The Health Care Reform law mandates that plans offered outside of Covered CA must mirror (plans and network must be exactly the same) what is offered in Covered CA. (SB 639 * Cahba.com * Crosby * 2.7.2014 Email to Cedars Sinai *
As part of changes created by the Affordable Care Act, Blue Shield of California (Blue Shield) revamped many of its Individual and Family Plan (IFP) products for 2014 and beyond. Through this redesign, the Blue Shield IFP products available to individuals through Covered California™ as well as directly through Blue Shield are the same in terms of benefits and provider networks and are known as “mirrored” products.* Family Doc.org *
Any plan that offers a product on Covered California offers a “mirror” plan with identical benefits and networks. The ID cards of all consumers who purchased plans through Covered California display the logos of their respective health plan AND the logo of Covered California. The ID cards of patients who purchased mirror products do not display the Covered CA logo ACPonline.org *
Cedars Sinai letter that Assurant has wide provider PPO list, not ACA limited list 1.2104
US News & World Report Which top hospitals take Obamacare 2013
Government Officials get upset if you try to explain anything…
President Trump said Insurance is complicated – see video in the footer
President Obama said you could keep your doctor see video at right
Kevin Knauss Post on if there are fewer MD’s in Covered CA then out of Covered CA? Confusing Provider Finders insuremekevin.com
Guaranteed Issue - No Pre X Clause
Quote & Subsidy Calculation
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(a) Contractor [Insurance Company] acknowledges and agrees that QHPs [Qualified Health Plan] and substantially similar plans offered by Contractor outside the Exchange must be offered at the same rate whether offered inside the Exchange or whether the plan is offered outside the Exchange directly from the issuer or through an agent as required under applicable laws, rules and regulations, including those required under 45 C.F.R. § 156.255(b), 42 U.S.C. § 18021, 42 U.S.C. § 18032. In accordance with Government Code Section 100503(f), Insurance Code Section 10112.3(c), and Health and Safety Code Section 1366.6(c), and other applicable State and Federal laws, regulations or guidance in the event that Contractor sells products outside the Exchange, Contractor shall fairly and affirmatively offer, market and sell all products made available to individuals [Free Quotes] and small employers [Free Quotes] in the Exchange to individuals and small businesses purchasing coverage outside the Exchange. …
The law appears to require that plans are exactly the same in and out of the Exchange – Covered CA
(B) provides the essential health benefits package described in section 1302(a);
(iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange [Covered CA] or whether the plan is offered directly from the issuer or through an agent; and
From another well informed agent, who is also setting up training for TX navigators
the statute does not use the term “mirror”, but how would a plan off the exchange have the same premium if it did not provide the same benefit [including networks] structure?
Section 1301 PPACA Qualified Health Plan Defined Page 44 steveshorr.com
(B) provides the essential health benefits package described in section 1302(a);
(iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange [Covered CA] or whether the plan is offered directly from the issuer or through an agent; an
Covered CA Board Meeting
3.2.2 Standard Benefit Designs and Off-Exchange Silver Plan
a) During the term of this Agreement, Contractor shall offer the QHPs identified in Attachment 1 and provide the benefits and services at the cost-sharing and actuarial cost levels described in the Benefit Plan Design summarized at Attachment 2 (“Benefit Plan Designs”), and as may be amended from time to time under applicable laws, rules and regulations or as otherwise authorized under this Agreement.
b) During the term of this Agreement, for any plan year that the cost of the cost-sharing reduction program (Our webpage on the court case that ruled the subsidy for CSR’s was illegal as it wasn’t authorized by Congress * House v Burwell) is built into the premium for Contractor’s Silver-level QHPs, Contractor shall offer a non-mirrored, Silver-level plan, that is not a QHP, outside of Covered California that complies with the benefits and services at the cost-sharing and actuarial cost level described in the plan design at Attachment 3 (“Off-Exchange, Non-Mirrored Silver Plan Design”). This plan must not have any rate increase or cost attributable to the cost of the cost-sharing reduction program.
3.2.3 Offerings Outside of the Exchange
a) Contractor acknowledges and agrees that as required under State and Federal law, QHPs and substantially similar plans that are identical in benefits, service area and cost sharing structure offered by Contractor outside the Exchange must be offered at the same premium rate whether offered inside the Exchange or outside the Exchange directly from the issuer or through an Agent. Covered CA Board Meeting 6.15.2017 *
(a) General requirement.
(1) A QHP issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.
(2) A QHP issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may instead comply with the alternate standard described in paragraph (b) of this section.
(3) Nothing in this requirement shall be construed to require any QHP to provide coverage for any specific medical procedure provided by the essential community provider.
(b) Alternate standard. A QHP issuer described in paragraph (a)(2) of this section must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards.
(c) Definition. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, including providers that meet the criteria of paragraph (c)(1) or (2) of this section, and providers that met the criteria under paragraph (c)(1) or (2) of this section on the publication date of this regulation unless the provider lost its status under paragraph (c)(1) or (2) of this section thereafter as a result of violating Federal law:
(1) Health care providers defined in section 340B(a)(4) of the PHS Act; and
(2) Providers described in section 1927(c)(1)(D)(i)(IV) of the Act as set forth by section 221 of Public Law 111-8.
(d) Payment rates. Nothing in paragraph (a) of this section shall be construed to require a QHP issuer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of such issuer.
(e) Payment of federally-qualified health centers. If an item or service covered by a QHP is provided by a federally-qualified health center (as defined in section 1905(l)(2)(B) of the Act) to an enrollee of a QHP, the QHP issuer must pay the federally-qualified health center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1902(bb) of the Act for such item or service. Nothing in this paragraph (e) would preclude a QHP issuer and federally-qualified health center from mutually agreeing upon payment rates other than those that would have been paid to the center under section 1902(bb) of the Act, as long as such mutually agreed upon rates are at least equal to the generally applicable payment rates of the issuer indicated in paragraph (d) of this section.
New rules for Federal Exchanges about “Narrow” networks.
Plans generally would have to contract with at least 30% of essential community providers in their market, including community health centers, HIV/AIDS clinics, and children’s hospitals.
Provider Finder & Narrow Network Pages
- Hospital and Provider Sites showing Insurances Accepted
- Latest News Articles
- Narrow Lists? Fewer MD’s than before?
- Class Action – DOI Investigation
- Continuity of Care AB 369 – SB 133
- Narrow Networks – 3 month grace period
- Out of Network Problems
- Negotiated Rates – Itemized Bill – Regular Price?
- Provider Finder – Misc. Comments