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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.


How to Change Plans?

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Question: I’m now enrolled on the Enhanced PPO plan of BlueShield but I’m coming to realize that their PPO network has been brutally cut back. In my region, San Francisco, it’s about 25% of the full PPO I had before. None of my regular doctors I have been with for years are in it and I’m looking at the correct provider directory on blueshieldca.com. Can I change still my plan to something else? (How does one do it in coveredca.com to change just the plan and nothing else?

Answer: Login in to your Covered California account and select “Terminate Participation” terminate.png Click on image to enlarge. You will directed to select a termination date that is a least 2 weeks from today. If you want the new coverage on February 1st, select a termination date of January 31st. Now you should be able to select another plan effective February 1st.

42 Comments

My wife has cover calif blue shield if we wish to keep this coverage during this period do we do nothing and it will stay the same? Or must we reapply?

Hi Anonymous Too.

I can very likely assist you with enrollment into a new plan (and new carrier), with a Qualifying Event. Of course, time is of the essence with regard to Qualifying Events. Give me a call (click link of my name for number). I will be glad to help.

I just terminated our Blue Anthem Gold PPO because our income has gone up and no longer qualify for premium assistance. Our primary doctor doesn’t even take this insurance when he was listed at sign up in March 14. I now have been told that I can’t purchase insurance outside of Covered California until the end of the year for Jan 1st because that is the Obamacare Law. Is this true? Is there anyway I can get out of Covered California insurance and buy our own insurance like I have done for years? It seems like its taking away our rights? Please help!

Phil. Yes, I can confirm this Anthem change in BOR policy is accurate.

I have had a very difficult time trying to speak to

any Blue Shield reps. I have tried to email them and haven’t heard back at all. When I call, it rings to a busy signal- and then hangs up. It has been so frustrating. I have been billed for many non covered amounts after my emergency hospital stay. One bill was a DNA test for over 4,000 that one of the 10 doctors that visited me in the hospital ran. The doctors all billed $600 for 5 minute conversations. I am responsible for paying $150 for each of these “visits.” This insurance hasn’t covered what I had anticipated with a “Gold PPO” plan and 0 deductible. I am still over 10k in bills. My freelance position has now ended and I will not be able to afford $400 in Blue Shield monthly payments. Can I switch to a more affordable plan?

An anonymous agent submitted this today. Can Anyone confirm or deny it. “As of late April, 2014, Anthem has changed its Broker or Record policy, so that if an Anthem member originally enrolled with Anthem without use of an independent agent/broker, at ANY time in the past, Anthem now says it will NEVER allow or approve a current Anthem member’s request to designate an independent broker as their Broker of Record.

So, if someone has enrolled in an Anthem plan through Covered California, and come renewal or at anytime, such Covered California Anthem member designates an agent/broker, said request, as made through Covered California will be denied by Anthem, so Anthem now says.

This is contrary to what Covered California has repeatedly stated that a Covered California member can designate an agent (broker) at any time.”

If you report a change in income to Covered California through your CovCal account, and outside of Open Enrollment, you will be eligible to change your health plan ONLY if your income-based eligibility for an Enhanced Silver plan also changes.

I’d be glad to help should you contact me.

How did this work out for you? Did you switch to HealthNet, and if so, is it a PPO, and was it accepted by PAMF? I am now in the same situation, and am not sure if it is better to switch or to just pay out-of-network prices.

If I notify CoveredCA of my increased income which will mean a smaller subsidy, will I be able to make a plan change within CoveredCA?

I did pay my insurance for january and february 2014. it was healthnet. And used for few times during those months. I did not like the service, so i canceled it in the of february 2014. But somehow coverd california told health net that the cancelation date was on the january 1st. So the health net did not want to cover those service. Now the medical billing been coming to my house. I have talking to both covered california and health net so many times to resolve the problem.but NO solution yet until now. Do you have better solution ? What should i do ?

Hi Ken,

After dealing with thos issue for about a month and reviewing all of the claims from my emergency hospital stay at Cedars- Blue Shield has paid very little on the providers bill.

I don’t think the average person will realize this until they actually have to use their “Gold” insurance. Having an “X” in front of your policy # qualifies you as an “Obamacare” patient- whether you pay premium dues or not. I unfortunately thought that paying over $400.00 per month would give me good insurance. Blue Shield pays pennies on the dollar- and the rest is considered “Patient Responsibility” because it is “Out of Contract.”

