Archive | State Health Exchanges

ObamaCare’s Secret Mandate Exemption

HHS quietly repeals the individual purchase rule for two more years.

ObamaCare’s implementers continue to roam the battlefield and shoot their own wounded, and the latest casualty is the core of the Affordable Care Act—the individual mandate. To wit, last week the Administration quietly excused millions of people from the requirement to purchase health insurance or else pay a tax penalty.

  • This latest political reconstruction has received zero media notice, and the Health and Human Services Department didn’t think the details were worth discussing in a conference call, press materials or fact sheet. Instead, the mandate suspension was buried in an unrelated rule that was meant to preserve some health plans that don’t comply with ObamaCare benefit and redistribution mandates. Our sources only noticed the change this week.
  • That seven-page technical bulletin includes a paragraph and footnote that casually mention that a rule in a separate December 2013 bulletin would be extended for two more years, until 2016. Lo and behold, it turns out this second rule, which was supposed to last for only a year, allows Americans whose coverage was cancelled to opt out of the mandate altogether.
  • In 2013, HHS decided that ObamaCare’s wave of policy terminations qualified as a “hardship” that entitled people to a special type of coverage designed for people under age 30 or a mandate exemption. HHS originally defined and reserved hardship exemptions for the truly down and out such as battered women, the evicted and bankrupts.
  • But amid the post-rollout political backlash, last week the agency created a new category: Now all you need to do is fill out a form attesting that your plan was cancelled and that you “believe that the plan options available in the [ObamaCare] Marketplace in your area are more expensive than your cancelled health insurance policy” or “you consider other available policies unaffordable.”
  • HHS is also trying to pre-empt the inevitable political blowback from the nasty 2015 tax surprise of fining the uninsured for being uninsured, which could help reopen ObamaCare if voters elect a Republican Senate this November. Keeping its mandate waiver secret for now is an attempt get past November and in the meantime sign up as many people as possible for government-subsidized health care.
  • Sources in the insurance industry are worried the regulatory loophole sets a mandate non-enforcement precedent, and they’re probably right. The longer it is not enforced, the less likely any President will enforce it.
  • This lax standard—no formula or hard test beyond a person’s belief—at least ostensibly requires proof such as an insurer termination notice. But people can also qualify for hardships for the unspecified nonreason that “you experienced another hardship in obtaining health insurance,” which only requires “documentation if possible.” And yet another waiver is available to those who say they are merely unable to afford coverage, regardless of their prior insurance. In a word, these shifting legal benchmarks offer an exemption to everyone who conceivably wants one.
  • Keep in mind that the White House argued at the Supreme Court that the individual mandate to buy insurance was indispensable to the law’s success, and President Obama continues to say he’d veto the bipartisan bills that would delay or repeal it. So why are ObamaCare liberals silently gutting their own creation now?
  • The answers are the implementation fiasco and politics. HHS revealed Tuesday that only 940,000 people signed up for an ObamaCare plan in February, bringing the total to about 4.2 million, well below the original 5.7 million projection. The predicted “surge” of young beneficiaries isn’t materializing even as the end-of-March deadline approaches, and enrollment decelerated in February.
  • Meanwhile, a McKinsey & Company survey reports that a mere 27% of people joining the exchanges were previously uninsured through February. The survey also found that about half of people who shopped for a plan but did not enroll said premiums were too expensive, even though 80% of this group qualify for subsidies. Some substantial share of the people ObamaCare is supposed to help say it is a bad financial value. You might even call it a hardship.
  • The larger point is that there have been so many unilateral executive waivers and delays that ObamaCare must be unrecognizable to its drafters, to the extent they ever knew what the law contained.

*Modified from a WSJ.com article

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“Junk” Health Plans and Other Obamacare Insurance Myths

Obamacare affects nearly all areas of health care, but the most disruptive provisions of the law affect insurance sold in the individual market. In 2013, at least 4.7 million policyholders across 31 states and the District of Columbia were notified that their current coverage was being discontinued. The number is likely even higher, since data were not available for 19 states.

  • Myth: The canceled health plans were “substandard” policies.
  • Myth: Before Obamacare, there were routine plan cancellations in the individual market.
  • Myth: Pre-existing condition exclusions were rampant before Obamacare.
  • Myth: Obamacare plans are “better” insurance.

