McHenry County insurance broker, consumers worry Blue Cross Blue Shield costs will skyrocket due to competitor on Affordable Care Act exchange

Illinois residents who buy federally subsidized health insurance plans from the state marketplace set up by the Affordable Care Act could see their out-of-pocket premium costs skyrocket in 2021 if they stick with the coverage they had this year, according to a longtime independent insurance broker and McHenry County members of the plans.

The price increase will take place for Blue Cross Blue Shield of Illinois members whose income levels qualified them for subsidies because an insurer called Ambetter of Illinois is offering plans on the exchange this year at far cheaper rates, said Trudy Hayna, the Woodstock-based insurance broker.

The lower rates will decrease the subsidies consumers will receive this year, which means members who stay with Blue Cross Blue Shield will see their overall costs rise.

Switching to Ambetter’s less expensive plans aren’t an attractive option to Hayna and other residents because of what they feel is a dearth of in-network hospitals, doctors and health care facilities in McHenry County under Ambetter’s plans.

Ambetter’s website as of Thursday evening showed only one in-network general acute care hospital within McHenry County: AMITA Health Behavioral Medicine Institute, 500 Coventry Lane, Suite 250, in Crystal Lake.

But that location hosts only one therapist and a program for adolescents, a receptionist at the 141-bed AMITA Health Alexian Brothers Behavioral Health Hospital in Hoffman Estates told a caller Thursday.

By Friday, the Crystal Lake facility had been removed from the Ambetter website’s list of in-network hospitals near a McHenry County ZIP code. The website now shows no in-network hospitals in McHenry County.

The insurer also has only one in-network pediatrician in the county. Hayna and her client, Vicki Stoneham of Algonquin, said they feel there also is an inadequate number of Ambetter-covered primary care doctors in McHenry County, and few of them have hospital affiliations.

Ambetter did not respond to multiple requests for comment and a detailed list of questions on this story sent this week through an online form on its website for media requests. Attempts to reach an Ambetter representative also were unsuccessful.

After this week’s removal of the Crystal Lake therapist’s office from Ambetter’s list of in-network hospitals, the nearest in-network facility labeled as a general acute care hospital was Northwest Community Health Care, which is about 18 miles away from central McHenry County in Long Grove, according to Ambetter’s website.

But that location is an outpatient care facility, at which immediate care, primary care, imaging, mammography, lab services, intensive cardiac rehabilitation and other specialty services are performed, according to the facility’s website. It does not appear to have an emergency room.

The Ambetter network appears to offer far fewer local options to McHenry County residents than Blue Cross Blue Shield plans, Hayna and Stoneham said. They said they feel it is wrong that the out-of-pocket costs on the Blue Cross plans will rise as a result of Ambetter’s lower premiums.

“They can offer a narrow network. This is anorexic,” Hayna said of Ambetter’s coverage.

She said a family of four she works with that was able to pay about $5 a month out of pocket for its Blue Cross Blue Shield premium last year would see those costs rise to $500 each month if they kept the same plan.

The deadline to purchase plans on the state’s marketplace during this year’s open enrollment period is Dec. 15.

Hayna said she lost a contract to sell Ambetter products after raising her concerns to the insurer.

She said Blue Cross already had notified its customers in McHenry County who purchased plans on the exchange last year that their premiums would not rise significantly, but that was before Blue Cross realized the subsidization would be calculated based on Ambetter’s lower rates.

Blue Cross rates for 2021 on average decreased slightly across its individual Affordable Care Act-compliant plans, Colleen Miller, a spokeswoman for the state’s largest insurer, said in an email.

“However, we understand that subsidy-eligible members in McHenry County may be experiencing higher out-of-pocket costs for our plans compared with previous years,” Miller said. “This is largely due to subsidy amount changes based on the rates of the plans available through the marketplace.

“When we prepared renewal packets for members covered by our individual and family plans, we provided an estimate of what their 2021 premium might be based on 2020 subsidies, as 2021 subsidy details were not available until the start of open enrollment – clearly stating the figure is an estimate based on the previous year’s information.”

She declined to answer questions about whether Blue Cross is taking any action to address the changes.

Illinois Department of Insurance officials believe the Ambetter plans being offered on the public marketplace meet the rules of the law, said Caron Brookens, a spokeswoman for the agency.

“The department’s role is to ensure the plan meets network adequacy requirements determined by the state and federal government,” Brookens said. “We have completed our review of the facility and provider lists provided by the insurance carrier and remain confident that the plan meets those requirements based on the lists provided.

“Insurance plan networks have the ability to change regularly throughout the plan year and continue provider/facility contracting efforts during the plan year to bolster their existing networks.”

Ambetter’s plans also meet the requirement that insurance carriers must cover emergency services for an emergency medical condition at in-network levels regardless of which provider performs the services, Brookens said.

“Emergency services include transportation services, such as ambulance services, as well as inpatient and outpatient hospital services that are needed to evaluate or stabilize the patient,” she said.

Stoneham, a local resident and a client of Hayna, said she is sticking with a Blue Cross plan for the coming year so she can access health care nearby when needed, despite knowing she may be unable to afford the premium if her income jumps and her subsidy falls. Her hours as a bus driver for Barrington schools were cut as COVID-19 precautions keep students out of schools, but a return to in-person instruction could return those hours.

“I won’t be able to afford [it] even if I’m working with hybrid [schooling] hours because of the lowball rate and lowball, inadequate care Ambetter is throwing out there,” Stoneham said.

Lynda Fulkes said her Crystal Lake family also balked when they saw what they considered too small a list of in-network doctors and health care facilities in McHenry County under Ambetter’s plans on the state exchange.

Her son was looking at plans on the exchange after turning 26 years old and no longer was able to stay on his father’s health care plan this year, she said. They decided against Ambetter after reviewing the options to receive care locally and instead decided to buy him a Blue Cross plan, knowing they’ll have to help him afford it.

“In looking at what Ambetter had to offer, I knew enough to look for doctor and hospital availability, and when I did that, Ambetter stinks,” Fulkes said. “It’s skewing the amount people are able to be subsidized for, but secondarily, if people choose it, whatever they’re providing is horrible in our community.

“We’re in the fortunate position where we can help our son. But there are many people in the community that don’t have that option.”