I believe that I may have a loophole due to the Balance Billing Laws in California and my emergency admitance to the ER. I am still receiving quite a few bills that are around $ 10k that I can’t afford.

Megan, I didn’t reply to your last comment earlier because I didn’t feel qualified. That’s still true, but (unfortunately) I do have a related anecdote to tell.

We changed from a Blue Cross plan to a Blue Shield plan because we learned our PCP of more than a decade was not in the BC plan. He also wasn’t in the BS plan, but we found a doctor belonging to the hospital we wanted with excellent recommendations.

We made an initial appointment (required for new patients), and my wife and I were each billed $450. We called BS and were told that the claims were incorrectly processed, as if our new PCP was not in-network when he is. (Their website clearly shows he is.) However, today we were told that, no, after all, he is NOT in-network; the website has not been updated to show the correct information!

So I can share your frustrations (which are obviously magnified since our bill is “only” $900), but I still don’t have an answer whether it would be better to change plans or not. It’s too late by now anyway. Good luck to you.

Health Net PPO is Bronze level only. Do you really want to have a $5000 deductible to have access to one of these celebrity hospitals?

Health facilities like Cedars-Sinai and UCLA and Providence Little Company of Mary are all “contracted” with Health Net PPO (check their websites). While these facilities will “accept” all insurances…it is not the same as being “contracted” with an insurance.

Thank you so much Ken, this is excellent info. I had an emergency 3 day in patient stay at Cedars in LA. I have an individual policy- Blue Shield PPO Gold. It is confusing because many of the bills say that I saved by using an in Network provider. To the contrary, other bills say that the provider is not contracted with Blue Shield and that I am responsible for the balance. The total of the 3 day stay was around 100k. Hospital Discounts were used to bring the bill down, however it appears that Blue Shield pays very little on the amount billed by the provider- leaving the patient responsibility portion very high. I am grateful for your advice on this topic. I’m wondering if I should switch to HealthNet or if all of the ACA policies offer the same cut rate experience?

Thank you so much Michael, this is excellent info. I had an emergency 3 day in patient stay at Cedars. It is confusing because many of the bills say that I saved by using an in Network provider. To the contrary, other bills say that the provider is not contracted with Blue Shield and that I am responsible for the balance. The total of the 3 day stay was around 100k. Discounts were used to bring the bill down, however it appears that Blue Shield pays very little on the amount billed by the provider- leaving the patient responsibility portion very high.

Thanks again for your advice!

Hi Anonymous.

Regarding your Blue Shield Gold plan, Ken’s reply provides good info. I’m wondering if the 3-day hospital stay you had was considered a non-emergency and at a non-participating hospital, meaning Out-of-Network hospital, and this is why you are being billed as such?

I have also noticed that the carriers are even starting to say that certain providers may be considered out-of-network even though such providers performed services at an in-network facility. Yet this would put one in a position of typically have no clue about one’s in-network facility’s use of out-of-network physicians (most anesthesiologists do not contract with the facility in which they work), and then (as I’ve seen with my clients) being balance-billed by the out-of-network physician. Balance billing is illegal in California, due to consumer protections instituted by Governor Schwarzenegger.

Or Blue Shield’s billing is simply messed-up because either Blue Shield messed it up, or because your hospital and providers sent incorrect billing information to Blue Shield, and should be resolved fairly easily.

But as Ken stated, your maximum In-Network annual out-of-pocket maximum is and should be $6,350.

Good luck, all the best.

Yes, it’s why I search my clients’ doctors and hospitals with them, at each carrier’s website, with the correct and appropriate pre-selected network and plan.

The fact that Blue Shield and that Anthem have rolled their current members into new ACA-compliant plans without so much as a mention that their new plan’s provider network has been cut significantly, and that access to their own doctors might be, and could be, and/or is, no more, is malfeasance.

It’s true that Blue Shield GOLD PPO has no deductible, but that doesn’t mean all services are cost free. There’s a maximum out of pocket (for in-network services) of $6350 per person, and $12700 per family. What is not stated at all is which maximum applies to an individual with a family policy (I don’t know if that’s your situation or not).

You are responsible for the copay. For in-network “high cost and infrequent services (e.g., hospital stay)”, the copay is 20%. Unless the family maximum applies, you will not have to pay more than $6350 (again, assuming all services were in-network).

