WASHINGTON -- In Washington state, a woman in Spokane named Cynthia Harvey bought health insurance from Coordinated Care, in part because the brochure promised a robust roster of physicians and coverage for an array of services, including, if needed, emergency room services.
According to a federal lawsuit, however, Coordinated Care failed to mention that in all of Spokane in 2017, the year in which Harvey was enrolled, there were exactly zero emergency room in-network doctors. That left Harvey with a $1,544 bill from an out-of-network ER doctor.
That same year, Steven Milman, a periodontist in Austin, Texas, enrolled in Superior Health, a health plan owned by the same parent company as Coordinated Care, the Centene Corporation. Milman chose Superior after reading on its website that the Austin Diagnostic Clinic, with its 140 physicians, was in its provider network.
After he was enrolled, according to the lawsuit against Centene, Milman discovered the Austin Diagnostic Clinic had informed Superior months earlier that it was no longer accepting Superior patients. When, after a lengthy delay and repeated entreaties from Milman, Superior finally assigned him a primary care doctor, he found his new physician was an OB-GYN. The doctor didn't even treat men.
The class-action lawsuit filed last month against Centene concerns the issue known as "network provider adequacy."
The Affordable Care Act required that health insurance plans sold on the marketplaces in every state maintain a sufficient number of in-network hospitals and physicians, including specialists, in their service area -- essentially, that they have an adequate network of providers. Policyholders spend less to see doctors in their network.
But the Trump administration last month weakened that federal oversight, potentially forcing patients to turn to more expensive providers, travel long distances for cheaper care, endure long waits for medical appointments or, critics worry, forgo care altogether.
"You want to be sure that the plan you've selected really has a robust network of providers for specialists and primary care, that they are accepting new patients, that you can get appointments in a timely way," said Cheryl Fish-Parcham, director of the health access initiative at Families USA, which advocates for affordable health care for all.
The rule, published in April and effective since the beginning of this year, reflects the Trump administration's overall preference for state versus federal regulation. It shifts to states the responsibility for monitoring and enforcing network adequacy. It also doesn't require states to use federal measures, such as limiting the time and distance patients should be expected to travel to see their providers, to determine network adequacy.
The change affects 28 states that rely on the federal health insurance exchange and 11 states that operate exchanges in some sort of partnership with the federal government. (Twelve states operating their own insurance exchanges already were responsible for determining network sufficiency.)