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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.

Doctors On and Off-Exchange?

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Question: Some of the doctors listed on Healthnet site say they are only on the ON - exchange Bronze PPO plan, but not on the OFF exchange Bronze PPO plan which is more expensive and the same coverage. Can Healthnet have a distinction of doctors covered if you buy the same exact plan just off the exchange?

Answer: No. Health Net’s provider network for any given plan is the same on-exchange and off-exchange. That’s true of all carriers that are part of the exchange. The provider network issue is like quicksand right now. There’s no solid ground on which to make a decision because carriers are still inn negotiation with medical providers to fill out their networks and like most negotiations, they come down to the wire - Dec 31st. The networks that the carriers are presenting to the public are confusing too. You could be looking at Health Net’s current provider directory and comparing it to their 2014 directory. You can’t get reliable information from your doctor either. For example, you doctor says they are in the on-exchange network, but not the off-exchange network. Do they even know what on-exchange and off-exchange means. They could be comparing their small group network with their individual network. It may be February or March before the providers networks are resolved to the point that a consumer can make an accurate comparison between provider networks among carriers in the individual marketplace. Until then it’s a crapshoot.


Effie …

Your question is a good one. As a “Staff Model” HMO, your access to healthcare at Kaiser is limited to their staff of physicians. Not to a subset, but to the entire set. As a Kaiser subscriber, you will have access to ALL of their services at whatever level of plan you select. (It’s also the reason that Kaiser premium are about the highest on the exchange — they really don’t want to add all that many new patients to their system, but will be happy to charge everyone for their participation.)

This is what is also going to be true about the other HMO and PPO networks, too. The insurers are not going to shoot themselves in the foot by making up on- and off-exchange networks as the anecdotal reports are stating. That simply makes no sense. Limiting networks causes complaints, and the PPACA penalizes insurers whose “Star rating” declines instead of increases.

Yes, HMO and PPO networks may be different at a company like HealthNet or Anthem, simply because of the differences in compensation to physicians. Some physicians do not want to participate in HMOs but will join PPO networks.

It’s the same reason that certain hospitals have dropped out of HMO networks. They don’t want to be forced to accept what the insurance companies are offering.

This is a vicious cycle begun under the auspices of 80% Medical Loss Ratios that were unjustified and unnecessary, but imposed by Congress nevertheless. It will eventually lead to the collapse of the commercial health insurance industry and force Americans to accept a “single payer” system none really want today.

Do you think that things are similarly up in the air about who’s in-network if we choose Kaiser? I’ve been assuming that if we choose Kaiser, we’ll get the same doctors that everyone in Kaiser gets, whether it’s an exchange plan, a mirrored plan or a non-mirrored plan.

You could have been looking at a HealthNet HMO provider network instead of the PPO network. The networks are not going to be different for on or off exchange plans of the same type. But HMO and PPO networks can certainly be different.

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