You should contact the hospital and/or Blue Shield to straighten this out.

I signed up for Blue Shield GOLD PPO with no deductible- thinking I had amazing coverage at around 450.00 per month. After an emergency and 3 day hospital stay, I soon discovered that Blue Shield barely covers anything. I am inundated with bills that say they paid a very small amount on provider bills that are astronomical. So I am left to pay the balance, I am already up to 10,000 with my “Gold” insurance plan. Buyer Beware. It is a huge scam. I am talking to people on Medicare/Medical and cheap ACA plans that are paying nothing for their monthly bill or their copays. Meanwhile, I will go broke after I thought I chose great coverage with a reputable Blue Shield plan. Not the case.

I’ve subscribed to the Anthem Gold PPO Covered California. My advice: BUYER BEWARE.

Here’s why: Medical groups which used to be part of Anthem’s OLD PPO network are not necessarily part of the NEW Pathway PPO network. In these cases, they will require “out-of-network” payment up front for any members of the Pathway or Pathway X PPO plan. (X = bought via Covered California, no X = bought from Anthem directly)

Anthem has confirmed (on the phone right now) that there are TWO PPO networks.

1) Old PPO. (what you think you are getting) 2) New, Pathway or Pathway X PPO (ACA / Covered California)

NOT ALL DOCTORS (probably the ones you wanted) on the OLD PPO have signed up to the NEW Pathway / Pathway X PPO.

Anthem uses the ACA as an excuse for the poor service, but it’s quite clear that they are profiting from this confusion. And of course, blaming the government for their shoddy implementation.

I’ll be switching to Kaiser, where at least you know will have access to all their doctors!

Unbelievable.

Here’s a response I got from CC

Response By Email (Barbara) (01/13/2014 11:57 AM) Hello Mr. Shorr:

Thank you for contacting Covered California. If the consumer would like to change the plan, Ms. xxx can call the individual line at 888-975-1142 and they can make the plan change. Otherwise, the only way an agent can choose a different plan is the current application would need to be terminated and a new one with the new plan submitted. You would need to choose “Terminate Participation” under actions once you have selected the applicants name. You would then need to submit a new application with the new plan which would change the effective date to 2/1/14 if submitted by 1/15 or 3/1 if submitted between 1/16-1/31.

Please let us know if you need further assistance.

Thank you,

Barbara Speck SHOP SCR

Michael:

You sound like someone who some kind of a handle on the current health insurance issue and I would love to keep a correspondence with you and share what I have encountered with others on your site.

I live in Santa Cruz….The main health care service provider is Palo Alto Medical Foundation. I am on a first name basis with “Robert” who has a big job; he is the health care business advisor at the main office.

PAMF in Santa Cruz has contracted with very few plans with Anthem/Blue…NONE under Covered California and they do not intend to for the balance of this year. Of the few Anthem Non Covered California, standard plans they have on contract ( per their website and their handout several DO NOT EXIST any more according to Anthem Blue. One that they have contracted is an HMO (ONLY)..for Direct Access. Anthem says they do not have a Direct Access HMO plan for California…..only Direct Access PPO’s.

When considering insurance in Santa Cruz whether with Coverage California Plans or a Standard Plan…I would suggest avoiding Anthem Blue….is just isn’t a good match.

I signed up for a Covered California plan with Anthem in mid December before I knew all this……Now I have to figure out how to change my plan on the Covered California Site. So your information is helpful and I would like to make this switch in the next two days before the end of the month. My choices in Santa Cruz and Palo Alto Medical Foundation appear to be Blue Shield or Health Net.

One of my other private independent doctors will not take Blue Shield at all. He will also not take an HMO plan.

I would like to stay in touch with you; my health advisor that I used in San Jose in mid-December did not know this information and she could not advise me on how to change from one plan to another on the Covered California site.

Can I call you today as I’m qualified for Covered Calif and was going to select the EPO Silver plan, but some of my docs are telling me they only take PPO’s…will they accept the EPO plan described above?

I’d like to talk if you could call me or email me: echayet@gmail.com

thanks,

Eric

Hi David.

“Terminate Participation” seems to work for me when I utilize it for clients.

The only issue is wanting to terminate/cancel with under 14 days from the effective date. In this case I have selected 14 days out and included a note in the notes sections to relay the actual date of cancellation wanted, and that member intends not to pay for the next month’s premium.