Obamacare’s advocates claim that the law and its plethora of new insurance regulations were necessary to better protect consumers in this market. They discount the large disruption of coverage for millions of people by claiming that the plan cancellations were for “substandard” policies and that plans were routinely canceled in this market regardless of Obamacare. Further, they assert that the law will replace these plans with “better” insurance all of which is largely untrue.

  • Myth: The canceled health plans were “substandard” policies.

President Obama has repeatedly referred to the 4.7 million discontinued policies as “substandard.” When the President announced his administrative “fix” that attempted to allow those with canceled plans to keep their existing plans for another year, Senator Tom Harkin (D–IA) said he was still “concerned about people having policies which don’t do anything. They’re just junk policies.”

Typically, “substandard” refers to plans with limited benefits, which are commonly seen as inadequate because they do not protect against catastrophic costs. These types of plans typically cover routine care, but if there were a major medical event, they might pay only up to a certain amount before leaving the enrollee to pay the rest.

Obamacare gradually phased out these types of plans from 2010 to 2013—completely outlawing them by 2014—by prohibiting both annual and lifetime limits on coverage.

Limited-benefit plans are not nearly as prevalent in the individual market as they are portrayed to be. Of the nearly 16 million enrollees in the individual market in 2012, 725,710 individuals were enrolled in plans classified as limited-benefit plans, and slightly more than a million were in student health plans, which also typically have a limited benefit package. Thus, less than 11 percent of the individual market in 2012 had a plan that could reasonably be considered “substandard.”

Limited-benefit plans are mostly offered by employers in the group market. Indeed, of the temporary waivers received by over 4 million plan enrollees from the Obama Administration for Obamacare’s annual limit caps before they were completely phased out, only 3.7 percent were for individual market plans; the rest were given to enrollees in group market plans.

  • Myth: Before Obamacare, there were routine plan cancellations in the individual market.

Many Obamacare defenders blame the discontinued policies on “bad apple insurers,” claiming that it was typical in this market to have plan cancellations and that they are not a result of Obamacare.

For instance, former Obama Administration official Van Jones called the individual marketplace a “‘wild, wild west’ where people were denied coverage for pre-existing conditions and policyholders were continually dropped by insurers offering thin, sketchy coverage.” In addition, President Obama said, “Before the Affordable Care Act, the worst of these plans routinely dropped thousands of Americans every single year.”

But since the enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), insurers have been broadly prohibited from canceling or refusing to renew coverage. One of the few exceptions to that prohibition is if an insurer discontinues a particular plan or type of coverage. In such cases, the insurer must provide the affected individuals the option to enroll in any other applicable coverage that the insurer offers.

That is largely what happened with the 4.7 million plan cancellations that were reported at the end of 2013. The insurers were discontinuing their pre-Obamacare plans and offering policyholders replacement coverage that complied with Obamacare’s wide variety of new mandates and regulations.

  •  Myth: Pre-existing condition exclusions were rampant before Obamacare.

Individuals being denied health insurance or kicked off their plans because of pre-existing medical conditions is often cited by defenders of Obamacare as justification for the law. The President has said that “up to half of all Americans have a preexisting condition.”

However, while the problem did exist, it was on a much smaller scale than depicted. The issue was in the individual market, where about 10 percent of the privately insured purchase coverage. In the group market, where about 90 percent of privately insured Americans are covered, the issue was mostly resolved by HIPAA.

Beginning in 2014, Obamacare enforced a blanket prohibition of pre-existing condition exclusions in the individual market. A consequence of this policy is that it incentivizes people to wait until they are sick to purchase coverage. Thus, the law also included an individual mandate to force all Americans to purchase health insurance or pay a tax penalty.

Since the provisions did not take affect right away, the law created the pre-existing conditions insurance plan (PCIP) to operate from 2010 to 2014. It funded new high-risk pools in each state to provide temporary coverage to those with pre-existing conditions.

The PCIP experience revealed that the number of individuals facing pre-existing condition exclusions was not nearly as large as it was portrayed. The Obama Administration initially estimated that 375,000 people would enroll in the PCIP by 2010, but the highest enrollment total ever to occur over the three-year period was in March 2013: almost 115,000, only about 30 percent of original projections.

  • Myth: Obamacare plans are “better” insurance.

Obamacare does indeed mandate a host of new benefits that every plan must cover and new rules that each insurer must follow, but the result is not just standardization and over-regulation of health insurance; it also increases costs, which is seen in premiums and cost-sharing levels.

