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Blue Shield Covered California Network?

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Question: I have a BS PPO family plan through Covered California. I have been told by UCLA Hospital & affiliated doctors that if you purchased BS PPO through CC then you are not in network. But if you purchased the same plan through an agency you are in network. When I asked the BS agent, prior to signing up at CC, about providers accepting BS PPO/CC I was told that if providers are in network with BS PPO then they're in network through CC. They said it was the same. Can you please explain this? The doctors offices are unaware and uninformed.

Answer: The provider networks of the health plans participating in Covered California, like Blue Shield, must match their off-exchange plans networks to their Covered California networks exactly. The are the same. However, the reverse is not true, these same carriers have other networks that do not match their Covered California networks. Examples of these are grandfathered individual plan legacy networks and group plan networks. So this statement "if providers are in network with BS PPO then they're in network through CC" is not accurate. Some doctors' offices are of the opinion that Covered California has it's own network and this is way not accurate.

20 Comments

I should have added that Cedars Sinai Hospital is one of only a handful of hospitals within about a 30-mile radius of Downtown LA that is not a Blue Shield in-network provider. But since Blue Shield’s plans are PPOs, a person can still go to Cedars on an out-of-network basis.

Within Cedars, some of the physicians may actually be contracted with Blue Shield as network providers.

Vonda …

No hospital or doctor, no laboratory or radiology center, or any other type of service provider has a contract with Covered California. They all contract separately with the various insurance companies.

If a person in Los Angeles County has enrolled in a Blue Shield PPO plan through Covered California, they have access to LAC-USC Medical Center, USC Norris Cancer Hospital, Keck Hospital at USC, as well as St. Vincent, White Memorial, Shriners for Children, California Hospital, Promise (East LA), Hollywood Presbyterian, Children’s Hospital, East LA Doctors, and Glendale Memorial — these are all listed as “within 5 miles” of downtown Los Angeles (ZIP Code 90012).

USC Medical Center is a provider (in-network) for Blue Shield PPO plans however, if the plan is through Covered California they refuse to accept it saying they have no contract with Covered California.

Max wrote:

“People need to understand that the $19 copay is a MAXIMUM amount, not the only amount, they would have to pay to fill a generic prescription.”

I just want to clarify —I wasn’t trying to claim in my post that if I had a Silver plan, I would have paid $19 for a $4 prescription.

I was just saying that the prescription drug benefit wouldn’t have saved me any money in the case of my recent need for an antibiotic to treat a minor infection.

The prescription drug benefits can be lifesaver for people who regularly take expensive prescription drugs — but generally you know if you fit that category. Obviously I could be diagnosed with something requiring expensive meds in April and be stuck for the remainder of the year — but my overall risk is still limited to my out-of-pocket max — and the advantage of ACA is that I will be able to switch plans for 2015 if my circumstances change.

Max wrote:

“Hey, as long as you ARE doing the math and you see a particular value in your bronze HSA plan, I have no bones to pick with you, so please don’t take my comment personally — the “you do the math” was intended in a more generic sense for other readers.”

OK, your tone seems kind of patronizing, hence my rather detailed response.

I would note that I have “done the math” extensively and I think that for MOST older individuals with incomes that put them either borderline for subsidy range or out of subsidy range altogether, who have moderate or low health care needs, that the Bronze plans are the more cost-effective solution, especially for those who opt to fully fund an HSA benefit. In my case, because I’ve already had an HSA set up for 10 years, there’s more than enough funds in the HSA to cover my deductible and/or out-of-pocket max.

For a person who goes to the doctor a few times a year, gets an occasional prescription for a generic antibiotic or painkiller — then, then the difference in premium costs will tend to outweigh the difference in benefits.

I think, like many relatively healthy people, I can safely assume that I am unlikely to even meet the $2000 deductible that comes with the Silver plan.

Keep in mind that insurance wouldn’t work unless the insurance companies were collecting much more in premium dollars than they pay out on average for subscribers — and of course they set their premiums accordingly. If someone who pays full premium costs opts for a higher metal level policy, their higher premium is a sure thing — they will pay that whether sick or well. If I were to opt for Gold in order eliminate the deductible entirely, I’d pay more than $3500 in extra premium dollars over and above the cost of a Bronze. If I am doing that in order to get the benefit of a $30 copay to a doctor a few times a year — that’s a false economy.

The math also favors the lower-cost premium for catastrophic level coverage, because of the out-of-pocket maximum. Once you exceed that level, then the insurance is paying for everything and the person with the lower premium is still ahead.

