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Lawmaker May Crack Down On Flawed Doctor Lists On Covered California

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Julie-Watts_BIO-HEAD Julie Watts
The recipient of the Emmy and AP Awards for Best Reporter, Julie’s...
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SAN FRANCISCO (KPIX 5) — A state lawmaker wants to require insurance companies to provide accurate lists of doctors who accept their health plans.

State Senator Ted Gaines (R-Roseville) said a fix is needed to address the inaccurate provider lists offered by some of the insurance companies selling insurance on Covered California, the state’s insurance exchange.

Right now, state regulations only require that insurers update their provider lists every three months. It’s a problem for some who signed up for plans under Covered California that discover their insurer’s provider list was inaccurate, out of date, or did not include acceptable physicians in their area.

Marta Green of the California Department of Managed Health Care, the state agency that regulates insurers acknowledges the lists may be flawed, but says there is only so much the state can currently do.

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“The Department of Managed Care holds insurers accountable against California law,” Green told KPIX 5 ConsumerWatch. “The law allows that list to change without notice and requires the health plans to update it quarterly.”

Green said while the state doesn’t check for accuracy, it does check for what is known as “network adequacy.” That is, whether an insurer has the adequate numbers of doctors to cover a given area.

Under state regulations, insurers must have at least one doctor – of any kind – for every 1,200 people enrolled in a plan, and one primary care doctor for every 2,000 customers. The state also requires that patients must be able to get an appointment within 15 days, and within 15 miles of their home.

So far, KPIX 5 has received nearly 100 complaints about provider list inaccuracies from people who bought insurance through the exchange. The Department of Managed Health Care said it has only received 30.

DMHC is urging consumers with insurance problems to file a complaint with them at

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