For instance, the average deductible for a bronze plan in the 34 states with a federally facilitated exchange is $5,095 a year for an individual, and the average catastrophic plan carries an individual deductible of $6,346. Moreover, 42 states will see significant average premium increases—in many cases, over 100 percent—for individuals purchasing from the exchanges. Therefore, enrollees may not see “better” insurance for their money.

*Modified from a heirtage.org article

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Health insurance marketplaces signing up few uninsured Americans, surveys say

The new health insurance marketplaces appear to be making little headway so far in signing up Americans who lack health insurance, the Affordable Care Act’s central goal. A pair of surveys released on Thursday suggest that just one in 10 uninsured people who qualify for private health plans through the new marketplace have signed up for one — and that about half of uninsured adults has looked for information on the online exchanges or plans to look.

  • One of the surveys, by the consulting firm McKinsey & Co., shows that, of people who had signed up for coverage through the marketplaces by last month, just one-fourth described themselves as having been without insurance for most of the past year.
  •  The survey also attempted to gauge what has been another fuzzy matter: how many of the people actually have the insurance for which they signed up. Under federal rules, coverage begins only if someone has started to pay their monthly insurance premiums.
  • And, the survey show, that just over half of uninsured people said they had started to pay, compared with nearly nine in 10 of those signing up on the exchanges who said they were simply switching from one health plan to another.
  • The McKinsey survey, its fourth since late November to measure the behavior of Americans in the new insurance marketplaces, is based on a national sample of about 2,100 people. It shows that 27 percent of people who had bought coverage by early February had been uninsured, compared with 11 percent a month earlier.
  • McKinsey’s survey also includes people who bought insurance outside the new marketplaces. It defined uninsured people as those who qualify for private health plans sold through the exchanges. It does not include anyone who is uninsured and has an income low enough that they qualify for Medicaid, a public insurance program that is being expanded under the law in about half the states.
  • The McKinsey survey also found, as it had during the previous few months, that, of people who are uninsured and do not intend to get a health plan through the marketplaces, the biggest factor is that they believe they could not afford one.
  • The second survey, by researchers at the Urban Institute and based on slightly older data from December, shows that awareness of the new marketplaces is fairly widespread but that lower-income Americans and those who are uninsured are less likely to know about this new avenue to health coverage than other people.

“If there is one point to the law, it is to lower the number of uninsured,” said Larry Levitt, senior vice president of the Kaiser Family Foundation, a health policy organization. “Ultimately, that has to happen for the law to be judged a success.”

With just over three weeks remaining in a six-month sign-up period, the question of how many uninsured people are gaining coverage so far is eluding both Obama administration officials and most of the private health plans being sold through the new marketplaces.

Inside the Department of Health and Human Services, staff analysts who have been producing monthly enrollment updates are confronted with a major hindrance to examining the question of people’s prior insurance status: the wording of the HealthCare.gov applications themselves.

The paper versions of applications, used by a small fraction of people who are signing up contain a multiple-choice question asking whether people in a household currently have insurance. “No” is one of the boxes people can check

However, the online application, used by most people to enroll, asks whether people want to apply for coverage but does not give them a place to indicate whether they have insurance now or have had it in the past. As a result, HHS analysts have no way of assessing how many of the online enrollees were uninsured n the past.

“We are a looking at a range of data sources to determine how many marketplace enrollees previously had coverage,” said Julie Bataille, director of the Office of Communication in the Centers for Medicare and Medicaid Services, the HHS agency overseeing the insurance marketplaces. “Previous insurance coverage is an important metric, and we hope to have additional information in the future.”

In the absence of information from people who have enrolled, Obama administration officials have drawn attention to recent outside polls, which suggest that the overall number of uninsured Americans is declining. It is not clear, however, whether the trend is because of the health-care law or other reasons.

So far, of 14 states that are operating their own insurance exchanges, instead of relying on the federal one, only New York has given any indication about how many uninsured people are signing up. Last month, the NY State of Health, the state’s marketplace, reported that 70 percent of the half-million people who had enrolled since it opened in October were uninsured at the time they signed up.

*Modified from a Washingtonpost.com article

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Consumers can keep old health plans into 2017, administration says

The Obama administration announced Wednesday that some Americans with health insurance policies that don’t meet consumer standards set by the Affordable Care Act will be allowed to keep their plans into 2017, three years later than originally envisioned.

