Some ACA Health Insurance Plans Have Many Members, Few Providers: Plans

The Affordable Care Act may be struggling with its own success.

The record number of enrollments over the past two years has drawn more consumers into the health insurance market. At the same time, many insurers began to offer smaller networks of doctors and hospitals, in part to be price competitive.

This combination has forced some patients to scramble to find an available doctor or medical facility in the network. This can be a challenge, especially when enrollees have to rely on inaccurate provider lists from their insurance company. A recent federal report found that 243 of 375 insurance company plans reviewed by regulators failed to meet network standards.

“The Last Thing She Needed”

Take what happened to an insured in central Pennsylvania who, in January, fell and broke his arm and a bone near his eye.

She was referred by the hospital who provided her with emergency care to follow up with an orthopedic surgeon, said Kelly Althouse, the patient’s insurance agent, who works near Reading, Pennsylvania. The Althouse client spent hours calling orthopedic doctors listed in the provider directory for her new health plan from insurer Ambetter Health, a national carrier that in 2019 began offering ACA plans in Pennsylvania. Several doctors said they weren’t part of the network, despite being listed by the company, Althouse said. It took about 15 tries before her client found a network doctor to see her.

It was “the last thing she needed when she was already feeling terrible,” Althouse said.

It’s a story that’s been told to him many times since January, when the regime’s new year began. Her clients “bombarded” her with calls, claiming that a range of doctors and other providers were not accepting the insurance, even though that provider was in the plan’s directory. “What shocked me was how many offices told my clients, ‘We’ve never heard of this company,'” Althouse said.

For their part, Ambetter officials said in a written statement to KHN that their network in Pennsylvania “meets or exceeds regulatory standards.”

The size of insurers’ contract physician and hospital networks, particularly in ACA plans, has long been a concern. In recent years, insurers have tended to offer smaller networks, partly to reduce costs and control premiums.

Problems arise when patients cannot find local in-network providers and must either pay more for out-of-network care, if that is even an option in their plans, or travel further afield for in-network care.

It wasn’t supposed to be that way anymore, after new rules came into effect this year to address these issues.

More control, but is it enough?

On the one hand, federal regulators are again checking whether insurers have enough suppliers. It comes after a 2021 court ruling that overturned a Trump administration decision to eliminate that federal oversight.

In addition, new “time and distance” standards have come into force, obliging insurers to provide, within certain driving distances, at least one provider for each of the various medical specialties. For example, a large metropolitan area must have enough endocrinologists that at least 90% of enrollees can find one within a 15-mile radius or 30-minute drive.

Still, insurance brokers in several states told KHN that many customers struggle to find in-network providers across a variety of health plans. Even when they do, patients under some plans face “a four to five month wait to see a primary care doctor,” said Tracy McMillan, president of Marketplace Insurance Exchange, an insurance brokerage firm. in the Dallas-Fort Worth area.

Under the Affordable Care Act, insurers must “ensure sufficient choice of providers”. But there’s no single national standard on what to measure to determine network adequacy, and federal and state regulators have the power to oversee plans.

“These exchange networks have never been rigorously monitored,” said Karen Pollitz, senior researcher at KFF.

But access is still limited in some areas and even the standards themselves may not be strict enough, experts and policy brokers say.

“We have insurers that don’t even have a hospital in some counties,” said Lauren Jenkins, owner of Native Oklahoma Insurance, a brokerage firm based near Tulsa. “How can they even be approved to be in these counties?

In a metropolitan area no larger than 40 miles in diameter, a plan could theoretically have as few as 10 doctors and three networked facilities and still meet those standards, Pollitz said.

In Texas, North Carolina, and other parts of the country, new companies, often charging lower premiums, have entered the ACA market. Some have networks “that are very, very small,” said Don Hilke, owner of ClearBenefits Group in Durham, North Carolina. Even the biggest operators are compressing their networks to compete on price or are recruiting so many customers that they are expanding their existing networks.

“Everyone in a Pickle”

In Texas, two small insurance companies exited the market, leaving the remaining insurers without enough doctors to absorb policyholders who had to find other coverage, said Ronnell Nolan, president and CEO of Health Agents for America. , a membership association for independent brokers. “It left everyone in a pickle.”

Federal regulators are proposing other changes for next year, including requiring insurers to meet wait time standards for appointments.

More was also done this year, including looking at insurer networks, said Ellen Montz, deputy administrator and director of the Federal Center for Consumer Information and Insurance Monitoring, part of the Centers for Medicare & Medicaid Services. .

Insurers deemed to have a shortfall in their networks must now report monthly to CMS their “good faith efforts to address these shortcomings” and the number of complaints they receive from consumers about access, she wrote.

Montz did not specify how many insurers had not responded, but the December report from the United States Government Accountability Office noted that CMS found that the majority of insurance companies whose medical or dental plans have were reviewed by federal regulators in August did not meet grid adequacy standards. CMS told GAO that all plans ultimately met the requirements or provided “acceptable justification as to why they were unable to meet the standards.”

Building networks and maintaining lists of participating providers pose ongoing challenges, said Jeanette Thornton, executive vice president of policy and strategy at AHIP, the health insurance industry’s leading lobby group. . These include the need to rely on providers to notify insurers when they move, retire, or stop accepting new patients.

Questions about the accuracy of supplier directories persist. According to a research letter published in the Journal of the American Medical Association on March 14.

A lawsuit filed in August 2022 in the U.S. District Court for the Northern District of Illinois alleges that Centene’s Ambetter plan provider networks “are simply bogus and are often just copies of physician directories from other sources”.

Without accurate directories, according to the lawsuit, patients face “delays in treatment, inability to obtain treatment, travel to see an in-network provider that is hundreds of miles away, and out-of-pocket payments for out-of-grid providers.” Similar allegations are included in ongoing lawsuits first filed in 2021 by the San Diego city attorney against three California insurers.

The No Surprises Act, which took effect more than a year ago, requires insurers to update their provider directories every 90 days. No insurer has yet been penalized for failing to update theirs, CMS’s Montz said. The law also states that if patients are hit with an out-of-network charge because they relied on inaccurate information, the insurer can only charge the patient the in-network rate.

In October, CMS issued a formal request for comment on whether the federal government should create its own national database of networked medical providers, a survey that elicited hundreds of responses, both for and against.

There is no indication whether such a plan will go ahead.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.