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Study finds that majority of Covered California plans have narrow physician networks

September 03, 2015
Area(s) of Interest: Access to Care Advocacy Health Care Reform 


A study by University of Pennsylvania researchers shows that 75 percent of health plans sold in California under the Affordable Care Act (ACA)—through Covered California—have significantly limited networks. More than 90 percent of California’s HMO networks for individual coverage were narrow, compared to a third of PPO plans in the state. Nationwide, 41 percent of provider networks were labeled narrow, meaning they included 25 percent or less of the physicians in a rating area.


Big insurers like Anthem Blue Cross and Blue Shield of California have cut the number of physicians and hospitals available to consumers in what they describe as an attempt to reduce costs.


While this may be another way of controlling health care costs for plans, consumers unfortunately have no easy way to tell if the plan they chose is adequate for their needs before enrolling. Researchers said better data on exchange networks is essential so regulators can ensure patients have sufficient access to doctors and consumers can determine whether a lower-priced plan with a narrow network is a good deal.


The California Medical Association (CMA) has urged state regulators to require insurers to provide additional instructions necessary for patients to successfully locate and navigate the specific network in which he or she has enrolled. This may also help to ensure that any cost savings the plans see from narrow networks are not partially the result of patients being unable to get needed care. More information also needs to be available to patients so they can make informed decisions when selecting a plan.


CMA has further asserted that California’s ability and standards for monitoring network adequacy and directory accuracy must continue to evolve to meet the challenges of this new health insurance environment, where minor fluctuations in a network can have major ramifications on access. Last year’s Senate Bill 964, which standardized much of the timely access reporting process and required annual provider network reviews, was a step in the right direction toward ensuring network adequacy, but inaccuracy in provider directories still remains an issue.


Inaccurate provider directories in particular make it hard for the state to regulate and monitor network adequacy standards. Provider and patient frustration with poor network information has grown significantly in recent years as a number of plans’ networks have continued to shrink. Indeed, the potential impact to a consumer of an erroneous physician listing is much higher when only a fraction of the physicians in an area are in-network for a health plan.


Last November, the California Department of Managed Health Care (DMHC) released the results of an audit of the Anthem and Blue Shield Covered California networks. Among other things, the audit found that 12.8 percent of the physicians listed on Anthem’s network were not accepting Covered California patients, while 12.5 percent were not in practice at the location listed in Anthem’s directory.


In the case of Blue Shield, only 56.7 percent of the physicians listed in Blue Shield's Covered California directory could be verified as accepting Covered California patients. These inaccuracy rates were consistent with CMA's own verification efforts and analyses.


DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories. Physicians who are misidentified as participating in a network by Anthem or Blue Shield when in fact they are not, or whose information in a network directory is inaccurate, are urged to contact CMA’s Center for Economic Services at (888) 401-5911 or economicservices@cmadocs.org.

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