SANTA ANA, Calif. — Hollie Young is trapped in a health care twilight zone that has vexed and confounded her since the beginning of the year.
Two weeks ago, Young’s exasperation gave way to fear. That’s when she found two new lumps on her breast and wondered whether she could possibly be having a recurrence of her breast cancer — the second in less than a year.
When something like that happens, the obvious thing to do is call your oncologist immediately and make an appointment. Except Young didn’t have an oncologist.
She and her husband, Steve Gambhir, residents of Newport Beach, had been forced to scramble for new medical coverage when their long-standing health plan was canceled at the end of 2013. They bought an Anthem Blue Cross HMO through Covered California.
The switch was a great deal financially, saving $1,333 a month in premiums compared with their old plan, thanks to a large federal subsidy. But it required Young to switch medical teams. Talbert Medical Group, where Young had been going for all of her breast cancer treatment, told her repeatedly it would not accept the new insurance.
After applying in late December for the new plan, which was to take effect Jan. 1, Young and Gambhir received their first bill from Anthem on Jan. 3 and promptly paid it online. Little did they know they were about to begin a maddening quest for a new cancer team.
Gambhir and Young are among the Orange County residents the Register profiled late last year as part of an ongoing examination of what the Affordable Care Act, or Obamacare, means for people of varying circumstances. Some of those people have since purchased insurance; others have not. One ended up getting coverage from her employer when she was bumped up to full-time status.
Young is hardly alone in the difficulties she has faced trying to reassemble a medical team after changing insurance. Numerous consumers facing similar challenges have stepped forward in recent weeks. In many cases, as with Young and Gambhir, their insurance companies have disagreed with their doctors about who is in the network.
Insurers selling through Covered California, under pressure to keep premiums as low as possible, responded by excluding doctors and hospitals that declined to accept significant payment cuts.
As a result, the provider lists are significantly truncated compared with health plans outside the exchange.
But the lists are in flux because negotiations are still ongoing in many cases, which may help explain the conflicting information about who’s in and who’s out. Covered California recently took a directory of doctors off its website because it was providing inaccurate information.
Many people also complain they have sent in their forms and paid their premiums, only to wait weeks for confirmation they are covered.
Young and Gambhir heard nothing back from Anthem — they weren’t even sure they were covered — until Jan. 23, when they received another bill along with an insurance card and a letter assigning Young to a primary care clinic in Costa Mesa. She drove to the given address, but it was not quite what she expected. It served a predominantly Spanish-speaking community and advertised exams for immigrants.
“I think they just randomly picked a doctor and put it on our ID card,” Young says. “I just wanted to go to a place that was a medical group like Talbert. It wasn’t a medical group. They were real nice. I’ve got nothing against them; it’s just that they would not be able to monitor me for any recurrences. Talbert had an imaging center with MRIs and PET scans. And they had a breast center — it was all there.”
So Young called Anthem and spent an hour on hold. Her insurance agent spent three hours. Young finally got through.
“I said, ‘Oh my God, you’re a human being. I don’t believe it.’ ” She explained her situation and requested a different medical group. The Anthem customer service operator asked her where she lived, then told her they didn’t have anything in Newport Beach.
“ ‘But in Fountain Valley we have Talbert Medical Group. Do you want to go to Talbert?’ ” Young recounts being asked. “I said, ‘Well guess what? I can’t.’ Then I called Talbert again and said, ‘Are you sure you don’t take Anthem Blue Cross in Covered California?’ She said, ‘Yes I’m sure.’ ”
Darrel Ng, a spokesman for Anthem Blue Cross, implicitly acknowledged there are some bumps on the road. “Anthem, like other health plans, is always working to improve the accuracy of our provider databases,” he said. “If a member is having an issue finding a doctor, they should contact our customer service team, who will assist them.”
In Young’s case, Anthem reassigned her to AltaMed, a network of community clinics that serve primarily low-income communities. For the second time in two trips, she felt a wave of culture shock when she entered the building. They handed her a form that asked whether she had been kicked, beaten or raped in the last year and whether she felt safe at home. It also asked whether she wanted an HIV test. “I said, ‘I’ve been with the same man for 30 years and never took a lover. Do you think I need one?’ ”
But Young found the facility to be “very clean and organized, and everybody was very nice.” So she decided to give it a shot. She waited and saw a doctor, who was also “very nice.” He said he would write up a referral for an oncologist, but she would have to wait for Anthem Blue Cross to approve it and pick the doctor. She feared it could take weeks.
She took an anti-anxiety drug called Xanax to help calm her nerves. She decided she didn’t want to wait for answers, so she called her breast surgeon, who is not covered by the Blue Cross HMO, and she agreed to pay $326 out of her own pocket for an ultrasound. But then the surgeon’s office called back to say they had made a mistake — it would cost $700.
So Young called the doctor she had seen at AltaMed and got an appointment for the next day. His office told her he had an oncologist referral already.
“That’s only three business days, so that’s good,” she says. “He must have put ‘urgent’ on it.” But Young still needed to see him first, on Tuesday afternoon, before getting the name and address of the oncologist.
When she found the lumps, Young decided to switch to a PPO, which would allow her to pick her own oncologist from a larger list of doctors. But now she is having second thoughts.
“It will be a big mess if I try to switch. It’s terrible,” Young says. “The only solution is to take a Xanax and eat chocolate cookies. Hopefully I’ll know something by next week. Hopefully they’re just fluid-filled cysts. I’ve had those before.”