Health Care Reform – Narrow Networks to save money?  FAQ’s

Narrow Networks - Myths & Facts
Click icon below to enlarge

Narrow Network Myths & Facts

 

Narrow Networks keep premiums down

One Union keeps costs and deductibles down, by giving up access to some of their city’s best known, and most expensive, hospitals.  Workers not only kept their insurance premiums under control, they saved so much money that housekeepers saw their hourly pay increase from $16.98 to $23.60 in five years, a 39% jump.

The price problem has been most acute in communities with dominant hospital systems, studies show.

In California, for example, hospitals that were part of Sutter Health and Dignity Health, the state’s largest hospital systems, increased prices almost 50% faster than other hospitals in the state between 2004 and 2013, researchers found.

Massachusetts General and Brigham and Women’s charged two or in some cases even three times as much as other academic medical centers in Boston.

For example, a hip replacement at the Beth Israel Deaconess Medical Center — which, like Massachusetts General and Brigham and Women’s is a teaching hospital for Harvard Medical School — cost $28,359, according to federal data.

Massachusetts General charged $55,362 for the same procedure, and Brigham and Women’s charged $65,073.  LA Times 12.17.2019 *

  1. 2017 Directories are still lousy
    1. Patients scrambling for Network MD’s due to flawed directories Penny Gentieu did not intend to phone 308 physicians in six different insurance plans when she started shopping for 2017 health coverage.  CA Health Line 12.13.2016
  2. How narrow are the new lists (See the Provider Finder Page) under Health Care Reform – Covered CA?
  3. Is there a difference in the Covered CA list vs if one buys coverage outside – direct from the Insurance Company or an Agent (at no additional charge)?
    1. Officially no, due to mirroring requirements
  4. Why do so many MD’s say they accept direct business from an Insurance Company – but not Covered CA?
  5. If your MD is not on the list and of course no one was told… is that a Material Provision and would allow one to change to a better list, with a new company under the rules for Special Enrollment?
  6. SB 137 effective 1.1.2016 hopefully will make things easier.
  7. Does this lawsuit filed against Blue Cross and Does 1-50 show a material violation?
  8. What about 2015 lists?  Will the be better? ♦  LA Times 9.29.2014   ♦  No 10.17.2014 CA Health Line   ♦ InsureMeKevin Health Net PPO EPO Comparison    ♦  CA Healthline 12.8.2015 – Fewer PCP’s and Clients having trouble locating them
  9. Are consumers showing a preference for narrow networks to save $$$?
  10. Out of Network Costs…vary by Insurance Company  Blog InsureMeKevin.com
  11. CMS Rule 9929 F leaves Network Adequacy to the States not the Feds. Modern Health Care 4.13.2017 * CMS.Gov 4.13.2017  * Amazonaws.com
  12. View LATEST news articles on Narrow Provider Lists
  13. View actual Evidence of Coverage page 14 and check out the definitions and explanations of the role of the PCP Primary Care Physician and IPA Independent Practise Assoc.

“If you’re competing on price and you can’t vary co-payment structure or deductibles, the only thing you can do is try and keep your networks as affordable as possible,” which means eliminating providers unwilling or unable to meet insurers’ cost expectations.  (CA Healthline.org 2.17.2015)

Here’s the letter from a client of ours that prompted today’s 4.18.2014 update to this website:

Dear Steve I was planning to get in touch with you because as sson as I had coverage it sems that I started to need my insurance… I found a great general doctor and all went smooth with him. My test and Xray had a charge and I paid it but my leg specialist first said that he was participating with Blue Shield but later when he discovered that it was Covered California he said he was not and I had to pay his visit and the MRI ( $500) A second  specialist that I contacted to check on my lungs upon suggestion of my GD, called afer I made the reservation to say the same thing and I had to find an other one, Does Blue Shield have two different PPO  one for general public ad one for CC?

***Here’s a screen shot from Blue Shield’s  provider search.  It shows that the MD list for PPO and EPO is the same for 2014 Health Reform Compliant Plans in and out of Covered CA.  More Explanation.I dont’ thing it is fair. What do you know about it? Amelia  – See laws & Regulations on “code” page.

Blue Cross Explanation of Provider Networks – PDF  on this website  Benefit Snapshot – Brochure  In an email dated 4.22.2014 I rec’d confirmation that networks are the same on and off the exchange.

I think it’s a real shame that the “authoritative” answers seem to be Facebook.  Nothing with actual proof or citations.

Guaranteed Issue - No Pre X Clause
Quote & Subsidy Calculation 
Find out your premium with Covered CA
or Direct without Subsidies

Instant complementary quotes & subsidy calculation

Missed Open Enrollment?
See our Special Enrollment page

No charge for our complementary services 

Detailed Video Instructions on using our Quote Engine

detailed instructions to use quote engine

How to use our FREE Quote Engine, Subsidy Calculator  and get the MOST from the experience.

