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Life Health > Long-Term Care Planning

California may add provider network checkers

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Covered California managers want to make sure the commercial plans it sells give patients an acceptable level of access to doctors, hospitals and health care providers.

The staff employees and board of the state-based Patient Protection and Affordable Care Act public exchange are looking into the idea of having an outside organization mobilize “secret shoppers” to check the provider networks.

The secret shoppers would call or visit the providers in a plan provider directory and see whether the providers would take new patients with coverage from that plan, or whether the providers would let patients use that plan to pay for care.

Covered California managers also are looking at other provider network verification options, including:

  • Moving up the date when plan issuers have to start reporting on enrollees’ primary care provider selections and use of preventive services.
  • Requiring plans to demonstrate the accuracy of the information they give out about providers’ in-network or out-of-network status.
  • Requiring plans to measure enrollee provider access satisfaction levels.
  • Sponsoring a plan enrollee provider access satisfaction survey this year, rather than waiting until a federal agency measures access satisfaction in 2015.

The exchange is already helping plan enrollees who call about provider access problems call their exchanges and referring consumers with serious problems to an outside legal assistance organization.

The exchange also is reviewing plan “welcome letters” for accuracy and completeness, and it is setting up information systems it can use to analyze provider network data, exchange managers say in a presentation included in a board meeting packet.

Insurers and independent health policy specialists have argued that letting insurers offer relatively narrow provider networks is a good way to control the cost of coverage while offering patients — including patients with serious health problems — a wide range of services.

Some consumers are objecting to the narrow-network cost control strategy.

Priscilla Myrick, a Berkeley, Calif., activist and plan enrollee, wrote to the board to say she was surprised to find  her providers are no longer in her  network, even though she replaced a pre-PPACA plan with a plan from the same carrier.

She said her plan issuer increases the deductible to $20,000 for out-of-network, from $10,000 for in-network care, and increases the annual out-of-pocket maximum to $30,000, from $12,700.

“This is not acceptable ‘insurance,’” Myrick wrote.

She said Covered California should require carriers to use standard networks for plans and ban the practice of setting extremely high maximum limits on out-of-network costs. 

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