It is only in the middle — when someone has a chronic medical condition that requires regular visits to the doctor or regularly takes expensive prescription drugs that the math starts looking different. Basically if a person projects out their medical expenses as being between $5000-$15,000 a year they may do better with the Silver or Gold.

The math becomes very different once subsidies are involved, especially for anyone who qualifies for CSR’s - in that case obviously the “Enhanced” Silver plan is going to be the best option.

And I’m guessing it might be different for younger people with lower end premiums, though I haven’t done the math there.

I’m just saying that from my perspective, it doesn’t make a lot of sense to pay more money in a single monthly premium than I am likely to pay for out-of-pocket medical costs in a typical year.

My situation is additionally complicated by the fact that I do tend to have higher medical costs for dental, vision, and chiropractic — none of which is covered by the plan I would pay a premium for — but all of which can be paid with HSA dollars. Even those costs are not likely to regularly exceed 10% of my income (so for the most part not deductible) — so once again the HSA is the most attractive option for me.

But bottom line: part of the “math” is to always add in the cost of premium dollars.

Freelancer …

Hey, as long as you ARE doing the math and you see a particular value in your bronze HSA plan, I have no bones to pick with you, so please don’t take my comment personally — the “you do the math” was intended in a more generic sense for other readers.

The problem is that most people don’t do — or know how to do — the math, and simply look at the premiums, which can lead to dreadful consequences for persons with chronic conditions or who have an unexpected, but costly, medical event.

You also mentioned “The out-of-network doctor prescribed a generic antibiotic; the pharmacy charged me $4 for the pills, a lot less than the $19 copay for prescription drugs on the Silver plan”, and that’s a very important statement.

People need to understand that the $19 copay is a MAXIMUM amount, not the only amount, they would have to pay to fill a generic prescription. Many common network pharmacies such as CVS, Walgreen’s, WalMart/Sams Club, Costco, RiteAid and others are still making many generics available for $4 to $10 for a 30-day supply. They will not charge a higher amount just because that’s what the plan permits.

Max wrote:

“Platinum & Gold medical deductibles are $0, Silver is $2,000/$4,000, plus a $250 drug deductible.

You have to do the math based on your situation.”

Yes, I am doing the math. I am counting the amount of my monthly premium in all of this.

Over the course of year, a Silver plan would cost me $1,650 more in premium dollars, assuming I pay full cost for the premium — which I definitely would, with a Silver.

With a Bronze HSA, I’ve got a $4300 tax deduction which may be enough to bring my within subsidy range. If I qualify for a tax credit, it will be at least $424/month, bringing the potential premium differential between Gold & Bronze to more than $6700.

I’ll switch doctors if my doctor isn’t going to join the network or negotiate down the fee. But as it stands I would need to run up $4500 in charges before it would matter.

I do understand that if I was on Silver, which has a copay rather than co-insurance, I would have paid $45 for each of the two doctor visits, if I had found an in-network doctor instead. Since I had the bad timing to get sick on New Year’s eve and didn’t decide that I needed to see a doctor until things obviously weren’t getting better 4 days later, I don’t think finding a new or different doctor would have been my best option.

If I factor in the extra premium dollars I would have paid for Silver (+$140)- that means that even with an in-network doctor I would have paid about the same in January — plus I would be obligated to pay the extra premium dollars for the rest of the year, even though I don’t plan on getting sick all that often. If I had done the same thing and gone to the out-of-network doctor, I’d still have the same charge because I haven’t met the $2000 deductible either. (On the Silver, out-of-network is 50% coinsurance, which probably does not kick in until after the deductible is met.)

In network or out of network, the amount that Blue Shield allows applies to the deductible. If I get sick with something expensive I’ll go to the in-network hospital or see an in-network specialist.

The nice thing about ACA is that I can act on the assumption that my risk in 2014 is defined by my experience over the past 25 years — but if I have the misfortune to be diagnosed with something chronic and expensive during the year, I can always change to something else during open enrollment.

But the math tells me that I personally will do better now with the Bronze. Let’s not forget that at a 25% marginal tax rate, $4300 in an HSA represents a $1,075 reduction in income taxes as well. As Covered Cal doesn’t offer a Silver HSA on the individual market, I’d forgo that tax benefit if I shifted to Silver. If you add that to the $1650 premium differential it comes to $2,725 — which is $225 more than the difference in deductible levels.

If I had a chronic medical condition or relied on expensive prescriptions, then the math would be different. But that’s not the case. (The out-of-network doctor prescribed a generic antibiotic; the pharmacy charged me $4 for the pills, a lot less than the $19 copay for prescription drugs on the Silver plan).

