To Prevent Surprise Bills, New Health Law Rules Could Widen Insurer Networks
By ROBERT PEAR
JULY 19, 2014 - New York Times
WASHINGTON — The Obama
administration and state insurance regulators are developing stricter standards
to address the concerns of consumers who say that many health plans under the
Affordable Care Act have unduly limited their choices of doctors and hospitals,
leaving them with unexpected medical bills.
Federal officials said the new
standards would be similar to those used by the government to determine whether
Medicare
Advantage plans had enough doctors and hospitals in their networks. These
private plans, sold by companies like UnitedHealth and Humana, provide
comprehensive care to 16 million of the 54 million Medicare beneficiaries.
States are free to adopt additional
standards of their own, and Washington did so in late April.
gI heard from many consumers who
were upset to find their health plan no longer included their trusted doctor or
hospital,h said Mike Kreidler, the insurance commissioner of Washington State.
gSome people discovered this only after they had enrolled.h
Mr. Kreidler said the new
standards were needed to deal with gan emerging trend toward narrower networks
of medical providers.h
If a network is viewed as
inadequate, patients may need to seek care from doctors outside the network,
incurring thousands of dollars in costs not covered by insurance.
New York adopted a law this year
to protect consumers against such gsurprise medical bills.h Before treatment,
doctors must tell patients what insurance they accept. If an insurer does not
have a doctor with the expertise to treat a patientfs problem, the patient can
go to providers outside the network at no additional cost.
The National Association of
Insurance Commissioners, representing state officials, is updating its
18-year-old model law to add new consumer protections, after finding that some
insurers tried to cut costs by excluding childrenfs hospitals and academic
medical centers. Cancer
treatment centers say they, too, have been excluded from many health plan
networks.
Consumers often chose health plans
this year on the basis of price, without paying much attention to their provider
networks. Even some careful, well-informed shoppers say they were misled.
Joshua P. Worth, a 43-year-old
graphic designer in Los Angeles, said he and his wife had been expecting a baby.
They chose a health plan offered by Anthem Blue Cross, a unit of WellPoint,
after checking to be sure that its network included their obstetrician and
pediatrician.
But after his wife gave birth in
March, Mr. Worth said, Anthem notified him that her visits to the obstetrician
were not covered because the doctor was gout of network.h In April, they visited
the pediatrician with their baby, presented their insurance card and were told
that the doctor did not accept their plan.
gIt felt like bait and switch,h
Mr. Worth said. gI was lured into paying for something, but then when I tried to
use it, it didnft work.h
Kristin E. Binns, a vice president
of WellPoint, said Anthem Blue Cross was working to improve the accuracy of its
provider directory. Since January, she said, the company has added more than
3,800 doctors to its California exchange network, an increase of 10 percent.
Shelley Rouillard, director of the
California Department of Managed Health Care, said she was investigating the
provider networks of Anthem and a separate company, Blue Shield of California,
because of a gpattern of consumer complaints.h
Stephen Shivinsky, a spokesman for
Blue Shield of California, said: gThere was definitely confusion in the
marketplace. The front-office staff in many doctorsf offices were also confused
about what networks they were in.h
Dr. Lindsay K. Botsford, a family
doctor in Sugar Land, Tex., said it was often difficult to find specialists
willing to take her patients. Even when specialists were listed as being in a
health planfs network, she said, many of the doctors had quotas limiting the
number of patients they would take from plans purchased on the exchange.
The federal government has years
of experience applying network adequacy standards in Medicare. The standards
specify the minimum number of primary care doctors and specialists to be
included in the network of a Medicare Advantage plan, depending on the
population of a county, the population density and other factors.
In addition, Medicare sets maximum
travel time and distance criteria. For example, in Muscogee County, Ga., which
includes Columbus, 90 percent of the Medicare beneficiaries must have access to
primary care providers within 10 miles and 15 minutes of their homes, and to
cardiologists within 20 miles and 30 minutes.
In a large metropolitan area,
Medicare beneficiaries are supposed to have access to primary care doctors
within five miles and 10 minutes.
Insurers oppose highly
prescriptive federal rules, saying consumers should be free to choose cheap
plans with narrow networks or more expensive plans with broader networks.
For many health plans sold on
insurance exchanges, premiums were lower than expected this year. One reason,
insurers say, is that they were allowed to devise health plans with fewer
doctors and hospitals than have typically been included in employer-sponsored
plans.
Moreover, insurers say, when they
are selective, they can exclude lower-quality doctors and hospitals.
June 27 was the deadline for
insurers to file applications with the Obama administration if they wanted to
sell insurance next year in the federal marketplace serving 36 states.
Aaron Albright, a spokesman at the
Centers for Medicare and Medicaid Services, which runs the federal exchange,
said, gWe are increasing our review of provider networks.h
In their applications, insurers
were required to list every doctor, hospital and pharmacy in their networks.
Federal officials are analyzing the adequacy of those networks with the same
computer software they have used to evaluate Medicare Advantage plans.
The software, developed by Quest
Analytics of Appleton, Wis., is also used by many insurers.
gThe Medicare standards have been
vetted and accepted by health plans,h said John P. Weis, the president and
co-founder of Quest Analytics. gItfs natural that the government would use
similar standards for the federal insurance exchange.h
The software measures the distance
between each potential beneficiary or policyholder and each doctor and hospital
in a geographic area, performing hundreds of thousands of calculations.
Under federal regulations, an
insurer must have ga network that is sufficient in number and types of
providersh to ensure that gall services will be accessible without unreasonable
delay.h
In a recent memorandum to
insurers, the Obama administration said it would focus on gthose areas which
have historically raised network adequacy concerns, including hospital systems,
mental
health providers, oncology providers and primary care providers.h
Under the new standards, insurers
will generally be required to have contracts with at least 30 percent of
gessential community providersh that treat glow-income, medically underserved
individualsh in their area. These providers include community health centers,
clinics for people with H.I.V./AIDS
and family planning clinics.
Some states are setting higher
standards. Monica J. Lindeen, the commissioner of securities and insurance in
Montana, said she had told insurers on the federal exchange that they must
strive to include 80 percent of essential community providers in the state.
gMontana is a huge state that is
sparsely populated,h Ms. Lindeen said. gThe 30 percent federal standard is not
in the best interests of Montanans and could result in the closest essential
community provider being 400 miles away.h