Premium Health Exchange plan not so premium for some

Premium Health Exchange plan not so premium for some »Play Video

SEATTLE -- Alex Szablya just wants the best health care she can get for her children. So she got a gold plan, the highest level possible with the Washington Health Benefit Exchange.  She picked a plan with Lifewise, an affiliate of Premera Blue Cross.

In early March, her 16-year old daughter had a medical emergency. Alex drove her to the nearest hospital, which was Seattle Children's. Alex says doctors there felt her daughter's situation was so dire she needed to be admitted to the hospital immediately. She was there for nine days.

Then came news that her stay, which involved specialized mental health care for adolescents, was going to cost $36,000 and her insurance would only pay for half because Seattle Children's was considered on out-of-network facility.

She thought by going for the highest premium PPO gold level coverage offered the state exchange, a majority of the bill would have been covered.

"I'm paying a premium for that and I'm willing to pay that premium, but I expect to get services that are not so limited by the insurance companies," she said.

She's not alone. Seattle Children's says its treated more than 125 patients who are not covered by policies offered by the exchange. In October, the hospital filed suit against the Office of the Insurance Commissioner, claiming the state office failed to ensure adequate network coverage in plans from its biggest providers like Premera Blue Cross.

"Because Seattle Children's was not included in the major plans, children coming for care here were going to be denied care and in fact that's what we are seeing," said Dr. Sandy Melzer, senior vice president and chief strategy officer for Seattle Children's.

Alex says Lifewise offered similar alternative care at other hospitals but it required traveling a three hour drive to Yakima or a two hour trip and ferry ride to Bremerton.  Children's is a five minute car ride from her north Seattle home.

"This limited network is preventing me to get the specialty services that my children and I need in this community," Aex said.  She's now facing an $18,000 hospital bill she wasn't prepared for.

Last year, many insurance companies announced they were dropping Seattle Children's from in-network status because their costs were too high. A spokesman for Premera says 80-percent of billed services from Seattle Children's are for routine services.

"They're twice as expensive as the rest of our hospital network," said Eric Earling, Director of Corporate Communications for Premera Blue Cross.

Earling says there are exceptions for specialized care if clients or children's applies for an exception.

"Children's is in-network for pre-approved, unique services. We work closely with Children's to provide that access to unique services with in-network benefits," Earling said.

Families need to check with their insurance provider and their primary care physician if they have one before making any decisions about health care. It could prove costly of those checks aren't done.