After Pam Durocher was diagnosed with breast cancer, she searched her insurer’s website for a participating surgeon to do the reconstructive surgery.

Having done her homework, she was stunned to get a $10,000 bill from the surgeon.

“I panicked when I got that bill,” said the 60-year-old retired civil servant who lives near Roseville, Calif.

Like Durocher, many consumers who take pains to research which doctors and hospitals participate in their plans can still end up with huge bills.

Sometimes, that’s because they got incorrect or incomplete information from their insurer or health-care provider. Sometimes, it’s because a physician has multiple offices, and not all are in network, as in Durocher’s case. Sometimes, it’s because a participating hospital relies on out-of-network doctors, including emergency room physicians, anesthesiologists and radiologists.

Consumer advocates say the sheer scope of such problems undermine promises made by proponents of the Affordable Care Act that the law would protect against medical bankruptcy.

“It’s not fair and probably not legal that consumers be left holding the bag when an out-of-network doctor treats them,” said Timothy Jost, a law professor at Washington and Lee University. Jost said it’s a different matter if a consumer knowingly chooses an out-of-network doctor.

Durocher learned only after getting her surgeon’s bill that just one of his two offices participated in her plan and she had chosen the wrong one.  She said the doctor’s staff later insisted that they had raised the issue during her initial consultation, but she doesn’t recall that, possibly because she was distracted by her cancer diagnosis.

Adding insult to injury, insurers are not required to count out-of-network charges toward the federal health law’s annual limit on how much of their medical costs patients can be asked to pay out of their own pockets.

Efforts by doctors, hospitals and other health providers to charge patients for bills not covered by their insurers are called “balance billing.” The problem pre-dates the federal health law and has long been among the top complaints filed with state insurance regulators.

Because the issue is complex and pits powerful rivals against one another— among them, hospitals, doctors and insurers— relatively few states have addressed it.  What laws do exist are generally limited to specific situations, such as emergency room care, or certain types of insurance plans, such as HMOs.

The federal health law largely sidesteps the issue as well. It says insurers must include coverage for emergency care and not charge policyholders higher copayments for ER services at non-network hospitals, because patients can’t always choose where they go. While the insurer will pay a portion of the bill, in such cases, doctors or hospitals may still bill patients for the difference between that payment and their own charges.

That means that in spite of having insurance, a consumer involved in a car wreck and taken to a non-network hospital might receive additional bills, not just from the hospital, but from the radiologist who read his X-rays, the surgeon who repaired his broken leg and the laboratory that processed his blood tests.

Networks Get Narrower

Advocates believe a growing number of consumers are vulnerable to balance billing as insurance networks grow smaller in the bid to hold down costs.

For example, there were no in-network emergency room physicians or anesthesiologists in some of the hospitals participating in plans offered by three large insurers in Texas in 2013 and 2014, according to a survey of state data by the Center for Public Policy Priorities, a Texas advocacy group.

Smaller networks are also becoming more common in employer-based insurance: About 23 percent of job-based plans had so-called “narrow networks” in 2012, up from 15 percent in 2007, according to a May report from the Urban Institute and Georgetown University Center on Health Insurance Reforms.

To protect consumers, advocacy groups, including Consumers Union and the American Cancer Society Cancer Action Network, want regulators to strictly limit balance billing when an insured person gets care in a medical facility that is part of an insurer’s network.

“Without protection from balance billing, the cost of out-of-network care can be overwhelming,” wrote Consumers Union in a recent letter to the National Association of Insurance Commissioners (NAIC), which is updating a model law that states could adopt to regulate insurance networks.

NAIC’S current draft does not directly address the issue of balance billing and consumer efforts have drawn sharp opposition from insurers, hospitals and doctors.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

FORT COLLINS, Colo. — When Pavel Poliakov’s small clothing shop in this picturesque college town closed last year, he felt lucky to be able to sign up for Medicaid just as Colorado expanded the program under President Barack Obama’s health law.

