Todd Miller was happy when the Affordable Care Act meant health insurers could no longer turn him down for coverage based on his prior case of tennis elbow. But the Monterey County internet entrpreneur was disappointed that his Anthem Blue Cross PPO did not have a specialist in his area who could treat his severe sleep apnea.
Having to go out of network means he'll have to pay a lot more for his care.
"I’ve gone from a place where I really should have been an ACA success story," he says, "to a point where I’m paying over $7,000 per year for health insurance but can’t really get much in return for that."
Miller’s story illustrates a new conundrum in the world of health policy: how to ensure consumer access to health care at a time when health plans are narrowing networks to hold down costs.
Among the proposed solutions: AB 2533.
The measure, authored by Assemblyman Tom Ammiano (D-San Francisco), would in some cases require health to plans to allow people like Miller to get care from an out-of-network provider at the same price as it would cost them to use an in-network provider.
"It does create a new protection where the insurer or health plan would either have to find them an in-network provider on a timely basis or arrange or assist them in arranging for out-of-network services" at no extra cost, says Dylan Roby, director of the Health Economics and Evaluation Research Program at UCLA's Center for Health Policy Research.
And, Roby says, that could ultimately prove significant to consumers.
"But I think it’s important to keep in mind the bill doesn’t explicitly say that a consumer can go out of network and then come back to their health plan and say, 'Your network wasn’t adequate and now you need to pay for the care I received out of network,'" he says.
The measure leaves the details of how consumers would receive the cut-rate out-of-network care to state regulators.
Opponents, including the California Association of Health Underwriters, say the bill will cost insurers more money, which they’ll be forced to pass on to consumers in the form of higher premiums.
The California Association of Health Plans, also opposes the measure.
"There are really strong consumer protections already in place," says Nicole Kasabian Evans, spokeswoman for the Association of Health Plans. "So we think this bill is redundant and unnecessary."
But supporters, which include the California Nurses Association and the American College of Emergency Physicians, say more consumer protections are necessary.
That’s especially true as so many low-and-moderate income families now have insurance under the federal health law, says AB 2533 supporter Anthony Wright, executive director of Health Access California.
"For these families going out of network is just simply not an option," he says.
AB 2533 would also expand the regulatory powers of the two state agencies that regulate heath insurance plans statewide: the Department of Managed Health Care, which oversees about 90 percent of health plans, and the California Department of Insurance, which regulates the remaining 1o percent.
Most notably, Roby says, the bill would for the first time give the Department of Insurance the ability to penalize insurers who fail to provide consumers with timely access to adequate provider networks, as the Department of Managed Health Care is already able to do.
But perhaps most immediately helpful to consumers, is a provision that would require health plans to report all of their denials of care and all the complaints they receive to DMHC and CDI, which would then post them on their websites.
"People could see which insurance companies have bigger problems with network adequacy and which ones didn’t; which ones had high rates of complaints or grievances," Roby says.
AB 2588 will move to the full Senate for a vote that could come as early as this week.