Obamacare: Consumers frustrated when their doctor is not in their plan

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For Sofia, a 58-year-old San Diego resident who's been fighting breast cancer since 2010, the Affordable Care Act was a godsend.  

"A year ago, I could not get coverage because of a preexisting condition," said the former communications consultant, who asked that her real name not be used.  "Now, I could at least get the coverage." 

Covering California series icon 2013Under the ACA, no one can be turned down for coverage because of a preexisting condition. The federal law came at a particularly crucial moment, since the cancer had forced Sofia to close her business at about the same time her husband lost his job.   


But finding the coverage she needs and wants has proven far more challenging than Sofia anticipated. After getting notice that the transitional federal insurance she had under the Affordable Care Act would be ending, Sofia went shopping for a new plan through the state’s insurance marketplace, Covered California. She says she spent more than 80 hours searching for a policy that would allow her to keep her doctors. 

"It was very hard to find out," she said of her quest that began in October, when Covered California first opened to the public.  "In order to get the information as a consumer, one would have to call every single assistant at every  [physician's] practice to find out, because there was no information available online or on the insurance companies sites."

Related: KPCC's Coverage of Covered California

Ultimately, Sofia found a subsidized plan that includes her UC San Diego cancer team.  But it did not include her cardiologist and most of the other doctors she’s seen for the past 25 years, because they are affiliated with Scripps Research Institute. 

"None of the programs under Covered California, which we need because of our financial situation, accommodated both UC San Diego and Scripps," she said. 

Insurance companies narrow their provider networks to save money, and they started doing it long before the Affordable Care Act was passed into law. But while the trend pre-dates Obamacare, it’s become more visible because of the federal health law.

Essentially, narrow networks happen in one of two ways: either an insurance company excludes providers it considers to be too expensive, or a doctor or hospital rejects the reimbursement rates offered by the insurer. Complicating things further is the lack of accurate information about who is – and isn’t – in Covered California plans.

"I think the narrow networks are going to be a really ugly surprise for a lot of people," said Jeffrey Miles, a Marina del Rey insurance broker and two-time past president of the California Association of Health Underwriters.  "I think even people on plans where they’re absolutely certain their doctor is on their network might find otherwise."

That’s what happened to Mona Rouse of Santa Ana. After years of being turned down for health coverage — due to her husband’s preexisting back problems — she says she was thrilled to finally get coverage under the health law. 

Like Sofia, Rouse, too, spent hours researching plans, calling providers and insurance companies before choosing a subsidized policy that she thought included her husband’s back surgeon.

 But when Rouse called to make an appointment, she was told that, while the doctor did in fact contract with her new provider, he declined to participate in the company’s Covered California plan. 

"The system doesn’t distinguish whether they’re accepting the affordable plan or not, so that’s really the dilemma," Rouse said.

As if that doesn’t make things hard enough for consumers, doctors don’t always know that the insurance company they contract with has included them as a provider in its Covered California plans.

"The plan can essentially require the physician to participate in this new product – which would be Covered California - without the physician signing a contract," said Lisa Folberg, a vice president with the California Medical Association, which represents 37,000 thousand doctors statewide.

And that’s frustrated insurance brokers, like Tom Frekker of Fountain Valley.

"The doctors' offices are literally telling their clients, 'we don’t know which plan we’re in, here’s our tax ID number, can you call and see if we’re in their plan,'" he said. "It's just bizarre."

Folberg says a big part of the problem is that insurance companies’ provider network lists aren't always accurate.   And now, she says, that problem is magnified by the ACA's requirement that most Americans buy insurance.

"There hasn’t been a time where new networks have been put together so quickly as with Covered California," Folberg said. "So I think a lot of the underlying problems are being highlighted through Covered California, even if they aren’t problems created by Covered California."

Folberg says until Covered California gets accurate network information that it can post in full on its website, consumers should make sure to confirm provider choices with their insurance company and with their doctor’s office. 

Those, such as Rouse, who have done so and have found their doctor missing still have until March 31 — the last day of open enrollment — to choose a new policy.