But when Poliakov developed such a severe toothache that he couldn’t eat on one side of his mouth, he was unable to find a dentist — even though Colorado had just extended dental benefits to adults on Medicaid.  Eventually, he turned to a county taxpayer-supported clinic that holds a monthly lottery for new patients.

Poliakov, 40, was a three-time lottery loser before his name was chosen in September.  “It was horrible” living with the pain so long, he said as the second of his seven cavities was filled at the dental clinic run by the Health District of Northern Larimer County.

Colorado was one of five states last year to begin offering routine dental coverage to millions of low-income adults in Medicaid — an unprecedented expansion. But like Poliakov, many have had trouble finding dentists willing to treat them because of Medicaid’s low reimbursements, according to providers, advocates and patients.

The upshot is that many Medicaid enrollees continue to live with the pain and discomfort of tooth decay and gum disease, which can exacerbate other health problems, such as heart disease, diabetes and rheumatoid arthritis. Eventually, some go to costly emergency rooms, which can do little but provide short-term pain relief.

“Translating Medicaid coverage into care is a significant problem,” said David Jordan, who directs the dental access project at Community Catalyst, a national consumer advocacy group based in Boston.

“The number of adults on Medicaid who are able to see a dentist is woefully short of where it needs to be.”

Many dentists are reluctant to participate in the government program for low-income Americans because it typically pays as little as half of what they get from patients with private insurance. For example, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared to the $150 and $800 that private patients typically pay.

While federal law requires states to provide dental coverage to children in Medicaid, adult dental coverage is optional. To save money, almost half the states either don’t provide any dental coverage for adults or cover only emergencies.

In addition to Colorado, California, Illinois and Washington added or restored adult dental benefits last year as they expanded Medicaid eligibility under the health law to those making up to 138 percent of the federal poverty level. The federal government pays the full cost of expansion through 2016, and then no less than 90 percent. The fifth state, South Carolina did not expand Medicaid eligibility, but added adult dental services to improve benefits.

Yet advocates in all five states say providers are struggling to keep up with demand.

“Getting oral health care is difficult, if not impossible, for many of Colorado’s Medicaid clients,” said a report released this month by the nonpartisan Colorado Health Institute, a health policy research organization.  The study found that in the past year, the number of Coloradans eligible for Medicaid dental coverage, including children, tripled to nearly 1 million, while the number of dentists who say they treat Medicaid patients increased by only 17 percent — to 877 practitioners.

Nationally, children on Medicaid also face a shortage of dentists willing to treat them, though the problem is typically not as severe.

Safety net providers in Colorado, such as federally funded community health centers, have tried to fill the gap, but in many places appointments for new patients are gone within hours of becoming available. Eight Colorado counties lack any dentists and seven more don’t have a private dentist who accepts Medicaid or a safety net clinic offering dental services, the study found.

Colorado Medicaid officials say they have enough dentists in most places. “We’ve not had calls from legislators or stakeholders that we flat out can’t get people into dental services,” said Bill Heller, director of the state’s Medicaid dental program.

Still, the state last summer proposed paying dentists a $1,000 bonus for taking five new Medicaid clients and seeing them at least twice a year. But the Obama administration has yet to approve federal incentive money

With little political support to increase reimbursements to dentists, advocates have looked at other ways to boost care. The Colorado Dental Association has urged members to take new Medicaid dental patients to alleviate waits, but it’s unclear how many have done so.

“The economic realities make it difficult,” said Greg Hill, association executive director.

Seeking other alternatives, Alaska and Minnesota have enacted regulations that allow dental therapists with two years of training to perform basic services, such as filling cavities, if they work under a dentist’s supervision. The therapists in those states are much more willing to see Medicaid patients.

But efforts to expand their use in other states have been opposed by the American Dental Association, which raises questions about patient safety.  Dental therapist legislation is pending in Washington and South Carolina, along with several other states.

Meanwhile, patients with Medicaid continue to struggle to get care.

Officials at Promise Healthcare, a community health center in Champaign, Ill., say demand for dental services is so great they frequently turn clients away. Last month, more than 150 people called for one of 12 new patient appointments, said Executive Director Nancy Greenwalt.  “Patients are desperate.”

