Regulators Urge Broader Health Networks

Featured on The New York times | By Robert Pear

WASHINGTON — 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.
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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.

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