Bill aims to help those with complex conditions if their insurer leaves the market

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In response to some health insurers leaving the individual market, state lawmakers are considering a bill that would ensure continuity of care for people with complex health conditions. The measure would require a new insurance firm to cover the providers of qualifying patients, even if the provider isn't in the insurer's network. The insurance industry says the bill would provide a blank check for out-of-network care in some instances.

Anthem Blue Cross recently said it will stop offering individual plans on and off Covered California in most of the state next year, and Cigna said it will pull out of California's individual market entirely in 2018.

Sen. Ed Hernandez (D-West Covina), the author of SB 133, recognizes the bill would obligate insurers to cover costly care provided by doctors who are not in their networks, but he says it would only be needed on rare occasions.

People with common health problems won't have trouble finding new doctors to treat them if they have to switch insurers, he said. "But [for] some very, very rare conditions, it could be difficult to find somebody who has a specialty in heart transplants for infants or children," said Hernandez.

The bill has passed the state Senate. A different version is in the Assembly. Hernandez hopes both chambers can agree on one version before the legislature adjourns on September 15. 

The insurance industry says it understands the concerns behind Hernandez' bill, but it is opposing the measure. 

The industry's main concern has to do with SB 133's provision that would guarantee "indefinite access to out-of-network care" to patients who require a heart, kidney or lung transplant, said Mary Ellen Grant, spokeswoman for the California Association of Health Plans.  "As a result, this proposal would increase health care costs and is counter to our efforts to provide quality managed care to our members."

Joanna Joshua says the bill would help her. Her two-year-old daughter, Jasmine Winning, has a rare congenital heart condition. Joshua not only ferries her around to several specialists, but she has spent a lot of time fighting with her insurer, Cigna, to make certain her daughter’s multimillion-dollar care is covered.

"It’s a struggle. It’s an everyday struggle," she said.

Now with Cigna leaving the individual market, Joshua hopes the legislature approves SB 133, so that she can keep her daughter's providers when she switches insurers.

Winning has had two open-heart surgeries and she'll need another surgery next year.

"I just need to be able to have one insurance company that knows her condition. And one hospital that’s familiar with her unique anatomy," said Joshua.

 

 

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