Some backgrounders related to things in the above comment:

Insurers restricting choice of doctors and hospitals to keep costs down
By Sandhya Somashekhar and Ariana Eunjung Cha, Washington Post, Nov. 20, 2013

As Americans have begun shopping for health plans on the insurance exchanges, they are discovering that insurers are restricting their choice of doctors and hospitals in order to keep costs low, and that many of the plans exclude top-rated hospitals.

The Obama administration made it a priority to keep down the cost of insurance on the exchanges, the online marketplaces that are central to the Affordable Care Act. But one way that insurers have been able to offer lower rates is by creating networks that are far smaller than what most Americans are accustomed to.

The decisions have provoked a backlash. In one closely watched case, Seattle Children’s Hospital has filed suit against Washington’s insurance commissioner after a number of insurers kept it out of their provider networks. “It is unprecedented in our market to have major insurance plans exclude Seattle Children’s,” said Sandy Melzer, senior vice president.

The result, some argue, is a two-tiered system of health care: Many of the people who buy health plans on the exchanges have fewer hospitals and doctors to choose from than those with coverage through their employers.

A number of the nation’s top hospitals — including the Mayo Clinic in Minnesota, Cedars-Sinai in Los Angeles, and children’s hospitals in Seattle, Houston and St. Louis — are cut out of most plans sold on the exchange [....]

[...] as a result, families like Jeffrey Blank’s, which has relied on Seattle Children’s since his daughter, Zoe, received a diagnosis of a rare bone disorder, face difficult decisions. Under some of the new law’s health plans, the family would no longer be able to take Zoe to Children’s for her routine checkups, or it could count as an “out-of-network” visit, saddling the family with huge bills.

“It just stresses me,” said Blank, 53, a self-employed massage therapist who is sorting through his options but readily admits that his family has benefited from other parts of the health law. “I hope things continue wonderfully for my daughter and that she doesn’t need the level of care she got after her diagnosis, but there’s this unknown.”

In New Hampshire, Frisbie Memorial Hospital took legal action against an insurer that excluded it from its marketplace plans, and in Missouri, consumer advocates successfully lobbied an insurer to add a children’s hospital after it unveiled a plan that lacked one [....]

Insurers “looked at the people expected to go on the exchanges and thought: ‘These are people coming out of the ranks of the uninsured. They don’t care about the Mayo Clinic or the Cleveland Clinic. They will go to community providers,” explained Robert Laszewski, a consultant to the health-care industry.

Insurers will typically cover out-of-network costs in an emergency. And most hospitals are included in at least one plan.

“I can’t find you a plan with all the major facilities, but if you give me a hospital I can find a plan participating in it,” said Elisabeth Benjamin, vice president of health initiatives for the Community Service Society of New York, one of the agencies helping consumers navigate their new health insurance options.

The Affordable Care Act requires insurers to provide enough doctors and hospitals to ensure quality care. But there is no detailed guidance from the federal government on what this means.

“It’s been mostly up to the plans to attest to it, and for now everyone’s taking their word for it,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation who focuses on health reform and insurance.

In New Hampshire, consumers who purchase insurance through the exchange have only one choice of carrier — Anthem BlueCross BlueShield— because no other insurer applied to join the exchange. The company’s network includes access to only 16 of the state’s 26 acute-care hospitals [....]
 

Doctors Complain They Will Be Paid Less By Exchange Plans
By Roni Caryn Rabin, Kaiser Health News, Nov 19, 2013

[....] The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.

Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions [....]

Some NYC hospitals not taking new health plans
By David B. Caruso, Associated Press, Nov. 20, 2013

[....] Those narrower networks are a result of insurers trying to control costs and hospitals being cautious about agreeing to take new, untested insurance products.

A spokeswoman for NYU Langone, Lisa Greiner, said the hospital was taking a "semi-conservative" approach to participation and working only with insurers with "strong records in resolving enrollment and payment issues."

The hospital also chose not to work with insurers that wanted to include the hospital, but not its doctors, in its treatment networks.

Negotiations at several hospitals were ongoing, and it is possible some insurer networks will grow by the time policies take effect on Jan. 1 [.....]

State Marketplace Profiles: New York

Kaiser FamilyFoundation, Sept. 30, 2013

[....]

Contracting with Plans: Insurers may participate in the individual Marketplace, the SHOP, or both and must offer one standard product at every metal level, in every county of their service area. Insurers must offer a standard catastrophic product, but if there is more than one catastrophic plan offered in a county, QHPs may be allowed to opt out of offering the product. An insurer that offers an out-of-network product in a county’s commercial market must offer an out-of-network product through NY State of Health at the silver and platinum levels in that county (an out-of-network product offers coverage for services provided by health care providers that are not in the insurer’s network). QHPs may choose to offer up to three non-standard plans per metal level and can offer non-standard products in a portion of their service area. Child-only plans, catastrophic products, and required out-of-network products will not count towards the non-standard maximum. Standard products must cover the Essential Health Benefits; however, insurers may substitute benefits in the Preventive/Wellness/Chronic Disease Management and Rehabilitation/Habilitation categories in non-standard product offerings. [....]