Allowing some consumers to keep old insurance plans past the end of the President Obama’s term in office marks the latest effort by the administration to get out from under one of the most damaging controversies shadowing the launch of the healthcare law.

Senior administration officials, briefing reporters on condition of anonymity, said they believe that about 1.5 million consumers nationwide currently are covered under such plans, about 500,000 of which were purchased by individuals and the rest by small businesses.

“The goal is to implement the Affordable Care Act in a common-sense way,” a senior administration official said, adding that officials believe that this latest announcement will be the last significant change the administration will make in the law’s deadlines and requirements.

Officials also announced that the open enrollment period for healthcare coverage next year would begin on Nov. 15 — notably after the fall’s midterm elections — and extend through February 2015.

Many Americans who had bought healthcare plans on their own were stunned last fall when insurance companies announced that their policies would be canceled because they did not include required benefits or meet other standards set by the law.

Because Obama had promised that people who liked their existing plans would be able to keep them, the cancellation letters quickly became a major political issue.

White House officials repeatedly have said that the vast majority of people who got cancellation notices were able to replace their old policies with new ones, in some cases at lower cost. However, those arguments have not quelled the political uproar. Conservative and Republican groups already have run millions of dollars’ worth of advertising against Democratic candidates on the issue, accusing them of participating in the “lie of the year.”

The healthcare law was designed to phase out health insurance plans in 2014 if they did not include a basic set of benefits or include limits on how much consumers can be required to pay out of pocket for their medical care.

After the controversy broke, the administration announced that state regulators could allow insurers to renew old policies in 2014. Not all states have gone along with that plan. Some, particularly those with liberal, Democratic insurance regulators, have balked at allowing what they consider sub-standard plans to remain on the market.

The new guidance would allow those plans to be renewed again as late as Oct. 1, 2016, meaning that some consumers could hold on to their healthcare plans into 2017.

The practical effect of the new extension may be limited. Officials said they believe that the number of consumers covered by plans that don’t meet the law’s standards will be significantly lower by 2016 because of the usual churn in the market for individual insurance.

“The expectation is that this will be a very small number of people,” a senior official said.

However, the new extension may defuse a political time bomb that the administration would have faced later this year if some consumers had once again received notices canceling their insurance plans just ahead of the November elections.

*Modified from a latimes.com article

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Many Reasons For Inaccuracies In Covered California Directory

Doctors, the insurance industry, and California’s medical establishment are shedding light on why there were so many inaccuracies in the now-removed Physician Directory on the Covered California website.

  • The reasons range from doctors opting out faster than insurance companies can update their lists, long-standing issues with accuracies on insurer’s provider lists, to confusion over whether doctors are required or not to participate.
  • Some doctors said that they are opting out because they said reimbursement rates for patients with Covered California plans are too low.
  • The California Medical Association blames a big part of the inaccuracies on confusion over whether doctors are required or not to participate in Covered California plans. The Association said most of the insurers on the exchange have fine print to their contracts requiring that doctors in their networks accept Covered California policies. As a result, some of those doctors are mistakenly turning patients away.
  • Other insurers, including Anthem Blue Cross and Blue Shield, are giving doctors a choice. And many, particularly independent physicians, are choosing not to participate.
  • Inaccuracies go beyond doctors being listed under Covered California plans they say they’re not accepting. There have also been reports that doctors have been listed as having the incorrect specialties, and that they were fluent in languages they couldn’t speak. One doctor on the list who has been retired for a year.
  • Customers aren’t the only ones complaining. Redwood City based internist Dr. Marie President said she is frustrated, about her inability to check what specialists are available to see her patients. “How do we know where to send them?” President asked.
  • Covered California denies physicians can’t get the information. Spokesman Dana Howard said doctors should check their contracts. Howard said Covered California is reviewing the issue of inaccuracies on the physician list.
  • He said if the agency discovers insurers tried to falsely claim they had a more robust list of providers, regulators will take action to remedy the problem.
  • But California’s insurance regulator, the Department of Managed Health Care (DMHC), said that could be an empty threat because inaccurate lists are not illegal.

*Modified from a CBSlocal.com online article

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Covered California Enrollees Complain Of Bait & Switch

A growing number of people who purchased health insurance through California’s state run exchange are complaining that they were misled about the availability of physicians in the network. Some are calling it a bait and switch.