Freelancer … if you are using your BSCA PPO out-of-network, be aware that although your DEDUCTIBLE is $4500 ($9,000 family), your OUT-OF-POCKET maximum is $9,350 ($18,700 family) compared to $6,350/$12,700.

BUT! out-of-network charges in excess of BSCA contract amounts DO NOT COUNT toward either the deductible or OOP maximum, as stated in Note 1 of the Summary of Benefits:

“Charges in excess of the allowable amount do not count toward the calendar years medical deductible or out-of-pocket maximum.”

Yes, obviously my “50% remarks” have to do with coinsurance AFTER the deductible has been satisfied — it means nothing until then.

So be sure you are clear — if you are using both in-network and out-of-network physicians and other providers, you are staring at the $9,350 out-of-pocket maximum, NOT $6,350. The $6,350 only applies if all your care is provided in-network.

I’m not sure you realize that fact. The out-of-pocket maximums are the same for Silver and Gold plans, and slightly lower in the Platinum plan ($7,000/$14,000). The BIG DIFFERENCE is in the deductibles. Platinum & Gold medical deductibles are $0, Silver is $2,000/$4,000, plus a $250 drug deductible.

You have to do the math based on your situation.

Max wrote:

“including PPO patients who would be covered (but only at 50% of contracted rates, with balance billings fully charged to the patient and not subject to the annual out-of-pocket maximums”

===========

I am not sure what you mean by that 50% figure. I have a Blue Shield PPO — my doctor is not currently on network. (I opted for Blue Shield because the best hospital near me, a Sutter facility, is in-network — my doctor isn’t on Anthem either. I’ve got a Bronze plan and I will probably just change doctors if my doctor doesn’t come onto the plan. In the meantime, I am nowhere near my $4500 deductible, so I’m paying out of pocket either way.)

I was sick this month and had to go to the doctor twice. The first time she billed $110, the second time $150. Blue Shield processed those claims very quickly — they noted that the doctor was out-of-network - and “allowed” these amounts to be applied toward my deductible:

For the $110 bill, $83. For the $150 bill,$122

I would be very surprised if that $205 allowed against a billed total of $260 is “50% of contracted rates.” It’s more than 80% of what the doctor actually billed.

It seems to me that Blue Shield authorized a fair amount — if I was past my deductible they would have paid that.

Your comments about the balance billing are correct, in theory — though I plan to ask my doctor to waive the excess. Based on the amounts that Blue Shield has authorized, I’m fairly optimistic that the billing person in the office will be willing to accept that.

If you are talking about the patient copay (which for me only kicks in after the $4500 deductible is met) — they you are correct, I would have to pay 50% of what Blue Shield allowed, as opposed to 40% for an in-network provider. So we can hypothesize a situation where the deductible is met - and Blue Shield is sending a check to the doctor for $102.50 instead of the $123 they would send if she were in-network. (Assuming the UCR is the same as the contracted network amount) Not a huge difference.

Of course my out-of-pocket max is also $3000 higher with the out-of-network provider… so of course I will save money when I switch doctors. But I’ve got to hit my deductible first- until then, insurance pays nothing, in or out of network.

Today, Anthem fixed their online FIND A DOCTOR tool. Hospitals are once again showing in-network with the Pathway X (and Pathway) network.

However, the information is still not 100% accurate. John Muir Medical Center in Walnut Creek shows in-network with Pathway X. This is incorrect. John Muir is not in-network. I confirmed this with a phone call to John Muir, and they are not in-network. Also, John Muir’s website only shows they accept Blue Shield PPO and Healthnet PPO Covered CA insurance. http://www.johnmuirhealth.com/patients-and-visitors/payment-and-insurance/healthplanenrollmentcenter/aboutcovered_california.html

I am not sure if this is an Anthem thing or not but I know for a while (2012) they dropped Stanford from all their plans then renegotiated and added it back. As an Anthem customer at the time I was NOT notified and only found out by looking at the online “find a provider” and then calling them. A friend who was HR director at a BayArea company was notified and kept me in the know. An important part of selecting health insurance is where you can get that help when needed. My own opinion is that Anthem seems like they drop, add, and negotiate more often than perhaps other carriers.

It is not possible for a health plan NOT to have a network hospital in a region. Anthem’s online provider directory is a shambles and does not accurately reflect its network at all. A subscriber may call Anthem, and if willing to wait on hold, can ask what hospital(s) are in network in their region.

Anthem has previously acknowledged that it recontracted with many providers at 2013 rates when they were unsuccessful in establishing sufficiently large networks in certain areas of California, particularly in the northern half of the state, based on their pathetic compensations scales for 2014.

