actuarial values for each "metal" level. Any silver plan is going to have the same actuarial value (the share of health care expenses the plan covers for a typical group of enrollees) - meaning they'll have comparable figures for deductibles, co-pays and out-of-pocket limits.

Once you pick a metal level, the choice between insurers is really a question of:

1) Customer experience (both Health Republic and Oscar are new so no track record to speak of. If you're curious, give both a call to ask questions and see how the experience is. They were both responsive and knowledgeable when I called).
2) Provider network. Again each insurer has to have an adequate provider network (i.e., you won't face a situation of: I have X condition and there's no provider in my network who can provide care for X condition). So the question is, is there a specific provider you want to keep seeing? If so, make sure he/she is in the network. Otherwise, there's no real efficient way to evaluate a provider network.
3) Distinctive plan features (like whether a PCP "gatekeeper" required, nurse / doctor helplines, etc.) These distinctive features are above the baseline essential health benefits that every plan is required to cover (i.e., they're "nice to haves.")

Also, re: the distinction between a co-op and a private health insurer. The former is a non-profit but in case you weren't aware, one of the other things that the Affordable Care Act did is require all health insurers to spend at least 80% of premium dollars on claims and activities to improve health care quality. So even private insurers are limited by law on what they can distribute as profit, spend on marketing and overhead etc. Just some food for thought.

Key takeaway is either plan will provide good health coverage for you at a reasonable cost.

----

Hope this is helpful to someone! In the end we both seem to be going for Health Republic. We'll see how the year goes!
posted by Salamandrous at 2:31 PM on December 24, 2013


As someone that is going to be without employer coverage for the first time, and having to deal with understanding what's out there--- this has been super helpful. Thanks!
posted by vlotty at 12:44 AM on January 16


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