  • Brent Undridge is one of those complaining. The Castro Valley resident said when he signed up for a Covered California plan back in December, he was led to believe he could continue seeing the same medical group he has been using for the past two decades.
  • But that did not turn out to be the case. I wanted to cry,“I’ve been going there for 26 years, I really like them and want to keep them as my doctors.”
  • Part of that expectation stemmed from President Barack Obama’s oft-repeated promise while campaigning for the Affordable Care Act that “If you like your doctor, you can keep your doctor.” A promise, the President later admitted was not accurate.
  • And it’s expected more Californians could find themselves in the same situation as Undridge as more and more doctors are opting not to accept Covered California patients, because they say reimbursement rates are too low or they can’t handle the additional clientele.
  • Covered California said it is investigating the complaints. The agency’s Dana Howard told KPIX 5: “If we do find that there is a preponderance of misinformation that is taking place,” the insurers will be held accountable.
  • But California’s insurance regulator, the Department of Managed Health Care (DMHC), said that could be an empty threat because inaccurate lists are not illegal. So far, DMHC said it has received about 350 complaints about Covered California insurance plans since the beginning of the year. Most of them from Anthem Blue Cross and Blue Shield customers.
  • Consumers who find their doctor was mistakenly listed at the time they enrolled, should call their insurer and ask it to make good on its promise.

Anthem Statement:

Anthem Blue Cross has made great progress in increasing the accuracy of the provider database and will continue to make improvements. Members who are having issues finding an in-network provider or who have questions about out of pocket expenses incurred should contact Anthem Blue Cross customer service for assistance.

Blue Shield Statement:

The number of complaints is accurate, but offers very little value out-of-context. More than 140,000 Californians selected Blue Shield plans as of December 31 meaning the 140 figure is a fraction of a percent of total enrollees. The high volumes have been challenging for Blue Shield and other plans, but we think it’s a good thing that so many Californians are purchasing health insurance through the exchange and we are working to address the backlog.

*Modified from a cbslocal.com – KPIX 5 article

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ConsumerWatch: Some Doctors Listed By Covered California Not Taking Coverage

Some frustrated enrollees of Covered California are accusing the insurance exchange of false advertising, after they said doctors listed on their website aren’t actually accepting Covered California plans.

  • After signing up, Guda Venkatesh couldn’t wait to pick his new doctors. “The first thing I wanted to do was to get a primary care doctor,” he told KPIX 5 ConsumerWatch. Venkatesh chose an Anthem plan specifically because the Covered California website said the plan had a variety of Stanford doctors near him.
  •  “Except when I started going through the doctors, each one and calling them up, none of them actually accepted the Covered California plan,” Venkatesh recalled. He then showed a three-page list of supposedly in-network doctors, but none accepted his insurance.
  •  Is it a case of false advertising? Anthem said it was a mistake and told KPIX 5, “Like other insurers, (Anthem) will continue to double check its provider lists to improve accuracy.”
  • KPIX 5 went to Covered California to ask if the list is their responsibility. Dana Howard with the exchange said, “Yes, it is our responsibility. However, we do not have an audit that goes on 24/7 to make sure that every bit of information is indeed accurate.”
  • Howard said if you signed up for a plan and it’s not what was advertised, there is still time to switch. Open enrollment continues until March 31st.
  • He said switching insurers is a lengthy and complicated process that should not be attempted online. Enrollees must work with a customer service representative to avoid gaps in coverage.
  • KPIX 5 asked Howard if there are inaccuracies on the website. “Well, there may be,” he said. Before signing up, Howard said it is crucial for enrollees to contact doctors to ensure they will be actually covered.
  • It was something Venkatesh assumed Covered California had done for him. “The premise of Covered California is that you’re able to compare plans and see which one is best for you. But if they are presenting that they have all these doctors in network but they don’t, then it doesn’t work,” he said.

Anthem said it is constantly updating their list of doctors to ensure accuracy. The insurer said in some cases, doctors may not realize they have an agreement to accept patients on some of these new policies.

*Modified from a cbslocal.com – KPIX 5 article

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California health exchange pulls error-ridden physician list–again

Admitting it gave some consumers bad information, California’s health insurance exchange pulled its physician directory for having too many errors. Covered California made the move late Thursday amid growing frustration among both consumers and doctors over inaccurate information about insurance networks in the state marketplace.

