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Uncertainty in Marketplace Health Plans Concerns Doctors

The uncertainty surrounding the medical provider networks of health plans offered through the federal health insurance marketplace has created a headache for both consumers and doctors.

A group of medical doctors in the hallway of the Capitol extension on Feb. 8, 2013.

As consumers weigh coverage options available in the newly launched federal health insurance marketplace, three of the largest medical associations in Texas have raised concerns about the uncertainty of provider networks offered by health plans in the marketplace.

The Affordable Care Act requires most people to carry health insurance beginning in 2014. While some states received federal financing to set up a state-run health insurance marketplace, Texas chose to participate in the federal marketplace, which offers dozens of health plans and sliding-scale tax credits to help poor individuals and families in Texas purchase coverage. Since the marketplace launched on Oct. 1, technical glitches have plagued the federal website and made it difficult for consumers to create accounts and compare health plans.  

The Texas Medical Association, Texas Hospital Association and Texas Academy of Family Physicians said many physicians and hospitals have also been unable to determine which health plans offered in the marketplace include them in their provider networks

“Physicians, they just want to know who's walking through their door and what kind of coverage they’re going to have,” said Lee Spangler, vice president of medical economics at the Texas Medical Association. “They’d like that uncertainty to be settled.”

Many insurance companies participating in the marketplace have created health plans with provider networks based on existing contracts with physicians and hospitals, and did not contact those providers to sign new contracts or ask if they were willing to participate in the new health plans, according to the associations. As a result, many providers do not know which of the health plans offered in the marketplace will pay them for services.

Spangler explained that many physicians sign contracts that allow insurance companies to include the physician in the provider network for any of their health plans. Often, the insurer is not required to notify the physician which of the health plan networks include the physician.

Physicians may not be able to offer alternatives that would be less costly for the patient, if they are unfamiliar with the patient's health plan network, said Spangler. Furthermore, health plans from the marketplace could present financial obstacles for physicians, because those health plans are required to have a 90-day grace period for policyholders that do not pay their monthly premiums on time. While other health plans would cut off coverage if a patient did not pay their bill on time, the health plans offered in the marketplace would still indicate the patient was covered during that grace period, and retroactively revoke payments to the physician for treatment provided during that time. In those situations, the doctor would be forced to seek payment from the patient for services already provided.

Lance Lunsford, a spokesman for the Texas Hospital Association, said the association has also received inquiries, mostly from small and rural hospitals, on why some hospitals haven’t been contacted to participate in the health plans offered in the federal marketplace and how those hospitals can determine whether they’re already participating through their existing contracts with insurers. The hospitals have the same concerns as doctors, said Lunsford, adding that the hospitals want to be included in the plans. 

Texas Oncology, one of the largest cancer treatment groups in the state, has chosen not to participate in any health plans offered in the marketplace because “there are many unknowns related to how the Health Insurance Market Place will cover cancer treatment,” according to a statement by the organization. “These details will impact our ability to provide patients with the latest and most effective treatments, so it is imperative that we are fully informed before a decision is made,” the organization further stated, while also indicating that it would re-evaluate its decision not to participate once more information was available.

Not all of the health plans in the marketplace are based on existing contracts between providers and insurers. For example, some insurance companies participating in the federal marketplace have signed new contracts with specific providers to create HMOs with "skinny networks." Those plans have fewer participating providers but lower monthly premium costs. 

All of the health plans in the marketplace are required to maintain provider networks that have sufficient numbers and types of providers to ensure all health services are available in a reasonable time period, according to federal officials at the Health and Human Services Department.

The uncertainty of the provider networks also creates a hardship for consumers, many of whom consider whether their current doctor is covered before purchasing a health plan. On average, Texans have 54 health plans in the marketplace to choose from, all of which have varying monthly premiums, deductibles and provider networks.

Before a consumer can view specific information on the provider networks of health plans offered in the federal marketplace, consumers must create an account on and apply for coverage. The website does not have a tool to search for specific providers to determine which health plans they’re participating in. Federal officials said that consumers could click a link associated with each health plan to review the provider network, but the Tribune was unable to access that feature because of glitches on the federal website that made it difficult to create an account.

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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