You're Enrolled in an Obamacare Plan: Will Your Doctor Accept Your Insurance?

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(Getty Images)
(Getty Images)

It's been about six weeks since a half-million people saw their Covered California health insurance plan take effect. And in that time, those who have needed care have experienced the good, the bad and the ugly of finding a provider who will accept their insurance.

Let's start with people who are dealing with some significant challenges.

I've been following Sue Kearney of Oakland. After confirming her doctors would take the insurance, she enrolled in an Anthem Blue Cross subsidized PPO plan with Covered California last fall. Then she scheduled appointments for early January. She has ongoing chronic health issues, and the thing she said she needs most is a colonoscopy.

But at her first appointment, she was told that the doctor did not accept any Covered California insurance. Ditto for the other doctors. Kearney set up a screen share with me, logged into her account and confirmed for me that doctors showed up as accepting her insurance, but the office said they didn't when she called them. Ultimately, Kearney was referred to a specific customer service representative with Anthem Blue Cross to help her find an in-network doctor to perform her colonoscopy. I promised to check back in.


In the meantime, I talked to Larry Levitt, senior vice president at the Kaiser Family Foundation. The Covered California "exchange has created a much more competitive market, and the main way plans have to control costs is by narrowing networks" of providers, he said. That's not necessarily a bad thing. The issue of limiting networks is not new but the implementation of the Affordable Care Act has "accelerated the trend," Levitt said.

The other thing the ACA has done is highlight how difficult it is to maintain an accurate provider database. Late last week Covered California took down its online database of providers because it contained too many errors. But Covered California's database can only be as accurate as what is provided by insurance plans. "It's always been a challenge to nail down these networks," Levitt said. "They're constantly in flux."

Indeed, doctors move from one group to another or are affiliated with a larger group. Plans are negotiated at the group level, but it might not be communicated to individual offices which health insurance they should accept. Or there could be other issues. Darrel Ng, a spokesman with Anthem Blue Cross, said the company has a "team of people" whose job is to maintain the database, but its "urgency and intensity has picked up" since Jan. 1. He also said that medical groups are contractually required to notify Anthem if a doctor leaves the group -- but he said that doesn't always happen.

Does a provider's office even know what insurance it accepts?

Heather Tralla or Northridge enrolled in a Blue Shield-subsidized Covered California plan -- the "Enhanced PPO Covered California" plan --  last fall. She has multiple sclerosis and, in mid-January, a doctor referred her for two MRIs. Tralla said she logged into her account with Blue Shield to look up facilities that would accept her insurance.

She then spent more than two weeks trying to find a provider. While her online account showed many facilities, when she called the offices all said they did not accept Covered California insurance. They said they would accept the "Enhanced PPO" plan from Blue Shield, but not the "Covered California" version. She said supervisors she spoke to at Blue Shield initially told her that the two plans have the same network -- then others told her they have different networks.

Ultimately, Tralla called one of the MRI providers so many times that the office finally called her in early February to say that the provider had signed a contract that day to accept the Covered California plan. She had her two MRIs late last week.

I contacted Steve Shivinsky, a spokesman for Blue Shield, who told me the networks for their "Enhanced PPO" plans are the same. "It doesn't matter if you purchase (the plan) on or off the exchange," he said via email.

But that has clearly not been Tralla's experience. "I got my MRI taken care of," she said. "But what's going to happen the next time?"

Without insurance, "I would have wound up in the ER, or probably dead"

Then there's Richard Walker of San Francisco. He's the kind of person advocates of a health insurance overhaul talk about. Walker had been uninsured since 2004. In December, he enrolled in an Anthem Blue Cross subsidized plan through Covered California. Walker had delayed medical care until his insurance became effective Jan. 1.

He may have gotten to a doctor in the nick of time.

Upon examination, Walker's physician, Luis Rodriquez of One Medical Group, suspected Walker had "DVT" or deep vein thrombosis -- a blood clot that had formed in a vein in one of his legs. In a later interview, Rodriguez called it a "life-threatening" condition and referred to Walker as a "ticking time bomb."

Walker needed an ultrasound test immediately. It confirmed the DVT. Treatment was two medications --  a blood-thinner, available as pills, and a second injectable drug, which is very expensive. Walker had only a few hiccups having his insurance cover both the tests and the medications he needed.

Today, he's pretty grateful. While he said he "had an idea" something was wrong, "I would have wound up in the ER or probably dead" without the Affordable Care Act and the insurance he accessed because of it.

Kearney still waiting

After I'd talked to Walker, I checked back in with Kearney. She said she needed a blood transfusion and ended up being hospitalized overnight. While that stay appears to have been covered by her insurance, the Anthem Blue Cross customer service representative she has been working with still has not been able to find an in-network doctor to perform the colonoscopy she needs, she told me.

"Where I'm supposed to go to get these tests is a huge mystery," she said -- and she's getting very frustrated.

The question of in-network versus out-of-network hits hard on the pocketbook. Kearney's out-of-pocket maximum is $2,250 -- as long as she stays with in-network providers. If she goes out-of-network, her maximum goes up to $10,000.

Covered California says more than 80 percent of California doctors are included in the exchange as well as a "substantial majority" of the state's hospitals.

California's Department of Managed Health Care regulates most of the plans offered under Covered California. (One Health Net plan falls under the Department of Insurance purview). Marta Green, a spokeswoman with DMHC, said that plans must have a primary care provider-to-enrollee ratio of 1-to-2,000 and an overall physician-to-enrollee ratio of 1-to-1,200. "If for some reason the health plan does not have a particular type of specialist that an enrollee needs to treat a condition," Green said via email, "then the health plan is obligated to find such a provider and cover those services."

Green added that anyone who is having trouble accessing care through his or her insurance can contact the department's help center.

Listen: Lisa Aliferis interviewed by Rachael Myrow on The California Report


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