  • The exchange yanked its online directory of medical providers in mid-October after acknowledging there were serious problems then with the data. It published an updated list in November.
  • Since Obamacare policies took effect Jan. 1, many enrollees have complained that doctors won’t take their insurance even though the physicians were listed as part of their network on the state website and by their health plan.
  • The exchange said Thursday that “while the combined provider directory was a useful service for many consumers, some enrollees located physicians thought to be in their plan, and subsequently discovered they were not.”
  • The exchange has touted the directory as an important consumer tool because some insurers have sharply limited the number of doctors and hospitals in policies being offered under the federal healthcare law.
  • The state said enrollees who are unsatisfied with their provider network still have time to cancel their coverage and sign up with a different insurer before open enrollment ends March 31. However, that may be little comfort for people who experienced computer errors and long delays to enroll the first time under the Affordable Care Act.
  • Customer service problems continue to plague the exchange and some insurers in light of 625,000 people enrolling through mid-January. Covered California said people waited nearly 52 minutes, on average, to speak with someone at the state’s call center last week.
  • Covered California said it will continue to include online links to insurers’ provider directories. But the exchange directory offered the advantage of enabling people to search for doctors across health plans while shopping for coverage.
  • In an interview last week, officials at the California Medical Assn. said they were still finding flaws in the state’s data, often because of incorrect information from insurers. Health insurance companies, in turn, blame some doctors’ offices for mistakenly turning patients away even though they are under contract for the networks.
  • Many insurers have adopted narrower networks to help hold down premiums on individual policies sold in and outside the exchange.

*Modified from a latimes.com article

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Obamacare enrollees hit snags at doctor’s offices

Many consumers faced hurdles signing up for Covered California health plans. Now they’re having trouble finding in-network doctors. After overcoming website glitches and long waits to get Obamacare, some patients are now running into frustrating new roadblocks at the doctor’s office.

  • A month into the most sweeping changes to healthcare in half a century, people are having trouble finding doctors at all, getting faulty information on which ones are covered and receiving little help from insurers swamped by new business.
  • Experts have warned for months that the logjam was inevitable. But the extent of the problems is taking by surprise many patients — and even doctors — as frustrations mount.
  • The Covered California exchange began enrollment in October without the provider directory it had promised. Delays and glitches ensued for weeks, frustrating many consumers who complained that it was impossible to compare health plans without details on what hospitals and doctors were included. In November, the exchange updated its directory.
  • To hold down premiums under the healthcare law, major insurers have sharply cut the number of doctors and hospitals available to patients in the state’s new health insurance market. Now those limited options are becoming clearer, and California officials say they are receiving more consumer complaints about access to medical providers.
  • Nationwide, about 70% of new insurance plans under the healthcare law feature relatively narrow hospital networks compared with many existing plans, according to consulting firm McKinsey & Co.

Aliso Viejo resident Danielle Nelson said Anthem Blue Cross promised half a dozen times that her oncologists would be covered under her new policy. She was diagnosed last year with non-Hodgkin’s lymphoma and discovered a suspicious lump near her jaw in early January.

But when she went to her oncologist’s office, she promptly encountered a bright orange sign saying that Covered California plans are not accepted. “I’m a complete fan of the Affordable Care Act, but now I can’t sleep at night,” Nelson said. “I can’t imagine this is how President Obama wanted it to happen.”

“It’s a little early for anyone to know how widespread and deep this problem is,” said California Insurance Commissioner Dave Jones. “There are a lot of economic incentives for health insurers to narrow their networks, but if they go too far, people won’t have access to care. Network adequacy will be a big issue in 2014.”

The latest travails come at a crucial time during the rollout of Obama’s signature law. Government exchanges and other supporters of the healthcare law are trying to boost enrollment, particularly among young and healthy people, ahead of a March 31 deadline.

Of course, complaints about outdated provider lists and delays in getting a doctor’s appointment were common long before the healthcare law was enacted. But some experts worry the influx of newly insured patients and the cost-cutting strategies of health plans may further strain the system.

Maria Berumen, a tax preparer in Downey, was uninsured for years because of preexisting conditions. The 53-year-old was thrilled to find coverage for herself and her husband for $148 a month after qualifying for a big government subsidy.