When you get a FREE quote, you can also see the benefits, view actual brochures, MD and Hospital Lists all ONE easy process with no obligation & it can be anonymous.   Enter your zip code, date of birth, family - household taxation relationships (MAGI - Definition),    Estimated MAGI - Modified Adjusted Gross Income for the upcoming - current year.  Last years tax return only gives an idea so that Covered CA can approve your advance tax credit to help pay premiums.

If you qualify for tax credits - subsidies and want them in advance (Pros-Cons) of filing your taxes click on "Health On Exchange" - Covered CAillustrated below.

This website and are individual consultation are provided to you FREE of Charge!  We are paid by Covered CA and/or the Insurance Companies to help you.  When you fill out the Covered CA ONLINE Application, just appoint us as your agent under Find Help in the Upper Right Hand Corner so that we get paid for helping you.  Click here for screen shots for more detail of how to do it.  If you prefer, you can pay us a consultation fee in lieu of appointing us as your agent, for educational services only.

You can then see all the quotes on the exchange, showing the Cost Share Reduction - Enhanced Silver  if available, subsidy - tax credit amount and your net premium.    If you click "Off Exchange" you will see more plans and companies which  may have larger provider lists.   Scroll down for more screen shots.

Then click on "View Plan Details" - "View Doctor's & Providers" - to compare and get more information.  Please note that the quote engine does not show enhanced silver, but shows silver at 70%.  Check our chart for the better silver coverage.

Learn more about the right to change plans when Silver Level Enhanced Changes

To apply, click on apply now or use the links in the right hand column, ON THIS PAGE, but it will have you redo the quote for that specific company.   The price is the SAME, no matter if you use us, go direct to Covered CA or the Insurance Company, as mandated by law!  If applying through Covered CA, be sure to sign the form to appoint us as your agent.  It's not all the easy to figure out how to do it on their website.

If you have any questions email [email protected] or call us 310.519.1335

Covered CA Certified Agent

Covered CA Certified Agent  
No extra charge for complementary assistance 

Videos on how great agents are

Enrolling in health plans has helped people focus on their families and careers, and feel protected against unexpected medical issues.

I'm in Charles VIDEO

I'm in Charles

I'm in Sonia VIDEO

I'm in Sonia

 

Quotit - #Find Provider - ALL Companies

quotit find provider all companies

Class Action Felser Lawsuit against Blue Cross

  • Felser Settlement 5.5.2016
  • Specifically, the lawsuit alleges that Anthem:
    • Delayed giving its customers complete information until it was too late for them to switch their coverage choice;
    • •Did not inform its customers that it no longer offered out-of-network coverage in four of state’s largest counties — Los Angeles, Orange, San Diego and San Francisco; and
    • •Misled or did not inform its customers about which doctors and hospitals were participating in the insurer’s new plans.   “intentionally misrepresented and concealed the limitations of their plans because it wanted a big market share.”

As a result of those alleged failures, the lawsuit states that many members received thousands of dollars in unexpected medical bills and were unable to see their preferred physician. (californiahealthline.org)

55 page complaint – brief (with my personal ONLY opinions, links and research)

If you have a similar problem, Mr. Biedart Esq (Website & Contact Info) would be happy to talk to you. /    I happen to know him socially.   Here’s a comment from one of our Insurance Clients:

Michael Bidart and his firm represented me in a bad faith claim against my home owners insurer some 13 years ago. As a lawyer myself, I can tell you that they are top notch in the field.    Jay  Gov. Jerry Brown (D) has signed a bill (SB 964) to increase oversight of insurers’ provider networks, the Sacramento Business Journal reports (Robertson, Sacramento Business Journal, 10/2). bizjournals.com/ Consumer Watchdog – files against CIGNA & Blue Shield californiahealthline.org/ 2nd Lawsuit latimes.com/

Lori Scarpo sued Blue Shield,

alleging they knowingly posted

bogus provider lists 

and made it a class action lawsuit.  The case was consolidated – see links below for more detail.

 

Here’s relevant links:

Settlement Website   harrington talon aca settlement.com

FAQ’s

Court Documents

Contact Information

Gibbs Law Firm

Appoint us as your Broker  No extra charge.  Blue Shield pays us.

lori scarpo.com  Web Archive

News Briefs 

HHS ruling to urge insurers to be liberal in Provider Lists and Premium Payment Date (CA HealthLine) actual regulation & will coverage really start 1.1.2014   Right to change plans if Provider Finder doesn’t work – Special Enrollment???

Nationally 1/2 of exchange programs have narrow networks modern health care.com

Covered CA urges insurers to expand network  california health line.org

12.12.2013 Covered CA claims 80% of CA MD’s are in their networks 10.15.2013 Covered CA apologies for releasing inaccurate provider list too early.

