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Provider – Doctor & Hospital Finder

Provider directories for some health plans sold through Covered California and in the private market are so inaccurate that they create an “awful” situation for consumers trying to find doctors, according to the lead author of a new study published in the journal Health Affairs.  Learn More ==>  CA Health Line 7.8.2016

AB 533 If you go to a contracting facility, but receive covered services from a non contracting provider, you only pay the in-network co pays, co insurance, out of pocket maximums.  Learn More Blog Insure Me Kevin.com

ACA Plans have higher premiums and narrower networks per several analyses  CA Health Line 11.12.2015

National Assoc. of Insurance Commissioners to address ACA Plan Networks

The recommendations — proposed in the form of a model state law — aim to:

  • Help consumers receive in-network care; and
  • Protect consumers from high costs if they receive out-of-network care.

The proposal recommends that when determining whether health plans have adequate provider networks, insurance commissioners should consider factors such as:

  • Appointment wait times;
  • The ability of insurers to meet the health care needs of low-income enrollees and “children and adults with serious, chronic or complex health conditions or physical or mental disabilities”;
  • The ratio of plan enrollees to the number of physicians in each specialty who are included in the network; and
  • The “geographic accessibility of providers.”

The proposal also would require insurers to update their provider directories at least once monthly.

The proposal calls for hospitals and insurers to notify patients of any possible extra charges they could incur from health care providers who are not included in their insurers’ networks.

Further, the proposal recommends that when individuals receive out-of-network care, they should not be required to pay more than the typical share of costs they would be required to pay for in-network services  CA Healthline 11.9.2015

Gov. Brown signs bill mandating accurate provider lists  Word & Brown 10.13.2015

75% of new individual plans in CA have narrow networks, meaning 25% or less of the physicians in a rating area.  The study  recommends a labeling system (Blue Cross Group Labels) akin to T-shirt sizes, going from extra small to extra large. Extra small and small are narrow networks under the researchers’ 25% definition.    LA Times 8.26.2015

Study Finds almost 1/2 of Obamacare Plans have very limited Physician Networks  KHN 6.26.2015

11 percent of plans “extra small” because they covered fewer than 10 percent of physicians in a plan’s region.
Another 30 percent were “small,” meaning they covered between 10 and 25 percent of physicians.
Just 11 percent of plans were classified as “extra large” because they covered at least 60 percent of physicians in the area.

New York Times 5.8.2015 White House moves require Insurers to:

  • have Accurate and Working Provider Finders
  • List plans by total expected costs – not just lowest to highest premiums

SB 137 Hernandez   Los Angeles Times   CA Law Website    CA Health Line  would require weekly updates to provider lists

10.28.2014 USA Today

Exchanges need better networks or better provider finders and explanations. modern health care.com/2014 08 07/

New Standards – Federal & State for MD Provider Lists californiahealthline.org2014/7/21/

Need to provide more and better information  modernhealthcare.com/2014 07 21

8.6.2014 Push to widen networks CA HealthLine

Narrow Networks – in vogue or what – discussion….  californiahealthline.org/

Health Net biggest culprit in Arizona Exchange californiahealthline.org/2014/7/8/

latimes.com 2014 06 29

•Anthem Blue Cross Blue Shield of California

***Who is that?

since Jan. 1 has increased the number of physicians in its exchange plan networks by 70% and the number of hospitals by 19%;
•Health Net has increased its physician network by more than 68%; and
•WellPoint has also substantially expanded its network.  californiahealthline.org/2014/6/10/


One reason we prefer email and the website to phone calls – Insurance Company Denies that policy holder was told procedure was covered and MD was on the list, even though customer taped the conversation. latimes.com 2014 05 16


HN bulletins on AB 369 Continuity of Care  healthnetpulse.com/2014/04/18/ab-369

Insight from another Insurance Agent….

I’ve been told repeatedly by the carriers that they do not have two different networks for on and off exchange plans. Doctors are confused about CC plans and off exchange IFPs.

The carriers have told me that the reimbursement schedules are the same for on and off exchange plans.

If the plan is a PPO, then out of network conditions will apply which might result in meeting a separate deductible and higher coinsurance.

I always defer to the carriers provider search function. If the doctor says they aren’t in-network, but the search function shows they are, then that is an issue for the carrier and physician to sort out. Unfortunately, the client is caught in the middle.

Both the carriers, physicians, physician groups and CC have been notably silent on this problem. There is lots of finger pointing and I doubt that DOI or DMHC will step up to the plate and force a solution.

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