She jumped at the chance in early January to visit a primary-care doctor for long-running numbness in her arm and shoulder as a result of bone spurs on her spine. The doctor referred her to a specialist, and problems ensued.

At least four doctors wouldn’t accept her health plan — even though the state exchange website and her insurer, Health Net Inc., list them as part of her HMO network. “It’s a phantom network,” Berumen said.

It was no surprise to her family doctor, Ragaa Iskarous. She has run into this problem repeatedly with other patients in the last month, the doctor said. “This is really driving us crazy.”

Insurers say they are working hard to resolve customers’ problems as they arise, and they continue to add physicians to augment certain geographic areas and medical specialties.

Looking to head off potential problems, government regulators and patient advocates are pushing for tougher rules to ensure health plans provide timely access to care.

Last week, the California Assembly approved legislation enabling people who lost coverage because of the overhaul to keep seeing their doctors if they’re pregnant or undergoing treatment for cancer or other conditions.

Nelson, the cancer patient in Orange County, and her family lost their previous coverage when Aetna stopped selling individual policies in the state last year. After numerous complaints to her new insurer, Anthem, and to public officials, the company said it would cover visits to her current oncologist through March 31.

Nelson said such a temporary extension doesn’t solve the problem, and as a result, she’s rushing to check out other policies for herself before open enrollment closes in March.

A spokesman for Anthem said the company “continually works to update its provider directories to ensure accuracy” and helps customers with these issues on a case-by-case basis.

“It’s pretty clear insurers responded to greater competition by trying to hold down costs through narrower networks,” said Larry Levitt, senior vice president at the nonprofit Kaiser Family Foundation. “Insurers have made the judgment that people prefer lower premiums to broader networks.”

Health policy experts and some consumer advocates say the trade-offs may pay off. Despite some consumer complaints, the exclusion of some higher-priced hospitals such as Cedars-Sinai Medical Center from nearly all exchange plans is a positive sign, they say.

“The Affordable Care Act often gets accused of not doing enough to control costs,” said Ian Hill, senior fellow at the Urban Institute, a Washington think tank. “Excluding some of the most expensive hospitals and providers who don’t demonstrate high-quality outcomes is one ripple effect that may help.”

The California Medical Assn. credits the exchange for fixing many of the initial problems but maintains that the state’s data are still flawed, often because of incorrect information from health plans. Insurers blame doctor’s offices for frequently giving wrong information.

Scott Marshutz of Dana Point said he picked a Blue Shield PPO plan in the exchange so he and his wife would have greater choice of doctors.

But when he booked an appointment recently with his orthopedic surgeon, the doctor’s office said it wasn’t taking Covered California plans.

“I’m wondering how many other people have experienced this,” he said, “and if it will backfire on the whole system.”

*Modified from a latimes.com article

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Anthem to raise some premiums as much as 25%

Up to 306,000 Californians with older, individual Anthem health insurance policies — unchanged by Obamacare — are subject to the rate increases. Individual customers with older insurance policies untouched by Obamacare are getting some jarring news: Their premiums are going up as much as 25%. 

  • Amid the fury last fall over canceled health policies, consumer advocates and state officials warned people that holding onto grandfathered policies purchased before the federal healthcare law was enacted in 2010 wouldn’t shield them from significant rate hikes.
  • The Affordable Care Act makes it easier for people in this situation to switch coverage because insurers can no longer deny applicants on the basis of preexisting conditions or charge them more because of their medical history.
  • The company said customers do have new options thanks to the healthcare law. “Many of the members affected exchange and may have lower premiums if they decide to switch to an Affordable Care Act-compliant policy.
  • But changing plans isn’t an appealing option for some consumers who like the benefits they have now and worry about losing access to their doctors.

In recent months, state regulators have criticized major insurers for overstating what they expect to pay for patients’ future medical costs in order to support substantial rate increases. Other insurers have met resistance when boosting premiums on grandfathered policies.

But state officials don’t have authority to reject health insurance rate increases. An initiative on the November ballot seeks to change that by giving the insurance commissioner the power to deny excessive increases for health coverage.

Opponents of the ballot measure, including insurers, doctors, hospitals and business groups, say it doesn’t address the underlying reasons for rising premiums.

Critics also worry that stricter rate regulation could undermine the new state exchange, which negotiates rates with health plans as part of the healthcare law.

*Modified from a latimes.com article

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