Exchange Plan Networks Still A Mystery


“Having a serious conversation about public exchange plan provider networks is difficult, because many of the plans are still creating their networks.” 

Editor’s Note: Why do exchanges, or anyone else for that matter, need to have networks of providers? Allow consumers to seek and receive medical care from the providers of their choice. Whether you go to Dr. Smith or Dr. Jones, the insurance plan would pay the same. It’s that simple.

Having a serious conversation about public exchange plan provider networks is difficult, because many of the plans are still creating their networks.

Dr. Robert Gottlieb, a physician affiliated with the American Enterprise Institute, made that argument during a House Ways and Means health subcommittee hearing on the Patient Protection and Affordable Care Act.

Gottlieb testified he and colleagues tried to verify rumors that typical exchange plans will have narrow provider networks in 2014 by reviewing exchange plan provider network information.

For the most part, Gottlieb said, “this information isn’t available. We looked hard for it.”

PPACA includes a vaguely worded provision requiring exchange plans to have enough doctors and hospitals in their networks, and some states with state-based exchanges haven’t gotten their provider directory databases working.

In some cases, the plans still seem to be putting their networks together, Gottlieb said.

When Gottlieb’s team looked at the directories they could locate, they found that one plan in New York City listed no gynecologists.

In San Bernardino, Calif., one plan directory showed that the nearest in-network urologist would be 80 miles away.

Gottlieb’s team tried to get a more systematic view by focusing on provider directories at one large carrier that operates in many states and has done a good job of posting the directories.

Even at that carrier, “the numbers are pretty grim,” Gottlieb said.

Some physicians are reluctant to accept exchange plan patients, because it’s not clear how physicians will get paid if they treat alleged exchange plan enrollees who fail to pay their premium bills and turn out not to have valid coverage, Gottlieb said.

But Mike Kreidler, the Washington state insurance commissioner, said many people in his state have had terrible health care access under the old rules.

One million are uninsured, and 300,000 have substandard policies that fail to cover essentials such as prescription drugs, Kreidler said.

Physicians have been calling to complain about carriers failing to pay their bills for years, Kreidler added.

PPACA and the exchange plan enrollment system might have glitches, but “Rome wasn’t built in a day,” Kreidler said. “We need to be patient and move forward.”