Health Care Reform – Narrow Networks to save money? FAQ’s
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 *
- 2017 Directories are still lousy
- 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
- How narrow are the new lists (See the Provider Finder Page) under Health Care Reform – Covered CA?
- 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)?
- Officially no, due to mirroring requirements
- Why do so many MD’s say they accept direct business from an Insurance Company – but not Covered CA?
- 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?
- SB 137 effective 1.1.2016 hopefully will make things easier.
- Does this lawsuit filed against Blue Cross and Does 1-50 show a material violation?
- 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
- Are consumers showing a preference for narrow networks to save $$$?
- Out of Network Costs…vary by Insurance Company Blog InsureMeKevin.com
- 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
- View LATEST news articles on Narrow Provider Lists
- 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.
I think it’s a real shame that the “authoritative” answers seem to be Facebook. Nothing with actual proof or citations.
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
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
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/
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 Notice – Deadline to opt out 2.15.2018
Settlement Website harrington talon aca settlement.com
Current Blue Shield Provider Finder
Appoint us as your Broker No extra charge. Blue Shield pays us.
Provider Network Access Standards
California Code of Regulations 10 CCR § 2240 et seq.
- § 2240. Definitions.
- § 2240.1. Adequacy and Accessibility of Provider Services.
- § 2240.15. Network Access Appointment Waiting Time Standards; Quality Assurance; Disclosure and Education.
- § 2240.16. Access Standards for Pediatric Vision and Oral Essential Health Benefits and Specialized Policies that Cover Dental Benefits Only.
- § 2240.2. Insurance Contract Provisions.
- § 2240.3. Provisions of Policies and Certificates.
- § 2240.4. Contracts with Network Providers.
- § 2240.5. Filing and Reporting Requirements.
- § 2240.6. Notice and Information to Covered Persons.
- § 2240.7. Discretionary Waiver of Network Access Standards.
See also – Special Enrollment Periods
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.
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
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
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.
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)
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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.
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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
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I have been reading about all kinda of night mares people are having with Drs not accepting the obama policy’s even thought they are listed on the exchange as expecting it.[Steve Shorr Insurance writes] It’s best to check each companies provider list. See above One may also double check with the doctor or hospital. The exchange just announced they would taking their list down.
It’s making me kind of nervous.
[Steve Shorr Insurance writes] Me too
I’ve been wondering why kaiser is more expensive then the ppo’s, I’m starting to think that’s kaiser may be the only real insurance … What’s your advise?[Steve Shorr Insurance writes] What plan do you have now? Is it grandfathered? Kaiser uses all their MD’s in all plans.
Are we better off leaving our kids on medi[Steve Shorr Insurance writes] -cal and getting a private policy for us?
[Steve Shorr Insurance writes] I can’t spend the money or lack of it in your pocket. Call me Monday to discuss. I was thinking about choosing anthem because cedars is taking it but it’s an EPO not a PPO, can I trust the drs we want will be taking it ? [Steve Shorr Insurance writes] Double check the Blue Cross Provider List and the doctors.
Also can you explain the difference bet a EPO and PPO?
[Steve Shorr Insurance writes] PPO – Direct Access Pathway X Tiered plans, you have the freedom to see any in-network doctor you choose. It’s also a good idea to have a primary care physician (PCP) for things like checkups and health issues that need ongoing care. However, you’re not required to select a PCP. Guided Access Pathway X HMO plans, you must choose an in-network PCP who helps to coordinate your care. When you see other doctors, you may need to get a referral from your primary care physician. Pathway X Tiered: An exclusive provider organization (EPO) plan is a type of managed care plan. The EPO network is made up of a select group of care providers. With the exception of an emergency situation, you may only get benefits from an in-network provider if your plan is part of this network. With these plans, you can see a specialist without a referral from your primary care physician Still confused – see 12.11.2013 email from Blue Cross to clarify. steveshorr.com Check out this brochure steveshorr.com
Thank G-D we are healthy but through having 5 children both in kaiser and cedars I learned a lot about insurance and I’m worried about choosing a plan with hidden problems.
[Steve Shorr Insurance writes] I’m worried about selling this stuff. Many of the terms above are brand new…. I’m mandated to have a malpractice policy by Covered CA. I’m concerned though that if they give me the wrong information to give my site visitors and clients, that they will claim Government Immunity. www.leginfo.legislature.ca.gov/
Ps. You have been so helpful so far I am hoping you can help guide me and help me choose the right plan.
[Steve Shorr Insurance writes] Depends what you want to pay… I just signed on to Assurant Life, assurant-life/ they are not in the exchange, but Cedars gave them high accolades. See link above You can change plans at next year’s open enrollment or till 3.31.2014
Also, if you earn more $$$ to change the Silver Level, that would give you a special enrollment period. special-enrollment-triggering-events/ Please send me what you have that might be relevant from the paper application pdfescape.com this one is fillable. updated the paper application to make it an input form….
Feb. 6, 2014 COVERED CALIFORNIA TAKES PROVIDER DIRECTORY OFFLINE – CONTINUES TO OFFER LINKS TO EACH PLAN’S PROVIDERS SACRAMENTO, Calif. — Covered California announced it will discontinue posting of a provider directory on its web site until further notice, after finding some errors in the physician lists. While the combined provider directory was a useful service for many consumers, some enrollees located physicians thought to be in their plan, and subsequently discovered they were not. Enrollees who selected a Covered California plan based on the provider directory on the exchange web site should contact the health insurance plan to verify the provider is in the network, or to ask for a different provider in their area. The plans will work with enrollees to resolve these situations on a case-by-case basis. If enrollees find the resolution unsatisfactory, they can contact Covered California’s Service Center to cancel enrollment in their plan, and enroll in a different plan before the end of open enrollment period, March 31.
While Covered California will discontinue its combined provider directory, it will continue to support consumers to find providers, by supplying links to each health insurance plan’s provider directory. Consumers can link to specific plan directories by clicking on “View Directory” while previewing plans.
Cedar’s Sinai called back, very polite and informative
“Yes hi Steve this is Doug Strack I’m calling from Cedars-Sinai hope you’re well Happy Friday. I’m calling in response to an e-mail you sent this morning to us about insurance plans and what is in your coverage mean in particular healthnet(?) and I just wanted to call to discuss that with you. Yes and your coverage means anything the offer on the exchange they have to offer off of the exchange at the same price. However it’s not vice versa which means they can offer plans completely outside of the exchange that they do not offer on the exchange. So the mirror is a kinda one way mirror what everything that’s on must be off but they can have unique things off so in that situation the situation with help that is the PPO bronze which is the broad PPO network that includes Cedar Sinai is offered on exchange and then all the other metal levels on exchange our HMO. However off the exchange they have all the metal levels on the PPO plan available so if you wanna discuss the I’m area code 323 866 8123.
Hope that makes sense.