The Big Squeeze: ACA Health Insurance Has Lots Of Customers, Small Networks

The Affordable Care Act may struggle to succeed.

A record number of participants over the past two years has attracted more consumers to the health insurance market. At the same time, many insurance companies have begun offering smaller chains of doctors and hospitals to keep prices competitive.

This combination makes it difficult for some patients to find doctors or medical facilities available online. This can be a problem, especially when claimants must rely on their insurance company's inaccurate supplier listings. A recent federal report found that 243 of 375 insurer plans reviewed by regulators did not meet network standards.

"The Last Thing He Needs"

Take, for example, the case of a police officer in central Pennsylvania who broke his arm and a bone near his eye in January.

Kelly Althaus, a patient insurance agent who works near Redding, Pennsylvania, said he was referred to a hospital that offers emergency orthopedic care. Althouse customers spend hours calling podiatrists listed in their new provider directory. The plan is developed by Ambetter Health, a national carrier that began offering ACA plans in Pennsylvania in 2019. Some doctors say they are not part of the network, although they are registered with the company, Althaus said. It took about 15 tries before his client found an online doctor to see him.

Althaus said that "the last thing she needs is for her to feel bad already."

He has been repeating this story on a regular basis since the beginning of the new planning year in January. His clients bombarded him with phone calls saying that various doctors and other health care providers did not accept insurance, even though those providers were listed in the plan's directories. “It amazes me how many offices tell my clients, 'We've never heard of this company,' says Althaus.

For their part, Ambeta said in a written statement to KHN that their network in Pennsylvania "meets or exceeds regulatory standards."

The size of insurance networks for contracted doctors and hospitals, especially in ACA plans, has long been a concern. In recent years, insurance companies have offered smaller networks to keep costs down and control premiums.

Problems arise when patients cannot find a provider in the local network and must pay more for out-of-network treatment if it is included in their plan or travel farther for in-network treatment.

This should no longer be the case as new rules were introduced this year to address this issue.

Take a closer look, but is this enough?

First, federal regulators are double-checking whether insurance companies have enough service providers. This follows a 2021 court ruling that rejected the Trump administration's decision to eliminate such federal oversight.

In addition, a new “time and distance” standard has come into effect, requiring insurers to provide at least one provider for doctors of various specialties within specified distances. For example, in a large urban area there should be enough endocrinologists that at least 90 percent of applicants can find one within a 15 mile or 30 minute drive.

However, insurance brokers in many states told KHN that many consumers struggle to find in-network providers with different health plans. Even when they do, some patients plan to "have to wait four to five months to see their PCP," said Tracy McMillan, president of the Marketplace Insurance Exchange in Dallas and Fort Worth.

Under the Affordable Care Act, insurers must "provide an adequate choice of providers". But there is no single national standard against which to measure network adequacy, and federal and state regulators have the power to oversee the program.

“This exchange network has never had very high control,” says Karen Politz, senior fellow at CFF.

But in some cases, access is still limited, and even the standards themselves may not be strict enough, policy experts and brokers say.

“ We have insurance companies that don't even have hospitals in some states,” says Lauren Jenkins, owner of Native Oklahoma Insurance, based in nearby Tulsa. “How did they get permission to be in this environment?”

In a metro area no more than 40 miles away, the plan could theoretically include 10 doctors and three network facilities and still meet those standards, Politz said.

In Texas, North Carolina, and other parts of the country, new companies have entered the ACA market, often charging lower premiums. Some chains are "too small," says Don Hilke, owner of ClearBenefits Group in Durham, North Carolina. Even the largest operators are strengthening their networks to compete on price, or signing up so many subscribers that they are expanding their existing networks.

'in all senses'

In Texas, two small insurers have pulled out of the market, leaving insurers without enough doctors to serve insurers who have been forced to seek other coverage, said Ronnell Nolan, president and CEO of Health Agents for America, an independent agent affiliate. "It sours everyone."

Federal regulators are proposing more changes next year, including requiring insurers to meet acceptance waiting time standards.

More has been done this year, including a review of insurance networks, said Ellen Montz, associate administrator and director of the federal Center for Consumer Information and Insurance Supervision, which is part of the Centers for Medicare and Medicaid Services.

Insurers deemed to have gaps in their network are now required to report to CMS on a monthly basis about "good faith efforts to address those gaps" and how many complaints they have received from consumers about access, he wrote.

Monz did not say how many insurers failed, but a December report from the US Accounting Office said CMS found that most insurers whose medical or dental plans were reviewed by federal regulators in August did not meet the network's eligibility standards. CMS told the GAO that all plans ultimately met the requirements or "provided an acceptable rationale for why they did not meet the criteria."

According to Jeanette Thornton, executive vice president of policy and strategy for AHIP, a leading health insurance lobby group, building a network and keeping the list of participating providers up to date is an ongoing challenge. This includes requiring providers to notify insurers when they move, retire, or stop accepting new patients.

Questions remain about the accuracy of the supplier catalog. Dr. Neil Butala, an assistant professor at the University of Colorado School of Medicine, found that less than 20% of more than 449,000 physician listings in five major insurance directories contained consistent address and regional data, according to a study published in March. 14 in the Journal of the Medical Association. America.

The lawsuit, filed in August 2022 in the U.S. District Court for the Northern District of Illinois, alleges that Ambater Centene's package provider network is "false and often a copy of a doctor's handbook from another source."

The lawsuit alleges that without a proper directory, patients face "delayed care, inability to get help, having to travel hundreds of miles to see in-network providers, and out-of-network co-payments." Included in ongoing lawsuits filed in 2021 by San Diego City Attorneys against three California insurance companies.

The No Surprises Act, which went into effect over a year ago, requires insurers to update their supplier directory every 90 days. CMS' Montz said no insurance company has yet been fined for not renewing it. The law also states that if a patient requests payment for out-of-network services based on inaccurate information, the insurer may only charge the patient for in-network services.

In October, CMS published a formal request for comment on whether the federal government should create its own national database of network health care providers, a request that received hundreds of responses both in favor and against.

There is no indication as to whether such plans will continue.

KHN (Kaiser Health News) is a national news service dedicated to in-depth reporting on health issues. Along with analytics and political research, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is a non-profit organization dedicated to providing information about the health of the nation.

Copyright 2023 Kaiser Health News. To learn more, visit Kaiser Health News.

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