Limited health networks undo the good of Obamacare
Health insurance companies, like Anthem, are empowered to pick winners and losers among hospitals like ours
By Al Felgar, New Hampshire Business Review, Oct. 18, 2013

This is interesting, AA.

I just went on healthcare.gov and found 11 PPOs at the Silver level for me. Not sure what this means relative to your experience in NYC. I believe I've also seen HSAs available, but they are pointless, IMO, unless you're at a higher income level. Otherwise, who has money to put aside for a rainy day or the need for the tax break? I never had enough to put aside for very long, but I did "launder" my medical expenses through the HSA to get the tax break.

As far as the geographic restriction goes, I haven't dug that deeply into it, but never in my life have I had to go out of town for treatment. Perhaps that's because I've been relatively healthy. When I get cancer and need to go to the Mayo clinic, this may change. Since everyone is now so concerned about whether they can keep their own doctor, I don't see why they'll be eager to fly to Kansas City for treatment, unless they need special treatment.

As I say, NONE, ZERO of my doctors have ever been in the two policies available to me over the years in D.C. Just two providers. I did get some out of network benefit, but not a whole lot. So basically, for the past 40 years, I've paid for almost everything out of pocket. Never met the deductible. My insurance was there in case I got cancer or had a heart attack.

So when my wife got a teaching job, we finally got "good" insurance. It pays for a lot more. So here's an ironic story: I've always wanted to go in for a sleep study. For a long time, I was waking up tired, etc. So finally, I have insurance that pays for sleep studies. So I go in, and it turns out, I have sleep apnea, a very dangerous condition. And lo and behold, the insurance also pays for a pretty expensive CPAP machine and regular supplies.

Did "my doctor" whom I love so well discover this very dangerous condition? Did he ask me about my sleep, whether I was waking up tired? No, he did not. And I could see the chagrin on his face when we discussed this. I didn't point fingers at him because I DO think he's a good doctor, and I believe that everyone makes mistakes, but he likes to be "the source" of medical wisdom between us.

Anyway, based on pure money considerations, I decided to leave "my doctor" and find one in network. What's the big deal?

I've been unclear about whether someone could buy a policy outside of the exchange. I guess, based on what you say, they can.

One thing that is supposed to kick in, but may take some time, is competition. Right now, people are still just trying to navigate the thing (though I personally haven't found it that hard), but once they start shopping on the exchange, then presumably, insurers will reduce prices to compete. And once more people go to the exchanges to shop, then more insurers will want into that game.

(Or, we'll find out that competition isn't a driving factor in the purchase of health care or insurance. My contention.)

Offhand, I'm not sure why one would want to buy a policy outside an exchange (technical difficulties aside). That's the old way. Comparisons are even more difficult. You have to contact each insurer separately. You have to figure out how to convert oranges into apples. I suppose IF you have very specific and expensive health care needs, there may be some point in doing so because you'll need highly customized coverage. But other than that...why?

I'm also not clear on why limiting the scope of providers saves the insurance company money. Less paperwork? Less need to rationalize many different ways of charging? I would think that broadening the network would bring more people in. I could see why a Mayo might not want its reimbursements cut, but surely Aetna would not want to exclude a Mayo or a Dr. Kildare.

At bottom, I believe that much of this hoopla is being driven by two big changes which apply across the board: no pre-existing condition exclusions and no caps. I think these are the big cost drivers and are certainly why some people's costs are going up.

I do think that a calculator that allows someone to enter ALL the cost factors that determine the FINAL cost of a policy would be a great idea. At a minimum, you should have access to a policy's formulary or be able to enter your prescriptions into the Web site and see if a plan covers them and how much of their cost. People don't really get all the trade-offs that affect the final cost of a policy.

Klein's article points out the difference between looking at the health care problem from a macro point of view v an individual point of view. An individual's costs may go up while the overall costs we ALL pay may go down. So, you may end up paying more in premiums, but you'll be covered when the "big one" comes no matter how high the bills go. And you'll never go without insurance. And the money other people are saving on premiums will go into the economy and, ultimately, put more money in your pocket from increased economic activity, lower taxes, and lower medical bills. Not trickle, but trickle around.

If we're going to bring down the cost of health care OVERALL--the ultimate driver in all this--then we're going to have to find efficiencies, find cuts, and, in some cases, pay more. But up until now, some people's "good time" has been financed by other people's "awful time." Now, some people will have a somewhat less good time, and other people won't have such an awful time. Equality-ish.

Anyway, good digging, AA.