On California's State Borders, People Struggle with Health Insurance Restrictions

By Pauline Bartolone, Capital Public Radio

For some people living along California's state border, the closest or most convenient care is often out of reach.

Kory and Stacey Felker experienced this problem for the first time this year, after they signed up for individual insurance with Anthem Blue Cross.

The Felkers live in Quincy with their two kids. The small community rests in an alpine valley at 3,500 feet in the Sierra Nevada mountains, a couple of hours northwest of Lake Tahoe.

"Reno is the closest city," says Stacey Felker. "That’s where we’ve always gone for health care."

Reno may be the closest, but it's still 80 miles away. The nearest California city, Chico, is about as many miles away, but requires a longer, more dangerous drive down a windy canyon road. Chico is also smaller than Reno, and its major hospital has more limited facilities.

Early this year, Kory Felker's health took a scary turn. He has Crohn’s Disease, an inflammatory disease of the intestinal tract, and it led to a perforated bowel. Felker was initially treated at the local hospital, but when his condition became more grave, the hospital called his wife.

“They said, 'He’s having trouble breathing. He’s pretty much collapsed on the floor. Flight care - which is the helicopter - is on its way.'" Stacey Felker remembers.

The local hospital sent Kory Felker to Reno for surgery. Then, the Felkers found out their Anthem Blue Cross plan didn’t cover routine out-of-state care. Under the Felkers' policy, Anthem did cover emergencies, but non-emergency care must be provided within state borders.

The Felkers could see this would be a problem for Kory's post-operative care. Stacey called Anthem and was told that the nearest provider was in Auburn, about three hours away from their home.

"Kory’s just gotten out of surgery. I’m pregnant. We have two little kids," Stacey said about the circumstances in which they were faced with that travel prospect.

The Felkers now face a tangle of high medical bills, some which may be covered, some perhaps not. Meantime, they started getting care in a California valley town, which is a a longer, more dangerous drive than Reno.

“We pay a lot of money for our health insurance, and to be so restricted, I feel like it’s just not fair," Stacey Felker says.

Thousands of Border Residents Face New Out-of-State Insurance Obstacles

At least 9,600 Northern Californians who live in counties bordering other states have policies through Covered California that don’t cover routine out-of-state care. For many of them, going to Nevada or Oregon may be the closest or most convenient care.

Anthem Blue Cross stopped covering out-of-state care for its individual policy-holders effective this year. The company declined an interview, but sent a written statement about the coverage change in their individual market plans.

"These are California plans for California residents with California providers," wrote Anthem spokesman Darrel Ng. "Anthem’s policies fully comply with state law and our contract with Covered California.”

Anthem does offer the out-of-state coverage benefit for people who have policies in Anthem's small group plans.

Anthem Blue Cross has over 90 percent of the Covered California market in far-Northern California -- which includes the region from Mendocino across to Nevada County, and stretches north to the Oregon state line.

Blue Shield of California also sells health insurance in the region, and, like Anthem Blue Cross, its plans restrict non-emergency care to within the state. Blue Shield's plans in other regions of California do cover out-of-state care.

The coverage restrictions are the same for people who bought on or off the exchange, who bought with or without a subsidy.

Out-of-State Restrictions Part of Limited Provider Network Trend under ACA

Dylan Roby at UCLA's School of Public Health, says it's fairly new that individual policyholders have trouble with out-of-state care.

He says before the Affordable Care Act, some plans offered broad choice in doctors, but they controlled cost in other ways, such as refusing to insure sick people. But Roby says consumer protections under the new health law have limited the ways insurers can cut spending.

“You saw plans having to figure out how to make money in the new world, where benefits were fairly fixed," Roby says, "they couldn’t have really high deductibles anymore, they couldn’t have annual benefit limits."

Roby says patients encounter limitations in doctor choice now because insurers are using provider payments as a budget-saving tool.

"They basically just negotiated contract with lower-cost providers, and so we’ve seen quite a few where the coverage is no longer as portable as it used to be," he says.

Out-of-State Coverage Restrictions Felt by Physicians

The new out-of-state restrictions change the way doctors practice, too. Just 25 miles from the Nevada state line, Dr. Dennie Chez has an urgent care practice in Truckee. He says when a patient needed specialty care, he sent them over the border, to Nevada.

“Reno is what we call downhill," says Chez. "You don’t have to go over a summit in the winter."

Bot now, Nevada doctors aren’t accepting some insurance plans. Chez must send his patients up to four times as far away for care, and he must form new relationships with specialists.

“I just don’t understand why one state would accept insurance and another state wouldn’t accept insurance," says Chez. "I mean insurance should be insurance. I thought it was all backed by Obamacare which is a national program."

The Affordable Care Act may be a national law, but insurance is regulated at the state level.

Nevada’s individual plan holders don’t have the same problems crossing state lines, according to Nevada's Division of Insurance.

There is at least one other option for Northern Californians who want coverage across state lines using an individual policy -- Assurant Health. But it’s not available through Covered California, meaning people who want the plan would not have access to subsidies.