2014 ACA Implementation: One Month In

Happy New Year!

With 2014 came the roll out of the “ACA compliant” health insurance plans. The Covered Ca website is up and running with enrollment far exceeding projections; the most recent figures released  show enrollment of 500,108 in 2013.

The new plans’ high deductibles and co-payments have been the focus of much discussion, but it looks as if the real issue may be low enrollment rate of Healthcare Providers in the networks. The combination of low provider enrollment with no out-of-network benefits leaves little option for the 500,000+ enrollees when it comes to their healthcare.

Why Not Join?

Providers are reluctant to join the networks for many reasons. When insurance plans shift more out of pocket responsibility to the patient, it becomes more difficult to recoup payment for services. Patients may not understand their benefits and why they have to pay out of pocket, and resistance is met. This is already common in the business of healthcare, but higher deductibles and co-payments will only exacerbate the issue. Putting too much focus on payment with the patient can make some providers feel the focus shift too far from care to business. It is a delicate balance.

In the same vein, many providers are reluctant to join because fee schedules are either unclear or unacceptable. Typically, PPO fee schedules hover near and slightly above Medicare, but many Covered California plans reimburse slightly above Medi-Cal rates. Medi-Cal rates are unsustainable for many practices in California, and many providers have opted out of Medi-Cal participation for years. Why then, would those same providers join networks reimbursing near the same? Without a large enough Provider Network, many patients will find themselves having to switch providers or wait long hours for care.

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