Consumers Complain About Narrow Insurance Networks

More people than now have health insurance in California, but is it the kind of coverage they want?

Several reports in the past weeks noted that insurance networks are narrowing under the Affordable Care Act. Some enrollees are finding that the doctors and hospitals they thought they’d have access to aren’t actually under their plan’s umbrella.

As enrollees begin to use their new insurance plans purchased on the open marketplace, known as Covered California, they’re beginning to notice some drawbacks.

Two San Francisco residents sued Blue Shield of California on May 14 because they say they were mislead into thinking that the insurance would cover visits to their preferred providers.

But the problem may be larger than just one insurance company.

In a letter submitted to the Covered California board on April 7, Priscilla Myrick of Berkeley complained about the narrow network of her Anthem Blue Cross plan purchased on the exchange.

“The new Anthem Blue Cross individual health plans (purchased on or off the exchange) offer restrictive, ‘second-class’ provider networks and draconian financial penalties for going ‘out-of-network,’ that do not serve the purpose of either insuring consumers against high or unexpected medical catastrophes or providing quality health care,” she wrote.

Myrick said she had believed her existing doctors would be covered, because they were under her previous Anthem plan.

“My cardiologist and local medical facility were providers under my Anthem PPO plan last year,” she wrote. “But they are no longer part of the new Anthem “Pathway” network. I just learned that my annual visit to my cardiologist is now ‘out-of-network’ and none of the office visit was covered. A mammogram and bone density test (ACA Adult Preventive Care) were done at a facility that Anthem now says is now ‘out-of-network’ — so I am supposed to pay 50% of the over $1500 billed.”

The Health Report covered this issue in March, in a profile of Affordable Care Act enrollees in Humboldt County. There, Blue Shield and Anthem Blue Cross offered plans on the exchange.

“When the companies came to negotiate with providers on the North Coast, they took a hard line, as they have throughout the state,” states the article, written by Thadeus Greenson, Grant Scott-Goforth and Heidi Walters.

“Blue Shield offered reimbursements that were 30 to 50 percent less than they would pay doctors under traditional insurance plans,” according to Catherine Markle, billing manager at Eureka Family Practice. “Similarly, Anthem Blue Cross offered 10 to 65 percent reductions from its traditional reimbursement levels.”

“‘These are major payers,’” Markle said in the story. “‘They don’t have to give you a reason, and they don’t have to negotiate. They really kind of backed us into a corner and they wouldn’t negotiate. They said, “Take it or leave it,” and we were forced to leave it.’”

Markle said she’s now tasked with telling many longtime patients that the Eureka Family Practice doesn’t accept their new Covered California insurance plans.

“I’ve had patients in tears and patients who are really angry,” she said. “It’s been awful and I feel terrible for our patients who are put in this position of non-coverage, really.”

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