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Finding health plans that include the doctors you want

HealthInsuranceConsumersAffordable Care Act (Obamacare)

Shopping for doctors is never easy. This year, the state's new health exchange seems to be making it tougher than ever.

Ask Ron Harris of West Hollywood. At age 62, he is looking to use Covered California to get a policy that lets him keep a handful of doctors he likes. But like many others applying for coverage, he finds his choices are not always to his liking.

“My internist is not on the plan,” he says. Neither is his orthopedist or any of the specialists recommended to him by his primary care doctor.

As a result, he has a difficult choice to make: Keep looking for an affordable plan with the doctors he likes, pick a plan with new doctors, or sign up for a plan that allows care by out-of-network docs — typically at a higher cost.

Many consumers like Harris who currently have insurance and are shopping for a new plan through Covered California are finding it difficult to locate policies that include the doctors and hospitals they're accustomed to seeing.

Insurance brokers aren't finding the process any easier. “Three words: It's a nightmare,” says Craig Gussin, insurance agent and principal of San Diego-based Auerbach & Gussin Insurance and Financial Services Inc.

Most of the insurance companies on the exchange are offering provider networks that are far narrower than the other plans they're selling outside of the exchange.

Just how much narrower, however, isn't clear. “It is hard to pin down,” says Lisa Folberg, vice president of medical and regulatory policy with the California Medical Assn.

Covered California issued a report last week saying that more than 58,000 physicians were available through the exchange's plans, compared with the 63,000 to 72,000 physicians in the state's largest commercial networks.  But how that plays out for consumers probably depends on the specific plan they choose.

Blue Shield, the San Francisco-based nonprofit insurer, says it is offering a network through its exchange plans that represents roughly 50% of its full network.

In many cases, even doctors themselves are unsure of their status in the new plans. Insurers have a long history of inaccurate and outdated provider listings, which the law does nothing to fix. And the provider lists found on Covered California have themselves been riddled with errors.

“We found quite a few inaccuracies,” Folberg says.

Changing and ever-shrinking provider networks do pose a challenge for consumers, but they're nothing new, says Patrick Johnston, president of the California Assn. of Health Plans, which represents 40 health plans insuring more than 21 million Californians.

“Even before the Affordable Care Act, networks changed because health plans and physician groups reached different agreements,” he says.

Many of the benefits of the Affordable Care Act may make coverage more expensive, he pointed out. Plans must now provide standard benefits across all of their products. Annual limits on out-of-pocket costs apply, and, of course, they must now accept all comers and cannot charge people with preexisting medical conditions more than the healthy.

To make insurance affordable, Johnston said, insurers are seeking to control costs in part by limiting the number of doctors and hospitals included in their networks.

The question for consumers, Johnston says, is whether they can locate a plan that has good doctors and hospitals at an affordable price.

And that's the very question Harris has been wrestling with for more than a month.

“What I'm concerned with is how do I decide if I continue to see my primary care physician? To be honest, I'm spoiled in being able to go to any doctor I want,” he says.

Experts offer some tips for consumers in the market for a plan that includes the doctors they wish to see.

Do your homework. Check directly with both your health plan and your doctors and hospitals, particularly if your choice of policies is based on keeping the doctors you like. Unfortunately, you'll need to check each plan's network individually for your doctor. Folberg offers an additional warning: Even if your doctors of choice are listed as participating with your plan, be sure to inquire as to whether the office is taking on new patients.

Don't be afraid to switch plans. Open enrollment runs through the end of March. If you're unhappy with the plan you purchased early in the year, or learn that you don't have access to the doctors you thought you did, you can switch to another plan before March 31, 2014.

Enlist the help of an insurance agent. Local insurance agents certified to sell you a health plan through Covered California can be invaluable.

Sam Smith, an Encino insurance broker and president of the California Assn. of Health Underwriters, says there is a misconception that if you use an agent you'll have to pay. “It costs you nothing extra to have a certified insurance agent who can help you with the decision,” he says. And, once you're signed up, an agent often works as your advocate when problems with your insurance plan arise.

Finding the right plan has been frustrating for Harris, but he's keeping his sense of humor. “Right now I'm starting to look to see if there's a psychologist in the network, because I'm going nuts.”

healthcare@latimes.com

Zamosky is the author of a new book, "Healthcare, Insurance, and You: The Savvy Consumer's Guide."

Copyright © 2014, Los Angeles Times
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