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Health-exchange subscribers have trouble finding doctors to accept their insurance

| Monday, Oct. 27, 2014, 8:21 p.m.

Now that some people finally have health insurance through the Affordable Health Care exchanges, many are running into a new problem: They can't find a doctor who will take them as patients.

Because the exchange plans often have lower reimbursement rates than commercial plans, some doctors are limiting how many new patients with the policies they will take, physician groups and other experts say.

“The exchanges have become very much like Medicaid,” says Andrew Kleinman, a plastic surgeon and president of the Medical Society of the State of New York. “Physicians who are in solo practices have to be careful to not take too many patients reimbursed at lower rates or they're not going to be in business very long.”

To prevent discrimination against ACA policyholders, some insurance contracts require doctors to accept their exchange-plan patients along with those on commercial plans unless the doctors' practices are so full they can't treat any more people. But lower reimbursement rates make some physicians reluctant to sign on to some of these plans or accept too many of the patients once they are in the plans.

Kleinman says his members complain that rates can be 50 percent lower than commercial plans. Cigna and Aetna, however, say they pay doctors the same whether the plan is sold on an ACA network or not. UnitedHealthcare spokeswoman Tracey Lempner says it's up to their physicians whether they want to be in the exchange-plan networks, which have “rates that are above Medicaid.” Medicaid rates are typically below those for Medicare, which in turn are generally lower than commercial insurance plans.

Shawn Smith of Seymour, Ind., spent about five months trying to find a primary care doctor on the network who would take her with a new, subsidized silver-level ACA insurance plan.

Last week, Smith found a practice that would accept her as a patient. Caroline Carney, chief medical officer of MDwise, Smith's insurer, says some doctors “might be participating with us, but just not able to take on new patients. It's at the doctor's discretion.”

Among complaints from doctors about how the whole system is working:

• If consumers have a federally subsidized plan, they get a 90-day grace period before plans are canceled if they don't pay their premiums. That means doctors have to pursue patients to pay for their services for most of that time as insurance companies refuse to pay the claims.

• Plans sold on the exchanges with the lowest premiums require consumers to pay the most out of pocket. Many of these customers have insurance for the first time and don't understand how much they have to pay, so doctor's offices have to spend a great deal of time explaining benefits packages, says Ripley Hollister, a primary care doctor in Colorado Springs.

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