increased-enrollees-and-narrower-networks-are-some-of-the-major-challenges-facing-several-aca-plans

It’s possible that the Affordable Care Act is battling its own success.

More consumers entered the market as a result of record enrolment over the past two years. In order to compete on price, many insurers started to provide smaller networks of physicians and hospitals around the same time.

Several patients struggled to find an available in-network doctor or hospital because of this combination. It can be difficult, especially if subscribers are forced to rely on incomplete provider listings provided by their insurance provider.

Consider what occurred to a policyholder in central Pennsylvania who fell in January and broke her arm and a bone close to her eye.

According to Kelly Althouse, the patient’s insurance agent who lives close to Reading, she was told to follow up with an orthopedist by the hospital that treated her for an emergency. Pennsylvania. Althouse’s client spent hours calling orthopedic specialists who were included in the Ambetter Health provider directory of her new insurance plan, a nationwide carrier that began selling ACA plans in Pennsylvania in 2019. Despite being mentioned by the company, a number of doctors said they weren’t a part of the network, according to Althouse. It took her patient over 15 tries to find a doctor in the network who would see her.

She already felt awful, so that was the last thing she needed, according to Althouse.

Since the start of the new plan year in January, she has heard this tale several times. Her customers had “bombarded” her with calls, complaining that a variety of doctors and other providers were not accepting the insurance, even if that provider was accepting insurance.The plan’s own directory contained a listing for r. The majority of offices telling Althouse’s clients, “We have never heard of this company,” astonished him, he added.

Ambetter representatives, for their part, told KHN in a written statement that its Pennsylvania network “meets or exceeds regulatory standards.”

Concern has long been raised about the extent of insurers’ networks of affiliated hospitals and physicians, especially in relation to ACA plans. In recent years, insurers have tended to offer smaller networks, in part to save expenses and maintain affordable premiums.

When patients are unable to locate nearby in-network doctors, they are forced to pay more for out-of-network care, if that is even an option under their insurance, or travel further for in-network care.