Centene's (Ambetter's) too-skinny network problems are far from over: Lawsuit pending...

Whenever I write or talk about the 3-Legged Stool of the ACA and the actual flaws in the law (as opposed to the ones deliberately created by the GOP), I usually focus on two "gaps" in the legs: The APTC subsidies getting cut off at 400% FPL and being too stingy below that level, and the individual mandate not being large enough (and not being properly enforced). As it happens, part of the first problem has already been unintentionally "solved" thanks to Trump's ham-handed CSR reimbursement cut-off (which ended up increasing APTC tax credits for those below the 400% cut-off), while the second problem has just been made a whole lot worse thanks ot the GOP repealing the mandate altogether.

However, in focusing on the legs of the stool, I often forget to mention another important issue: The width of the seat itself. That is, how wide the network of doctors and hospitals which accept the policy is. The Affordable Care Act does give some guidelines/regulations about how wide ACA-compliant policy networks have to be, like so:

The Affordable Care Act established the first-ever federal rights guaranteeing private insurance consumers access to adequate networks. The law requires that consumers in marketplace plans have a “sufficient choice of providers,” defined in rules as a right to networks that are sufficient in the “number and types of providers, including providers that specialize in mental health and substance abuse services, to assure all services will be accessible without unreasonable delay.” Under the law, marketplace plans must also include in their networks essential community providers that serve predominantly low-income, medically underserved individuals, such as federally qualified health centers, Ryan White HIV/AIDS providers, and sole community hospitals. The law also mandates that insurers create provider directories for consumers. Marketplace plans are required to post accurate information about which providers are in-network and which providers are accepting new patients.

If a health plan’s provider directories are inaccurate, consumers will have a hard time finding a provider when they need one. Inaccurate provider directories can also misrepresent the adequacy of a plan’s network by making it appear much larger and more robust than it really is. Because problems with health plan provider directory accuracy have persisted for years, health plans, states, and the federal government should look for innovative ways to address this issue. For example, in 2013, the state of New Jersey enacted a regulation (N.J.A.C. 11:24C-4.6) requiring plans to confirm that any provider who hasn’t submitted a claim for 12 months still intends to participate in the plan’s network. Plans can also help address the problem by posting an email address or phone number on their provider directories where consumers can report inaccurate directory information to the plan so that the plan can correct the error.

The Affordable Care Act created essential new federal network adequacy protections for plans in the marketplaces. Many states also have laws and/or regulations to help ensure that networks are adequate to meet consumers’ needs. However, many of these need to be strengthened, and in states that don’t already have laws and/or regulations, policymakers should consider enacting standards. In addition, federal policymakers should consider how to strengthen network adequacy requirements for marketplace plans under Affordable Care Act regulations and guidance. Network adequacy laws passed in California and New York can serve as models for other states and the federal government, as can standards from Medicare Advantage. In addition, the National Association of Insurance Commissioners (NAIC) is currently updating itsmodel law on network adequacy.

OK, so that's the theory. The reality is that while I'm sure most ACA policies have decent networks of doctors, hospitals and specialists, I've heard from plenty of people who've complained that their plan's networks are too skimpy, or that they feel like they've been bait 'n switched by the carrier into thinking a doc/hospital is in the network when it turns out they aren't.

I don't have enough expertise in this area to know how widespread the problem of narrow networks actually is; some of it might be a perception problem, some might be honest misunderstandings, but I know it's enough of an issue to be concerning.

That brings me to the point of this entry. Back on December 15th (the last day of the official open enrollment period, no less, although not in WA), there was some unexpected drama in Washington State when the Insurance Commissioner, Mike Kreidler, suddenly pulled the plug on insurance carrier Centene (aka Ambetter, aka Celtic...for God's sake, guys, pick one name and stick with it), cutting off their ability to continue enrolling people in individual market policies:

Centene, Lacking Doctors, Is Forced to Halt Sales in Washington State

Centene Corp. halted sales of health insurance plans in Washington State after regulators found the company failed to cover enough doctors and other care providers, threatening to leave some counties with no Obamacare insurance options.

...The halt is a setback for Centene, which has been rapidly expanding in Obamacare, relying on a strategy of offering consumers a limited choice of doctors and hospitals, in exchange for a lower up-front premium. Bloomberg found earlier this year that some Centene customers faced difficulties visiting their preferred hospitals and doctors in the insurer’s Affordable Care Act plans. In their Dec. 12 order, Washington regulators said the problem was systemic.

The issue was supposedly resolved a few hours later after some emergency meetings between state regulators and Centene officials...

Coordinated Care Corp. fined $1.5 million, agrees to fix provider networks

Contact Public Affairs: 360-725-7055
December 15, 2017

Coordinated Care Corp. has agreed to a consent order detailing steps it must take to fix its provider network deficiencies and other ongoing issues. The company was fined $1.5 million with $1 million suspended, pending no further violations over the next two years.

Insurance Commissioner Mike Kreidler issued a cease and desist order Dec. 12 ordering the company to stop selling individual health plans in Washington state because it failed to maintain an adequate network of medical providers.

In particular, Coordinated Care admitted to not having enough anesthesiologists in King, Snohomish, Pierce and Spokane counties. According to the company’s own data, its provider network is also seriously deficient in other categories of providers, including immunology, dermatology, and rheumatology.

With the consent order in place, the order instructing the company to stop all sales is canceled.

Anyone who bought Coordinated Care plans through Washington state’s Exchange after Dec. 12 will have those policies effect for 2018.

...and that was the last I heard about the brouhaha, until this afternoon, when Zach Tracer of Bloomberg News posted this update:

Centene Corp. rushed to fill the void when many bigger insurers gave up on Obamacare, but a lawsuit alleges that the fast-growing insurer’s coverage is less robust than advertised.

The company misled customers about the number of doctors covered under its health plans, offering individuals who bought Obamacare coverage skimpier insurance than they signed up for, according to the federal suit filed in Washington State on Thursday.

Customers in Centene’s Affordable Care Act plans had difficulty finding care providers who’d accept their insurance, the suit says, and discovered that even doctors listed by Centene as taking its coverage often didn’t.

“Members have difficulty finding -- and in many cases cannot find -- medical providers who will accept Ambetter insurance,” according to the lawsuit. “After purchasing an Ambetter insurance plan, they learn that the provider network Centene represented was available to Ambetter policyholders was in material measure, if not largely, fictitious.”

The suit, filed on behalf of two Centene customers, seeks class-action status to represent all customers of the insurer’s Obamacare plans, which are sold under the Ambetter brand.

“Our networks are adequate and we work in partnership with our states to ensure our networks are adequate and our members have access to high-quality health care,” said Centene spokeswoman Marcela Hawn. She said the insurer had not seen the lawsuit.

Centene, which specializes in covering low-income individuals, has been expanding in the Affordable Care Act’s marketplaces even as rivals retreat. That has left consumers in some parts of the country with little choice of Obamacare plans; in many counties where it expanded, Centene is the only insurer offering coverage under the health law. The company, based in St. Louis, now has more than 1.4 million customers in its ACA plans across 15 states, placing it among the largest insurers in the program.