Covered California and ACA related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the ACA and Covered California knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Covered California Provider Networks?

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Question: If the difference between PPO and HMO is diminished, it seems the choice among various insurance plans comes down to one important factor: network. But this piece of information is nowhere to be seen. Certainly Covered California already knows what they are, so what’s the delay?

Answer: Right. Provider networks and price are the only differences among plans on the exchange. When can we see them? Certainly by October 1st. Where? Definitely on the individual insurance company websites and hopefully it will be available during the plan selection phase of the enrollment process on the exchange.

11 Comments

I just found out that I have liver cancer. My Dr recommended me to UCLA but they don’t take Blue Shield PPO(Covered CA). The procedure would be out of network and very costly. UCLA will take Blue Cross. How do I go about getting my insurance provider changed? Covered CA enrollment period is over. The next enrollment is in mid-Oct and won’t take affect till Jan 2015. I don’t know if I will make it till then.

Anyone have any suggestions?

I have covered calif anthem blue cross ppo with no deductible (platinum direct access ceab) There should be no charge to me

And PPO means any Dr. Dr Irene Teper is on cvered calif…….. Claim # 2014142BS1715 Acct# 3901440

Thank you

Why has Covered California waited until the 11th hour to start to write agent contracts? Shouldn’t that have been done prior to training and certifications- sounds like putting the cart before the horse.

An applicant can change plans during open enrollment right up to the 15th of the month prior to their effective date of coverage.

A consumer can change plans (more than once even) right up to the cut-off date before their effective date.

Max, I hear you. But the problem is we don’t know what PPO restrictions there will be on ACA plans until SBCs are out. I suspect ACA PPOs will be much more in-line with HMOs today. That’s all in the SBC, as I mentioned, which, as I mentioned, we won’t get until October 1.

I’m betting the ACA PPOs will be considerably more restrictive than what we are used to, which is probably (again, my opinion) why Covered California is denying access to the SBCs prior to open enrollment.

My understanding of Covered California is that enrollee gets one chance and one chance only. It’s not like Medicare Advantage open enrollment during which a beneficiary could change plans every day until December 7.

They’ve had the better part of three years to get this done, and the present situation is shameful. HHS gets some of the blame for dragging its collective feet in the “Final Rule” game. Agent certification should have begun in August, with appointments completed in early September.

They have fooled around with the agency contracts for the SHOP, crafting a camel out of multiple carriers’ forms, and apparently they still haven’t got it right.

The public has good reason to be confused and skeptical about the whole thing. The only thing I know of in California that’s worse than this is the High Speed Rail boondoggle. Million$ expended in $alarie$ and not one inch of track laid.

Granted, HMOs are not impacted by this, but the effect on the consumer in terms of deciding is no different - you can’t make an informed decision on October 1, because you won’t have any idea what the PPO/EPO coverage networks are to compare against available HMO options.

The problem is the same for Covered California - until provider networks are published, people are buying blind. They lack one of the three key things needed to compare plans - the other two being plan rates, and Summary of Benefits and Coverage. We know the former, and CoveredCA has promised the latter will go live October 1.

Covered California did not tell me what would happen if the networks go live after October 1, and consumers realize that they made the wrong choice. I can’t get a straight answer as to if someone can change their mind during open enrollment or what the cutoff is.

Basically, I’m advising everyone to not sign up for the exchange until the provider networks are posted. If they’re live October 1, great. If not, I wouldn’t touch the enrollment process until they are live.

Provider networks are not governed by Covered California. Each insurer assembles its own network. Networks are always subject to fluctuation but there are not likely to be different networks for Covered California. HMO vs PPO, of course. But Blue Shield’s HMO network, for example, is the same across all HMO plans as far as I can tell. You can go to their website, search for a provider and find out if your (any) doctor is in their network.

Covered California confirmed to me via Twitter (@CoveredCA) that they do NOT expect insurance company provider networks to be ready by October 1.

Which does beg the question, if you order on October 1, without access to coverage networks, how can you make an informed decision? Covered California has not answered if you can change providers during open enrollment, if the coverage networks are later posted, and result in an adverse change to if you can see your existing doctor or not.

It’s a real problem. We’ve gone from “certainly by October 1” to “hopefully before open enrollment closes.”

“Networks and price are the only differences” is NOT an accurate statement. And the differences between PPOs and HMOs have not been “diminished”

When covered by an HMO, except in actual emergencies, a subscriber MUST obtain ALL care within the provider network, and must see his/her Primary Care Provider/Physician for most care and all referrals to specialists. One cannot just go to any in network provider at any time.

Some HMOs will allow persons to access their network providers in other networks when traveling. But this is NOT the same as being covered by a PPO.

In a PPO, the subscriber is free to use any healthcare providers in or out of the network, understanding that out of network services will require a larger out of pocket amount (including the deductible). Appointments with specialty physicians do not require referrals.

This is no small difference.

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