The nation’s insurance commissioners are recommending sweeping new standards to address complaints from consumers about limited access to doctors and hospitals in health plans sold under the Affordable Care Act.
Limited networks of health care providers are a feature of many insurance policies offered in the public marketplaces, or exchanges, where people with low incomes can often obtain subsidies that reduce their monthly premiums to $100 or less. Such “narrow networks,” consumers say, often do not include the doctors they need for specialized care for themselves or their children.
The National Association of Insurance Commissioners, which represents state officials, would require that insurers have enough doctors and hospitals in their networks to provide all covered services to consumers “without unreasonable travel or delay.” States remain the primary regulators of insurance, despite a huge increase in federal insurance standards since adoption of the health law in 2010.
The thrust of the recommendations is to help consumers get care from providers affiliated with their health plan and to protect them against exorbitant costs if, for some reason, they receive care from doctors or hospitals that are not in the insurer’s network. Patients are typically required to pay more of the bill if they receive care outside their network.
Many consumers have been infuriated after using a hospital in their network and then receiving large medical bills from doctors who work at the hospital but are not in the network.
Under the commissioners’ proposals, in the form of a model state law, insurers and hospitals would be required to inform patients of any possibility that they may be charged extra by “a health care professional, such as an anesthesiologist, pathologist or radiologist,” who does not participate in the insurer’s network.
In such situations, the proposals say, patients should not be forced to pay more than their usual share of the bill for services provided by doctors affiliated with their health plan. Doctors who object to the amount of the payment could haggle with the insurer in a mediation process, but the patient would be “held harmless.”
Stephanie Mohl, the manager of government relations at the American Heart Association, said the proposals were “a huge step forward” for patients.
In determining whether a network of providers is sufficient, state insurance commissioners would consider factors like the ratio of people enrolled in a health plan to the number of doctors in each specialty, the “geographic accessibility of providers,” waiting times for appointments, and the ability of health plans to meet the needs of low-income people and “children and adults with serious, chronic or complex health conditions or physical or mental disabilities.”
The commissioners developed the proposals in an exhaustive 18-month drafting process that was open at every stage to consumers, insurers, health care providers and other experts.
The Obama administration said this year that it was waiting to see the “model act” devised by the commissioners’ association before deciding whether to adopt detailed federal standards for provider networks.
Insurers defend smaller networks as a way to hold down costs and improve care by steering patients to selected high-performing doctors and hospitals. Moreover, they say, most consumers seeking insurance on the exchanges focus on price more than any other factor and are willing to accept limits on their choice of doctors and hospitals in return for lower premiums.
But William J. Psolka, a 50-year-old photographer in Somerset, N.J., is one of many patients aggrieved by such narrow networks. He visits doctors in Boston and New York for a complex heart defect he has had since birth. For decades, his insurance policy covered those visits.
“But in 2014,” Mr. Psolka said, “the insurer got rid of out-of-network coverage, as did many carriers in New Jersey, and I don’t know if I will be able to continue seeing the specialized cardiologists at the clinics in Boston and New York.” For months, he said, he has been seeking permission from his insurer.
Separate studies issued last week by the Robert Wood Johnson Foundation and Avalere Health, a consulting company, suggest that insurers in the federal marketplace are offering fewer plans with broad networks of health care providers than they did in the last two years. At the same time, many insurers are reducing or eliminating coverage of providers outside their networks.
“Exchange plans are moving toward networks with fewer providers,” said Elizabeth Carpenter, a vice president of Avalere.
Kevin McCarthy, 58, of Ventura County, Calif., said he and his wife had bought a plan from Blue Shield of California after checking its online provider directory to confirm that their doctors were all covered. But, he said, after they went to the doctors last year, they received bills stating that the doctors were not “in network.”
“We were shoehorned into a plan with a very limited network of doctors,” Mr. McCarthy said. “But we did not realize it because the provider directory was very misleading. It was out of date.”
The State of California imposed fines last week on Blue Shield of California and another big insurer, Anthem Blue Cross, after finding that their provider directories had been inaccurate.
Another provision of the model law would require insurers to update their doctor directories at least once a month. Federal and state investigators have found directories riddled with errors. Some include doctors who have died, are no longer practicing at the listed location or are not taking new patients.
Harvard researchers reported last month that nearly 15 percent of health plans in the federal insurance marketplace “completely lacked in-network physicians for at least one specialty.” Most often missing were rheumatologists, who treat arthritis and related conditions; endocrinologists, who treat diabetes and thyroid disorders; and psychiatrists.