Misc. Comments on finding a provider under Health Care Reform

Same Surgery Different Price – Cooling Device after knee surgery
.latimes.com

Small Group Plan – Network – Plan Name Summary  11.14.2014 revision

(Cheat Sheet for names)

Hey Steve!

Long time no talk to……….hope all is well with you and you are getting over the fiasco of CC…….

I am running into some snags, but nothing that does not surprise me—like MDs not accepting BC through CC, but accepting BC outside of CC……..

[It’s my understanding, the lists are the same]

and the pool of MDS that DO accept it are pretty much the bottom of the barrel……….other than that, life is good……..

 

Steve, I’m sorry, but the one time (back in Nov. 2013) that I tried to use your search engine for a quote, it wasn’t working for me …

At any rate, there was no accurate information in my area code for Doctors, hospitals, etc. that were participating in all of the personal plans … anywhere. Period. I spent hours and hours doing my own research, making my own phone calls to try to confirm who was accepting which plans. For me, HOAG Hospital (of which all of my doctors were affiliated with) had flat out stated that they were not accepting any Blue Shield PERSONAL policies NOR Anthem (which switched to EPO’s in Orange county). None of my doctor’s were either. I went to each individual Insurance company web site to try to find what was available, and made many follow up calls to verify. It was a mess. Some doctor’s offices would think they were on a plan (for example Cigna PERSONAL PPO) when in FACT they were not. THE ONLY WAY I WAS ABLE TO OBTAIN THE MOST ACCURATE INFORMATION WAS THROUGH HOAG HOSPITAL’S ADMINISTRATIVE EXECUTIVE WHO HANDLED THE INSURANCE COMPANIES THAT THEY WERE ACCEPTING. It went down to the wire just a few days before Dec. 15, 2013. In mid March, I heard that there was some change … I made multiple phone calls and verified that Blue Shield (covered ca) PPO was now accepted by HOAG along with majority of my doctors.

I have been under an enormous amount of stress and extremely busy in other endeavors as well.

 

Email with client who did the research on the provider finder above

Exactly. That’s why many agents have nicknamed this “ObamaCRAP.”

Steve:

I think I am not expressing this clearly enough. What I am saying, focusing only on Blue Shield because that is what we are used to, is that the only serious network problem is with Blue Shield Individual EPO. Obviously this is a snapshot, things might change in a month or 6 or 12, but as of right now here is how our potential networks stack up:

Current Small Bus PPO Network vs. Future Obama Small Bus PPO Network: No issue or Problem
Current Small Bus PPO Network vs. Future Obama Individual PPO Network: Very slight problem
Current Small Bus PPO Network vs. Future Obama Individual EPO Network: Massive problem.

Tom F

Steve:

I just discovered something interesting to me, and which I thought I should pass on to you in case it is helpful. I mentioned Blue Shield EPOs to you last night. It turns out that is a creature only of the Individual Blue Shield Obamacare plans, and only in counties where PPOs are not offered.
[Steve Shorr Insurance writes]

That’s what I was trying to tell you… That group plans may have BETTER networks.

In other words there are Individual Blue Shield Obamacare plans, but no Small Business Blue Shield Obamacare plans.
[Steve Shorr Insurance writes]

Nope. They are ObamaCRAP too.

Furthermore, as far as I can tell EPOs are only offered in counties (such as Alameda) where PPOs are not offered. So if you search for small business plans Blue Shield shows you only PPOs and HMOs. If you search for individual plans with a zip code in a county (like Contra Costa) that has PPOs, Blue Shield shows you only PPOs and HMOs. But if you search for individual plans in a county like Alameda – try 94501) that does not have PPOs, Blue Shield shows you only EPOs and HMOs.
[Steve Shorr Insurance writes]

That’s what I was trying to explain…. One must check the provider search option and then consider double checking with your MD.

This is kind of a wild card to us, because it turns out that the individual EPO plans are the ones with the highly restricted networks.
[Steve Shorr Insurance writes]

Right.
See below. I asked Blue Shield customer service last night what happens if I move to a county (I was thinking of Alameda, obviously) where PPOs are not offered. He said you would be switched to an EPO.
[Steve Shorr Insurance writes]

OK, EPO is there too for Blue SHIELD.

