Clearing the Provider Network Quagmire in Individual Health Insurance

Today’s article in the Los Angeles Times “75% of Obamacare plans in California use narrow networks, study shows“ states that California is the 3rd worst state when it comes to “narrow networks” with Obamacare Plans. However, the article does not clarify if they are simply referring to Exchange purchased plans or those purchased Off-Exchange meaning directly through the insurance company with or without an agent.


The confusion for Providers started because all insurance companies are allowed to offer insurance coverage either through an Exchange (known in California as Covered California), directly to consumers, through insurance agents, or all three. Here are the areas that providers did not first understand even though they had 3 and a half years to study the impact of the new law.

  1. All individual health plans issued with January 1, 2014 effective dates or later are “Affordable Care Act” also known as “Obamacare” plans.
  2. Hospitals, Doctors and other providers are allowed to determine which companies/plans they want to accept unless they are forced to by network contracts.
  3. When you simply say you have an “Affordable Care Act” plan (See 1 above), the provider may think you mean through Covered California.
  4. If someone says they have Anthem-Blue Cross or Blue Shield in Fresno County, California the provider may say we don’t accept “Obamacare” (See 1 above).

Searching the “Find a Provider” with your insurance company website may lead to even more confusion since you will need to know the exact name of your particular plan, and if the provider is a member of a group or if they are listed individually. Unfortunately, the insurance companies have not made this process simple and with some doctors joining or leaving group practices, maintaining the lists is not easy either.

So, in order to be sure you choose the right company and plan for 2016 when Open Enrollment begins on November 1, 2015 you should start your search now.

Ask your current providers billing department which insurance plans they accept. And b & c are where the insurance companies could improve their search sites.

  •  They should be able to tell you the insurance company(ies),
  •  Whether they accept HMO or PPO coverage.
  •  Which Metal Tier (Bronze, Silver, Gold, or Platinum).
  •  The name of the Network(s) they will work with for particular insurance companies.

After interviewing your providers, research the plans and rates accepted by your providers and determine how much you can afford to pay.

Of course the article puts much of the blame on the insurance companies, however, we know that many providers refuse to work companies due to the lower reimbursement rates for care. After all, you can’t continue to buy something for $10 and sell it for $5 and remain a viable business.

As always, we are here to help you through the twists and turns while finding the plan that is right for you and your family.


Photos by Phillie Casablanca,

Leave a Reply