JACKSONVILLE, Fla. -- Sandi Muhich knows insurance. She is an independent agent, but even her skill set was not enough to prevent a problem with the Affordable Care Act.
"I'm going to keep going to the mat on this," she said.
Several weeks ago, Muhich enrolled in Obamacare. She elected an HMO plan and was fine until she received her "welcome package." The plan had assigned her a different primary care physician.
"It said the doctor was a Medicare provider," said Muhich, "I'm not eligible and the Affordable Care Act has nothing to do with Medicare."
Adding insult, her long-term care provider was not part of her new health care plan. Muhich said trying to get the problem corrected is far more difficult than expected.
"They did not ask at the exchange 'who do you choose as a provider,'" she said, "They just gave me somebody."
After more than a dozen calls to her new insurance company, they told her they will give her an override.
"I have the right to choose my primary care doctor, not them," said Muhich.
Joyce Case is program director with Health Planning Council of Northeast Florida. The agency is a navigator of the Affordable Care Act.
"In any insurance plan, they ask if you have a primary care doctor or a medical home," said Case, "If you don't, they will do an assignment. "
Case doesn't know the specifics of Muhich's case but said if there is still a problem,the easy solution is to start over.
"The companies in the marketplace are good companies and they're willing to work with people to resolve issues," said Case.
Muhich doesn't know if the override has truly solved her problem and won't know until the next time she has to see her doctor.
A spokesperson with the Department of Health and Human Services said there are no restrictions, but anyone who wants to keep their current doctors need to check to see if they are part of the plan they are enrolling in.
Another possible solution is to go back to the broker or a navigator for help.
These are the rules per HHS:
- The Exchange Final Rule and the Letter to Issuers (http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf) lays out our standards in regards to network adequacy.
- CMS is enforcing those standards, and, as the final rule explains, Qualified Health Plan (QHP) issuers are required to maintain a network that is sufficient in number and types of providers to assure that all services will be accessible without unreasonable delay.
- All QHPs must comply with the statutory and regulatory requirement that they maintain provider networks that are sufficient in number and types of providers to assure that all services will be accessible without unreasonable delay.
- Most states also have longstanding network adequacy requirements that issuers need to comply with to ensure adequate numbers of providers. Therefore, the starting point for Marketplace plans are the network requirements that are similar to those imposed on plans today, and Marketplace standards ensure that consumers will have doctors to see and hospitals to use when they need care.
- We clarified in December that issuers should provide in-network provider directories for Marketplace plans that are the most accurate and up to date, so that consumers have all the information they need to choose the plan that's right for them. We are also strongly encouraging insurers to treat out-of-network providers as in-network to ensure continuity of care for acute episodes or if the provider was listed in their plan's provider directory as of the date of an enrollee's enrollment.
- Plans are required to cover emergency services wherever, even if the enrollee uses these services out of network. https://www.healthcare.gov/how-does-the-health-care-law-protect-me/#part=6.
- Also, consumers can purchase a PPO or POS plan in the Marketplace.