The Affordable Care Act may be struggling with its own success.
Record enrollment over the last two years brought more consumers into the health insurance market. At the same time, many insurers began offering smaller networks of doctors and hospitals, partly to be price competitive.
That combination left some patients scrambling to find an available in-network physician or medical facility. That can be a challenge, especially when enrollees must rely on inaccurate provider lists from their insurance company. A recent federal report found that 243 out of 375 insurance company plans reviewed by regulators failed to meet network standards.
‘The last thing she needed’
Take what happened to a central Pennsylvania policyholder, who in January fell and broke her arm and a bone near her eye.
She was directed by the hospital that provided her emergency care to follow up with an orthopedist, recounted Kelly Althouse, the patient’s insurance agent, who works near Reading, Pa. Althouse’s client spent hours calling orthopedic doctors listed in the provider directory of her new health plan from insurer Ambetter Health, a national carrier that in 2019 started 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 an in-network doctor who would see her.
That “was the last thing she needed when she was already feeling terrible,” said Althouse.
It’s a story that has been repeated to her multiple times since January, when the new plan year began. Her clients have “bombarded” her with calls, saying a range of physicians and other providers were not accepting the insurance, even if that provider was listed in the plan’s own directory. “The thing that shocked me was how many offices told my clients, ‘We have never heard of this company,'” Althouse said.
For its part, Ambetter officials said in a written statement to KHN that their network in Pennsylvania “meets or exceeds regulatory standards.”
The size of insurers’ networks of contracted doctors