Now that is strange, if you think about it, because I called customer service for my small business plan and unless I am mistaken there are no small business EPOs. So he must have interpreted my question as having to do with individual plans. [Right? If you were setting up a small business plan for a client whose operations were only in Alameda County, could you set them up with a Blue Shield PPO plan?
[Steve Shorr Insurance writes]

I have to do the quotes to know for sure. Please check the brochures.

blue-shield/

small-business//blue-shield/

I think the answer is yes, but you would be a better judge of that. We certainly had Alameda County employees on PPO plans through Hewts, Inc., but of course our principal address was in Contra Costa County.]

At any rate, to demonstrate how limited the EPO networks are for individual plans in Alameda County, take this sample. I looked up 9 doctors we use or are about to use, as well as the 2 big hospitals we would likely use and the 2 labs we have used in recent years. Here are the results for different types of plans.

Our existing small business plan: 9 Drs. Yes 2 hospitals Yes 2 labs Yes
Obamacare small business PPOs: 9 Drs. Yes 2 hospitals Yes 2 labs Yes
Obamacare individual PPOs: 8 Drs. Yes, 1 NO 2 hospitals Yes 2 labs Yes
Obamacare individual EPOs: 3 Drs. Yes, 6 NO 1 hosp. Yes, 1 NO 0 labs Yes, 2 NO

In short, people in Alameda who get stuck with an EPO through Blue Shield are in a nightmare scenario. I don’t know if this is temporary, because of some glitch with negotiations between Blue Shield and providers, or a permanent artifact, but it is a problem.
[Steve Shorr Insurance writes]

See the articles on “narrow networks”

 

We currently have both a house in Contra Costa and a PO box in Contra Costa. I suppose we could keep the PO box if necessary, if we moved to Alameda, and use that for all Blue Shield matters, if that would work.
[Steve Shorr Insurance writes]

As long as you are not in an HMO where there is a law about being within 20 or 30 miles… should be OK? More on residency issues Residency.Guidelines

EPO might be considered and HMO too? These are brand new terms and I haven’t had time to fully research them….

Tom F

Part of the reason for Narrow Networks, is cost cutting features to make sure that duplicate and unnecessary services are not billed for.

It’s going to be a hot political issue…. modernhealthcare.com

 

Visilia Times – Covered CA not paying much….

visaliatimesdelta.com/

 

Response from an Insurance Wholesaler – General Agent on my 2.7.2014 email to Cedars Sinai to claify their networks
http://www.steveshorr.com/individual_and_family/Providers/cedars.sinai.verify.md.list.mirror.plans.pdf

You are correct that carriers have same benefits/network in Exchange and off Exchange and the carriers of note in Exchange (SHOP) are HN, BS and Kaiser and a few local ones.

Your statement about HN having Cedars in their PPO in and off exchange is correct. BS does not in the exchange nor in their “mirror plan” off exchange however BS has other plans off exchange that include Cedars.

 

2.6.2014 LA Times on Narrow Networks and MD’s refusing to see patients. Please note that the Covered CA network is unfortunately exactly the same as getting a policy out side of the exchange and subsidies.

http://www.latimes.com/

 

Feds to require more providers and approval of lists, etc….modernhealthcare.com

As discussed in private emails, your MD advised that he’s on the BS and HN list which I’ve verified and sent you new proposals. Plans can be changed during open enrollment till 3.31.2014 with no problem

 

Steve

I don’t think this is the right plan. My wife went to the doctor today that she’s been to for 15 years and they won’t take this plan because they say its Covered California. We want the one that is not thru Covered Califorinia – the exchange. We want one that is direct thru Anthem.

Please let me know where we went wrong and how we can fix this.

Doug

***More on “narrow” networks More on narrow networks – http://www.latimes.com/

***The problem is, that the law mandates the companies offer the same “junk” both in and out of the exchange, so it doesn’t matter if it’s Covered CA or not. It’s the same benefits and network. Even though BC shows all these different tiers and pathways, it’s the same. The only way around it is maybe an employer group plan or a grandfathered plan. Grandfathered plans just got a 25% rate increase. I will forward you that email. (Scroll down on this page http://healthreformquotes.com

[Steve Shorr Insurance writes]

The health plan choices offered by Covered California are as good as you can get in any marketplace — even if you are not eligible for a subsidy. Health insurance companies must offer the same products at an identified price whether they are offered through Covered California or in the open market.
https://www.coveredca.com/FAQs/
[Steve Shorr Insurance writes]

Note that Sharp in San Diego offers alternate networks – Performance & Premier http://healthreformquotes.com

Related Pages in the Provider – Doctor & Hospital Finder Section

 

 

 

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