Consumer

Covered California Enrollees Complain About Limited Doctor Choices Nearby

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ALAMEDA COUNTY (KPIX 5) — California’s health care exchange promised potential customers they would have enough physicians to choose from. But some new enrollees, including an Alameda County woman, are discovering that their doctor choices are extremely limited.

Julia Turner is surprised that she even has to search for a doctor. When she signed up for a policy through Covered California late last year, her long-time physician was listed as participating in her Blue Shield plan. When she tried to make an appointment last week, however, he told her he was not accepting patients with her Blue Shield policy, purchased on the Covered California exchange.

When Turner called around to find someone else to treat her, she got more frustration. “The only doctors accepting new patients are urgent care clinics,” Turner told KPIX 5 ConsumerWatch.

None of the doctors are located in the city in which she lives. Instead, Turner said, “They are in areas of East Oakland that have a lot of violence.”

More On Covered California Issues:

When KPIX 5 contacted all of the 41 doctors on the list Blue Shield provided to Julia, it found only four of the doctors were actually accepting new adult patients, and only one of them was board certified.

The California Department of Managed Health Care said there is no law that requires the insurer’s provider list to be accurate. However, state law does require insurers to have an “adequate” network of doctors. That means there must be at least one doctor for every 1,200 enrollees within 15 miles of their home.

But many enrollees, in both Blue Cross and Blue Shield plans purchased on the exchange said they are struggling to find even one doctor willing to take new patients due to what are now being call “narrow networks.”

The narrowest networks – those with the fewest doctors – are in some of the Northern California counties with the lowest median household income and the highest number of Medi-Cal recipients. Alameda County falls into that category.

One insurer told KPIX 5 that so many doctors in Alameda County initially declined to accept the low reimbursement rates, the insurer couldn’t get enough doctors to meet the state’s minimum network adequacy requirements.

So the insurer came back and offered similar reimbursements to a much narrower network of doctors. Those doctors agreed to the rates in exchange for the insurer limiting patient provider options, and funneling more patients to fewer doctors.

Pat Johnston of the California Association of Health Plans, the industry group representing the insurers, admits there some issues with doctor availability. Johnston calls it a “tradeoff.”

“Remember one of the factors here is trying to make it affordable,” he explained. He admits that depending on the insurer, there are fewer provider options for enrollees who purchase the subsidized policies on the exchange.

Anthem Blue Cross and Blue Shield of California are the two primary insurers who have different provider lists for plans purchased on and off the exchange.

In response to questions from KPIX 5 about Julia Turner’s situation, Blue Shield said “the medical group Turner’s doctor participates in was notified last year of its inclusion in the network under current contractual terms, for the purpose of meeting access requirements.” The Doctor and his medical group, part of the Lucile Packard Children’s Hospital / Stanford Hospital group of doctors, contend LPCH doctors were not initially included in the Blue Shield plans sold in Alameda through Covered California.

While Julia’s doctor was not among the list of in-network doctors provided to Julia by Blue Shield, a spokesperson says he will now be included.

Still, she’s unhappy about what she’s had to go through and concerned about others just beginning the Covered California enrollment process.

“This is not what we were promised. I see those (Covered California) commercials now and I want to scream,” Turner said.

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