If you are paying full price for a PPO policy, and not eligible/receiving a subsidy, then the best option for a wider network might be Cigna.

Cigna is selling PPO policies in some areas of California (they are selling them in Alameda county where I live). Cigna did not participate in the CC exchange which has not handcuffed them and has allowed them to offer a much wider network of doctors/hospitals. Their premiums are very similar to the Anthem PPO rates. The Cigna coverage and deductibles seem to be similar to the Covered CA PPO plans, such as offered by Anthem, but I havn’t done a comparison.

However, Cigna’s Drug List is not any better than Covered CA PPO plans. Cigna choose to skimp on the drugs and only offers the bare bones minimum required by the Affordable Care Act.

Bayarea, I just checked Anthem website and you’re right. That’s pretty amazing. I have long distance clients in Fremont and San Jose areas and there are NO hospitals shown at all. Blue Shield shows El Camino and Washington hospitals. I may have to ask them to change their plans to Blue Shield. This provider problem is much bigger than any enrollment problems people had to deal with so far. I don’t even want to imagine what will happen once people try to use their plans. It’s scary.

Many hospitals, such as UCLA and Cedars-Sinai, have chosen not to participate in most/all CoveredCA networks. The reasons are not entirely clear, but not having to accept or negotiate ridiculous reimbursement rates with insurers allows these hospitals to collect top dollar from out-of-network patients, including PPO patients who would be covered (but only at 50% of contracted rates, with balance billings fully charged to the patient and not subject to the annual out-of-pocket maximums.

Just another thing for which folks can thank Congress, President Obama and the PPACA.

To the person who initiated this central question:

UCLA Medical Groups are NOT within Blue Shield’s PPO provider network for plans offered directly by Blue Shield, or for Blue Shield plans as offered through Covered California.

Phil is correct in that health plans and the PPO network as offered by Blue Shield, are identical for all new ACA-compliant Blue Shield health plans, whether offered by Blue Shield through Covered California or if purchased directly from Blue Shield.

If you want access to UCLA Medical Groups as In-Network providers, then the only Covered California health insurance carriers which offer UCLA Medical are Anthem Blue Cross, and Health Net. Anthem offers only EPO plans (Exclusive Provider Network), and Health Net offers PPO plans, but Health Net only offers the Bronze PPO plan in Southern California, through Covered California.

If you would like assistance I’d be happy to help, and you may find my contact information through the ‘Find Help Near You’ blue link at the top of the page when logged in through your Covered California account, or through the ‘Find Local Help’ button on the CovCal home page.

I signed up for Anthem Silver Enhanced through CC. In the time since I signed up in early December Anthem has reduced the number of providers listed when searching the “find a doctor” under my specific plan. Many providers that were there last week are no longer there, some of which have been my past providers. I’m in Santa Barbara and the remaining providers on the plan are mostly Sansum Clinic physicians. Without Sansum, there would be only a few or no doctors for many specialities. Sansum originally opted opt of all CC plans but the backlash from the community was swift and harsh and they opted in in December. Guess I’m lucky they are included, because without them my provider choices would be very limited.

While helping a family member apply for Medi-Cal I looked at the current provider list for Santa Barbara. I was distressed to see that their provider list was more comprehensive and of better quality (IMO) for many specialties.

Is it possible that Medi-Cal has contracted better rates with the doctors than than Anthem for the CC plans?

My wife and I are finding out just how few doctors and just how limited the coverage is within any given insurance company on the exchange here in the San Diego region. What a disappointment. Any plans for expansion? How will doctors be encouraged to participate because right now it is dreadful. Something like only 35% of doctors are participating. We have care both inside of and outside of UCSD Medical which makes it impossible to find a comprehensive plan.

In the past day or two, Anthem updated their website FIND A DOCTOR in-network information. After the update, there are no hospitals found in the Pathway X (and Pathway) network when searching a 100 mile radius of Fremont CA, or the entire Bay Area. Prior to the Anthem update, several hospitals were showing in the Pathway X network, such as Stanford Hospital, El Camino Hospital, Sequoia Hospital, Washington Hospital. What happen to all the hospitals? Are there no hospitals included in the Anthem PPO Covered CA network (Pathway X and Pathway)? Is Anthem’s website incorrect now, or was in incorrect before the update? If there are no hospitals in-network, how is this possible? What happened to affordable and ACCESSIBLE healthcare?

This is happening with “mirrored plans”. More and more of my clients are complaining that their doctors are saying no to “all Covered CA plans” even when they are shown by the Provider Search to accept the same plans off exchange.

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