A Texas couple who switched health care plans thought they were getting a good deal until they tried to use it.
Cris and William Lyle had a plan through her employer, but they decided to shop around when Cris said the deductible increased and William needed a procedure. But after signing up, the couple got an unpleasant surprise.
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"In terms of payment and in terms of knowing that we have a procedure during this year for him, I really thought it was a good deal," Cris said.
But then, they started to look for a primary care doctor.
"So we started to look around and try to find a physician and that's when I start to get really nervous," William said.
The Lyles estimate they called about 20 doctors listed as Molina Healthcare providers, but none would accept their insurance.
"It's bait and switch," William said. "It's like a commercial they show on TV or whatever. I want to show you this nice beautiful car, come and get it. It's only $30,000 and then you show up, they say, 'That one's gone, but I've got another car for you.'"
"It doesn't surprise me at all," Texas Medical Association President-elect Dr. Don Read said.
"It's a very common problem. And the biggest problem is the insurers do not keep their records up to date as to who's on what plan."
But an association for the insurance industry, American's Health Insurance Plans, told us doctors are part of the problem too, saying providers often fail to update their information in a timely manner and notify a patient about changes in network status.
Doctors say it's not just a paperwork problem. They claim some insurance networks are shrinking.
"We've seen networks that were extremely narrow, meaning even in Dallas you know with all the healthcare systems here," Dallas County Medical Society head and Aids Arms CEO John Carlo said. "We have patients that the nearest network provider is in Waco. That is simply not acceptable."
"The insurance companies have nothing to lose by not keeping their provider manual is up to date," Read said. "The Texas Department of Insurance does not ride herd on the insurance companies. They do not enforce the law to require them to have adequate network of physicians."
The Texas Department of Insurance regulates insurance companies.
"Texas healthcare plans are required to maintain adequate networks and to have accurate information on providers available for their members," the organization said in a statement.
Officials said consumers like the Lyles should try to work it out with their insurance first and then file a complaint.
"We contact the health plan to try and get immediate help for the consumer, and it alerts us that there may be a problem so we can look into the issue and take action if necessary," TDI stated.
The Lyles, who live in Plano, now have an appointment with a primary care physician in Dallas, but they're worried. Especially as they try to find a specialist for William.
"I'm still pretty nervous about them," William said. "I don't know if they're going to be able to really take care of her health care needs."
Molina Healthcare released the following statement:
"We currently have a network of nearly 4,000 providers including specialists directly in Collin and Dallas counties who are ready to serve our Marketplace members. As always, we are working with additional providers to expand our network to continue to improve access to care. Our online provider directory is updated weekly to ensure that all contracted providers are included. As part of our commitment to our members, Molina's member services team is available to assist members with PCP selection and help arrange appointments."
They also reached out directly to the Lyles to help them find a specialist.
Before you sign up for any plan, call the doctors on the list and ask directly if they accept that insurance. Call the insurance company's customer service line and see how quickly you are able to get hold of someone. Finally, if you have an issue, file a complaint with the Texas Department of Insurance. The Lyles said they will do that. You can also check to see how many complaints your insurance company has.
America's Health Insurance Plans
"The Texas Medical Association likely failed to acknowledge that one of the biggest challenges in maintaining up-to-date provider directories is the fact that the providers themselves often fail to update their information in a timely manner or fail to notify a patient about changes in network status. This is a shared responsibility between health plans and providers to make sure patients have the right information, and health plans have processes in place to make daily updates to provider directories. But it comes down to providers to play their part as well.
"All of plans offered via the Marketplace have to meet state and federal requirements for network adequacy to be sold to consumers."
Texas Dept. of Insurance
"Texas health-care plans are required to maintain adequate networks and to have accurate information on providers available for their members. Doctors also have a responsibility to let plans know if they aren’t taking new patients or leave the network.
"Texas has had rules in place for some time about accurate network directories, and state lawmakers strengthened those requirements again last session as part of House Bill 1624. That bill increased the frequency that health plan directories must be updated to every month. Plans also must have an email and toll-free number available on their directories to report inaccuracies. Once reported, they have seven days to correct the errors or face fines.
"If a consumer has trouble finding a doctor, the first step is to call the health plan. If the health plan doesn’t resolve the issue, please call TDI’s Consumer Help Line at 1-800-252-3439 and file a complaint. We contact the health plan to try and get immediate help for the consumer, and it alerts us that there may be a problem so we can look into the issue and take action if necessary.”"
Information from Texas Association of Health Plans
A new poll released by Kaiser Family Foundation found that 9 out of 10 insured Americans are satisfied with their choices of doctors and the value of their health plans. Still, it is a shared responsibility by the entire health care community — health plans, providers, and facilities-to work together to ensure all Texans have enhanced access to quality health care when they need it and where they need it. This alignment is critical in achieving our mutual goal of improving care and developing creative solutions to improve access to care for consumers.
Information from Families USA
A Healthcare Advocacy Group about network adequacy.