Obamacare Odysseys: Some Confusion as Patients Activate New Health Plans

Enrollment in new individual health plans under the Affordable Care Act ended in April. Almost 200,000 people in the Houston region signed up, and more than 700,000 across Texas. But as the new coverage kicked into gear, some patients had trouble finding doctors.  

 David Via, the office manager for an internal medicine practice in Sugar Land, said patients who have never had insurance got confused and discouraged.

“We’ve had people call and ask to pay us their premiums,” Via said. “We have to explain to  them we can’t take their premiums, they have to send that to the insurance company.”

Via said other newly-insured patients didn’t understand how an HMO works. Some showed up at the office, but with a different doctor designated as the primary care physician on the patient’s insurance card. At that point, Via had to turn the patient away until he or she can call the insurance company and switch the doctor.

“These people want to be seen, they’ve paid for their insurance, but they’re at the wrong office,” Via said. “They don’t take it well, in a lot of cases.”

But even experienced consumers have had problems using the new plans created by the Affordable Care Act.

Paul Hendriks has had job-based insurance before. Currently, he works as an independent contractor at oil and gas drilling sites, monitoring waste fluids that return to the surface.

Hendriks hadn’t been insured for a while, so he was intrigued by the Affordable Care Act, and the fact that it offered some limits on out-of-pocket spending. He purchased a Blue Cross Blue Shield plan on the healthcare.gov website.

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Dr. Elizabeth Torres is a Sugar Land internist and president of the Harris County Medical Society. She and her office manager (and husband) David Via say both doctors and patients have experienced confusion about how the new health plans work.

When Hendriks got bronchitis, he called the Houston doctor on his new insurance card.

But Hendriks was told she wasn’t in that HMO’s provider network. He tried other doctors listed on the website, and still couldn’t find one nearby who could be his primary care physician.  

“It was an exercise in frustration to try to find somebody,” Hendriks said. 

Finally Hendriks called the company’s help center. But he says he got disconnected twice after long waits.  Finally, Hendriks visited a walk-in clinic at a pharmacy, and paid cash to see a provider and get antibiotics for his bronchitis.

But the experience made him decide to drop the coverage this year. “I did spend a lot of time on trying to find a doctor and I finally gave up and said I’ll take the one-percent penalty,” he said.

It’s unclear what happened. The doctor Hendriks originally called is listed on the Blue Cross website as participating in his plan. Two calls to her office were not returned.

Recent polls indicate that the new law has put a dent in the number of people without insurance. But the impact was much less in states like Texas that hadn’t expanded Medicaid.

 So far customers seem to like the plans.  A survey from the Commonwealth Fund found 73 percent of people who had purchased a new private plan were satisfied. When it came to accessing doctors, however, the results were mixed: 54 percent reported their new plan had “all” or “some” of the doctors they wanted. But 39 percent didn’t know which doctors were included on their plans. (Five percent said the new plans had none of the doctors they wanted.)  

Consumer advocates point out the problem is not a new one.

It’s not always clear to insurance customers what doctors are in which plans, said Stacey Pogue, an advocate with the Center for Public Policy Priorities in Austin, a left-leaning think tank.

It’s a problem that preceded the national health law, she added.  

“Consumers have complained for a long time, long before the Affordable Care Act, that the provider directories aren’t up to date, and aren’t accurate,” Pogue said. “That’s a real problem: if you’re picking an insurance company and you’re picking it based on the fact that it has a particular provider you care about, and the directory is wrong, that can be really harmful for a consumer.”

Texas law requires HMOs to update their provider lists every three months.  Blue Cross Blue Shield of Texas spokesman Louis Adams said the company does better than that – they update the online lists every week. But doctors also need to give notice, if they’re retiring or dropping out of a network plan.

There’s been confusion on all sides, according to Dr. Elizabeth Torres, president of the Harris County Medical Society and one of the internists at the Sugar Land practice.  

“The Affordable Care Act has been able to give more patients insurance coverage,” Torres said, “However, it’s been very confusing for patients, because they’re not sure which doctors are on the plan. As a matter of fact, the doctors don’t know which plans we’re on. So that makes it equally confusing.”

Pogue, the consumer advocate, has been trying to figure out what happened.

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Paul Hendriks grew frustrated trying to find a doctor with his new HMO plan through the Affordable Care Act. He dropped the plan but wants to re-enroll in a new plan for 2015.

She said last summer insurance companies really had to rush to put together new plans and networks to meet deadlines under the Affordable Care Act. And perhaps the insurance carriers didn’t do a good job communicating with doctors.

But doctors might also have neglected to check their contracts, Pogue said, or might have failed to educate the receptionists who answer the phones.

Pogue said the process will probably go more smoothly next year. Drilling contractor Paul Hendriks hopes so too.

“I’m sure that when the enrollment period comes around, I’ll go through this again, because I do want the insurance,” Hendriks said. “I just don’t want to pay $500 a month for something I can’t use.”

That next enrollment period begins November 15. 

 

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