Health Care Reform – Narrow Networks to save money? FAQ’s
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/
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]
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. Thank you.”
Cedars Sinai letter that Assurant has wide provider PPO list, not ACA limited list 1.2104
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 *
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 *
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 at right
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
Related, Child Pages & Site Map
- Class Action – DOI Investigation
- Continuity of Care AB 369 – SB 133
- Covered CA vs Direct Provider Lists?
- Narrow Networks – Codes & Regulations
- Out of Network Problems