As consumers pick health plans, sorting out which doctors are in which plans is still a headache

As the third enrollment season winds down, the Covered California health exchange is still pushing hard for last-minute new signups. Since the beginning of November, 83,000 people and counting have signed up for first-time coverage under health plans offered by the state's health insurance exchange, officials announced.

But challenges remain for those still shopping the exchanges for a new health plan. The insurance marketplaces offer consumers a multitude of options, but sorting out which plan bests suit their needs can be a slog. That’s especially true when it comes to figuring out whether a particular doctor or specialist is part of a plan’s network of providers.

“Right now, it’s supposed to be possible to search but it’s very difficult,” said Dena Mendelsohn, a staff attorney with Consumers Union. “You should be able to see what providers are in the plan before you buy the product.”

That’s especially important for consumers who want keeping seeing their chosen primary care doctor or specialist. Policyholders can’t assume that because a doctor signed on with a plan one year, he or she will do the same the next. Such assumptions could mean big bills later if a patient visits an out-of-network physician, either by necessity or by accident.

Consumers may be savvy enough to understand that due diligence is required, but the information isn’t always easy to obtain. Covered California’s website points would-be policyholders to insurance carriers for more information about the network within a given plan. But carrier websites don’t always make the information available, and if they do, it may be incomplete or inaccurate.

In November, the California Department of Managed Care fined Blue Shield of California $350,000 and Anthem Blue Cross $250,000 for inaccurate directories that unwittingly led consumers to get care out of network at a much higher price. Such “surprise bills” have been a rising concern in recent months.

Instead of relying on directories, some consumers will check with their doctors to see if they’re included in given plan, said Mendhelsohn. “That’s a good choice, but in some cases the providers don’t even know what insurance they’ve contracted to take.”

In addition, a doctor may officially be part of a plan’s network, but not accepting new patients. Or the wait to see a specialist can be months. That’s because all over the state, enrollments in Covered California and Medi-Cal, the state’s Medicaid program, are squeezing the limited supply of doctors.

The physician shortage is hitting residents of rural areas especially hard. The Sacramento Bee recently reported that there are 214 “doctor deserts” in California, in which there is only one physician to care for every 3,500 people. In non-desert areas, the average is one doctor per every 1,000 people. Even if every available provider signs on with an insurance carrier, there simply are not enough doctors.

“Any time you’re looking at specialized care, it is much harder to access,” said Bekki Emery, deputy director of Employment and Family Assistance Services with the Health and Human Services Agency in Mendocino County. “If you live in a town of 100 people, the likelihood that you will have all the specialized treatments is significantly lower. It’s one of the challenges of living in a rural area.”

Which is why understanding exactly which providers are covered by a given plan is important, said Mendelsohn of Consumers Union. Key to that is an easily available, up-to-date provider directory for every insurance plan.

The Healthcare.gov federal exchange recently rolled out a new website feature that allows consumers to enter the name of any provider or prescription drug and know immediately whether a given plan covers it or not. Unfortunately, the same has not happened in California. Nonetheless, help is on the way, Mendelsohn said. In October, California’s legislature passed SB 137, which will require carriers to make available updated and accurate provider directories. The bill goes into effect in July 2016.

But whether such updated directories are easy to use and widely consulted by patients remains to be seen.

[Photo by Pete via Flickr.]