Christina Peters, of the Washington Children’s Health Alliance, said only about 15 percent of adult Medicaid enrollees in that state received dental care last year after the benefit began.

In Hartsville, S.C., CareSouth , a community health center, has one dentist who’s seen 60 new dental patients in the past month— but more than 400 have sought care.

Alfredo Rodriguez, 51, a Longmont, Colo. landscaper, visited a dentist at the Salud Family Health Center in February with several loose and broken front teeth that made it hard to eat. “I’m so thankful to be here,” he said while waiting to get three teeth pulled and to be fitted for a partial denture.

The North Larimer County Health District dental clinic gets between 150 and 300 people entering its lottery each month, hoping to qualify for 50 or 60 slots.  Over half the clinic’s 5,000 patients are on Medicaid.

Rob Gartland, a clinic dentist, says the value of Medicaid is that patients can afford more expensive procedures, such as crowns and root canals, rather than just extractions.

In Fort Collins at least, Medicaid patients will soon get more help when Salud’s clinic here adds a dentist later this winter.

Sitting in the center’s waiting area recently, Tiffany Rickman, 23, said she would definitely use the service. She says she feels pain every time she eats, but has been unable to get care. “I would really like to get into a dentist and have a place where I can be a regular patient,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Obama administration often touts the health benefits women have gained under the Affordable Care Act, including the option to sign up for coverage outside of open enrollment periods if they’re “having a baby.”

But advocates complain the special insurance enrollment period begins only after a birth. As a result, uninsured women who learn they are pregnant outside of the regular three-month open enrollment period, which this year ended Sunday, can get stuck paying thousands of dollars for prenatal care and a delivery — or worse, going without  care.

The advocacy groups, including the March of Dimes, Planned Parenthood and Young Invincibles, are asking the administration to allow women to sign up whenever they become pregnant – a change opposed by the insurance industry. They say they’ve sought the change unsuccessfully for several years.

Cynthia Pellegrini, senior vice president of March of Dimes, notes that about half of pregnancies are unintended. And women often can’t predict when they will have a challenging pregnancy requiring more services.

The advocates have applauded the health law for including maternity coverage among the list of “essential benefits.” But they say that allowing women to get covered as soon as they’re pregnant would give them and their unborn children greater protection. It would also allow those with high-risk pregnancies to change plans to get more comprehensive coverage that might include access to certain hospitals and doctors.

The health insurance industry contends that allowing reproductive-age women to enroll any time they become pregnant would give women an incentive to wait to buy coverage.

“If you only create incentives for people to enroll when they have a health need, it poses a tremendous risk to the risk pool and affordability for everyone else,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the industry’s trade group.  She said insurers would have more difficulty setting their prices because it would be harder to predict who would buy coverage.

Before the Affordable Care Act, individual insurance policies rarely included maternity coverage — and women could not buy policies after they became pregnant. Today, they can buy such coverage during open enrollment.

A spokesman from the Department of Health and Human Services declined to comment.

The Obama administration allows people to enroll outside of the regular enrollment period in several circumstances, including after adopting or having a child, losing other coverage, moving out of a plan’s service area or getting married. The list of so-called “qualifying events” is similar to the circumstances that allow people with employer-sponsored insurance to change their coverage outside of open enrollment. The administration last week said it was considering adding a special enrollment period for people who discover they owe a tax penalty due to lack of coverage.

“If you have to spend $10,000 to $20,000 out of pocket on maternity care, it certainly puts women in a difficult position and insurance coverage [after a child’s birth] would be coming too late for them,” said Christina Postolowski, health policy manager for Young Invincibles, the nonprofit which has worked with the administration to boost enrollment.

The group is releasing a report Wednesday that looks at the economic and health consequences of not making pregnancy “a qualifying event” to sign up for coverage any time.

Without access to a health plan, women may be more likely to forgo prenatal care because they can’t afford it, which can put them at higher risk for conditions than can affect their own health as well as that of their child, such as pregnancy-related diabetes and high blood pressure, the report said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.