AIS Health Explanation  Los Angeles Times 9.15.2013 on “Narrow Networks” to keep costs down on plans in Covered CA.   Video about what networks are.  Notice in MD office, not a provider.    Blue Shield of California has said it will include just 50% of the physicians and 75% of the hospitals in 2014 that it did in this year’s individual plans.  However, Blue Shield has said it will offer exclusive provider organization plans — or EPOs — to first-time buyers for a lower cost than other plans on the exchange  CA HealthLine.org   NPR

Kevin Knauss Post on if there are fewer MD’s in Covered CA then out of Covered CA? Confusing Provider Finders insuremekevin.com

For more information – View the Comments Section of the Provider Finder Page

Myth of MD Shortage – Modern Health Care.com 11.11.2013

 

Covered CA Contract with Insurance Companies – Provider List Requirements… See Page 9, et seq.

2.23.2014 A Sonora mechanic is in so much pain that he can barely walk, but he can’t seem to find a doctor to fix his ailing back after he and his wife switched their insurance coverage through Covered California. Chris Dunn reached out to CBS13 hoping we could get answers. He needs his surgery yesterday. But instead of scheduling his date, he and his wife are navigating a confusing maze of doctors and insurance plans. sacramento.cbslocal.com/ 2.23.2014 San Jose Mercury News Lowering costs by forcing doctors and insurers to compete for millions of new patients is a primary goal of the nation’s new health care law, but a group of gastroenterologists in the East Bay and internists near Chico are exposing a fissure in that plan. mercurynews.com/

Provider Network Access Standards

California Code of Regulations  10 CCR § 2240 et seq.

See also  – Special Enrollment Periods

♦ Material Violation 

♦  MD Not in Network

Department of Insurance Investigation – errors in lists

“It boggles my mind that insurers can’t keep their list up to date,”  “There is no excuse for how messy it is. Health insurers are engaged in false advertising.” Fines coming…   CA Health Line 2.10.2017  *  Blog Insure Me Kevin.com 2.11.2017 DMHC fined:

  • Anthem $250,000; and
    • Felser Settlement 5.5.2016
  • Blue Shield (BS) $350,000.
    • Letters to be sent to members about resubmitting claims by 12.31.2015.  BS asked us not to post, so email us or call BS @(888) 256-3650  to discuss.    FAQ’s

State officials said that Blue Shield faced a higher fine because it was less cooperative with regulators. In addition to the fines, DMHC has ordered both insurers to:

  • Improve the accuracy of their provider directories; and
  • Reimburse enrollees who have been negatively affected by the inaccurate information.

According to the Times, Blue Shield already has reimbursed more than $38 million to consumers who had been charged out-of-network costs. Officials said they do not yet have a reimbursement estimate for Anthem.  Learn More  CA Health Line 11.4.2015

1.5.2015  DOI Emergency Regulations!   Rules Approved CA Health Line 2.3.2015  SB 137 Hernandez         Los Angeles Times

The emergency regulation requires insurers to:

  • Adhere to new standards for appointment wait times (DOI release, 1/5);
  • Offer an adequate number of physicians, clinics and hospitals to patients who live in certain areas;
  • Provide an accurate list of in-network providers (“KXJZ News,” Capital Public Radio, 1/5);
  • Provide out-of-network care options for the same price as in-network care when the number of in-network providers is insufficient; and
  • Report to DOI information about their networks and any changes.   CA Health Line 1.5.2015

CA Health Line 2.17.2015 Sutter – Blue Shield could affect 280k patients – CA Health Line 1.6.2015

12.12.2014 – Health Net Sued – Narrow Lists – Alleged Actual Harm

CIGNA sued for narrow lists

11.18.2014 CA Healthline  Errors Found by DMHC – Both Blue Shield and Anthem said the investigation’s methodology was flawed. For example, providers who responded to the survey with “no answer” were recorded as not accepting exchange patients.

12.9.2014 CA Health Line  1/2 of Medicaid MD’s on list, not really available.

californiahealthline.org

So far, complaints have included:

•Failure to receive health plan identification cards and enrollment information; •Inaccurate provider lists; and •Narrow networks.

State regulators mostly are hearing complaints about the difficulty of determining physicians who are included in provider networks. For example, the Humboldt-Del Norte County Medical Society last month analyzed one insurer’s provider lists and found that only about 33% of area physicians were accurately listed  (californiahealthline.org)

Open Letter to regulators from Concerned Consumer 10.14.2014

One comment on “Narrow Lists? Fewer MD’s than before?

  1. I received your letter and I would like to go forward this case (No.CJC-14-004800)

    Reply
    steve says:
    February 13, 2018 at 9:15 PM
    This website is not the place to opt in or out of the lawsuit

    Please double check any correspondence that you have received or the links above to make your election as to what you want to do

Leave a Reply

Your email address will not be published.