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Covered California Q&A

Covered California and Obamacare 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 Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


How Can I Keep My Existing Provider Network?

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Question: I read … that Blue Shield has significantly reduced its doctor network (shrunk around 50%) and excludes the UC system (UCSF, UCLA) for their ACA/metallic/exchange plans. Those UC medical centers are available to me in my current non-grandfathered plan … If I am unable to keep my existing non-grandfathered plan, how do I keep my existing network?

Answer: Blue Shield refers to it’s existing PPO network as the “legacy” network. Your description of the new Shield individual network is accurate. Members on non-grandfathered plans can keep their plans with legacy networks until the next plan renewal date. Small Group plans will continue with the legacy network. Incidentally, Covered California says it will have a consolidated (all carriers) provider directory on their website on October 1st.

4 Comments

I am beyon P.O’d that my hospital no longer accepts Blue Shield/Blue Cross as of 2014. All my doctors are there, and I’m not going to any hospital other than that one since most of the other ones near me are on the same level as a dog hospital.

People misunderstand this whole Network thing. Providers are not being “left off” any lists. A few physicians may not have had their contracts renewed. “The better hospitals” are choosing NOT to participate in various networks due to low reimbursement rates.

You can still have access to any hospital of your choosing (assuming your physician/surgeon has privileges there) by enrolling in a PPO. If the hospital is not in the network, you will have higher deductibles and coinsurance and out-of-pocket limits to contend with.

Having just gone through the Blue Shield network Platinum level “Ultimate PPO”, I found I shuddered when I reviewed the new in-network hospitals for 2014. Most of the better hospitals have been left off the list, leaving mostly small community hospitals that are fine for run of the mill conditions, but terrible for care of more rare conditions. To cut off such patients from the very care they desperately need is a real disappointment. I’m a supporter of the ACA, both as a consumer and as a healthcare provider, and I am concerned for those who now have access only to providers not equipped in any way to handle some of these conditions.

PPO networks and HMO networks are not the same things. While the often include many of the same providers, it’s up to the providers to decide if they want to accept the terms of the PPO or HMO contracts.

A few years ago, at least 17 Southern California hospitals refused to renew HMO contracts with Anthem Blue Cross because of the tactics ABC was using to stall negotiations and force acceptance of reduced compensation.

So seeing certain networks become smaller is not unusual in and of itself.

As far as physicians are concerned, I had a long discussion with my personal physician last Friday about this subject. He is a member of a number of HMO networks with various insurers. His contract with one network will expire on 12-31-13 because he sold his practice to a competing health group early this year. But he is still in the insurer’s provider network under two other IPA groups.

When asked if he heard anything about “Obamacare causing different groups in or out of the Exchange” he flatly said that he has heard of no such thing … that the physician networks will not be different on or off the exchange.

Could some physicians be exiting some networks on 1-1-2014? Of course, that’s their prerogative, or, as in the case of my physician, the result of a non-renewal decision by Anthem for one particular provider group.

Are physicians being forced out of networks willy-nilly as the suggestes by comments that there will be on-exchange networks versus off-exchange networks?

I don’t believe that will be the case. There is no upside to insurance companies to do this. Remember, plans will be “star-rated” going forward. Lose a star and you could be off the exchange.

What’s the fastest way for a star to become tarnished? BAD SERVICE — as in: “My doctor is no longer in the network, and I don’t like any of the ones whose names I cannot pronounce,” or “I can’t ever get an appointment,” or “I needed a referral to a specialist, and they refused,” or “They denied a claim, and it took months to get them to pay it, but they finally did.”

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