Once “Terminate Participation” has been selected and completed, then go to “Report a Change” and ‘Choose a Health Plan’ through the ELIGIBILITY screen. The new plan selected will automatically defer to the next available plan effective date, based of course, upon the date of enrollment while ‘Choosing a Health Plan.’

Do not select “Terminate Participation”. I did and was locked out of selecting a new plan until after the termination date. I know that doesn’t make any sense but the 2014 web site clearly has problems. Instead, call the customer service number, wait on hold for an hour, and the customer service agent can change the plan. Also be aware that the start date of the new plan may be no sooner than the start date announced on the CoveredCA landing page.

Hi Kristine.

With Anthem you MUST select the ‘Pathway’ Network.

Yet be careful here again: with Anthem, it depends whether Anthem offers PPO plans (all metallic level PPO plans are the same Pathway PPO network in your region) in your Rating Region, or whether Anthem offers EPO plans in your Rating Region (all metallic level EPO plans are the same Pathway EPO network in your region), or whether Anthem offers HMO plans in your area (all metallic level HMO plans are the same Pathway HMO network in your region).

For instance, in Los Angeles South, Rating Region 16, Anthem ONLY offers EPO or HMO plans (for all metallic plans), yet in neighboring Ventura County, Rating Region 12, Anthem offers PPO plans only.

So, at the Anthem.com/ca website and its ‘Find A Doctor’ provider search tool, and in Section #4 of the this provider search tool (filled blue circle with ‘4’ inside), you MUST select the correct Pathway-X (or Pathway without the X is if one buys a plan direct with Anthem and not though Covered California, yet are the same) with either Pathway-X PPO/Individual via Exchange, or Pathway-X Tiered (EPO)/Individual via Exchange, or Pathway-X HMO/Individual via Exchange.

Then rely upon this search information FIRST, is my recommendation. If your doctor’s office, and/or medical group tell you something other than what you find on the Anthem provider search tool, then get tougher with them (be nice, and even help them help you) and find out from your doctor or medical group ‘why.’ Many, many doctors and medical groups have it wrong, still. I just set an entire medical group on the right track the other day. Some think Covered California is offering health plans when in fact only private insurance companies are offering health plans… just through Covered California which is used as a tax credit eligibility function, predominantly.

If you or anyone need assistance, feel free to reach out to me. You can search for me, Michael Freedman, as an Agent and my contact information through the ‘Find Help Near You’ top-of-page blue link at Covered California, or direct from the CoveredCA.com home page with the ‘Find Local Help’ button on the main web page. No cost to you to use an agent.

Do you know if the bridge line that Covered CA suggested Agents use for technical issues is active? I dialed 1.703.948.0488, input the conference ID 850015584, waited on hold for 15 minutes, and was disconnected because there was no leader available.

I called the bridge line because I cannot upload a new employee roster or edit employee data in the Covered CA SHOP application. I get a “fileOperationFailed” or “Sorry, An Error Has Occurred in the System.” message, respectively.

“And when searching for providers you MUST select the correct plan and/or network from Anthem, or from Blue Shield, or from Health Net, or any other carrier.”

Michael: can you advise what plan(s) to search under when using the provider search on Anthem’s website. The CC Silver plan isn’t specified. Do I search under PPO? Thanks!

Simon, I found it was my error. Check “Personal Data” section, under “Tax Information”, for the child under 18, I mistakenly checked “No” to the question, “Is this person expected to be claimed as a dependent this year. You can fix it is they have not yet selected a plan.

“I recommend you DO trust the Anthem website.”

I’m not sure what to trust.

I have my current PCP, and then I picked out a possible replacement. Anthem’s website (when logged in, so it’s showing results for my specific plan) shows my current PCP is in-network, and my potential replacement is not.

Contacting the associated medical groups, I got the exact opposite answers from both. The one that Anthem’s site says is in-network insists they no longer belong to any PPO plan. The one that Anthem’s site doesn’t list as being in-network swears that they definitely are.

As you might imagine, I find this situation highly frustrating!

Coveredca.gov site for eligibility says not eligible for subsidy (cost-sharing reduction or CCR) based on AGI (adjusted gross income) of $24,000 for family of 2. All the subsidy calculators say otherwise - is it maybe because we are both self-employed?

Hi Joey.

I recommend you DO trust the Anthem website. Many to most doctors, and offices, even medical groups, DO NOT KNOW if they are or are not in-network with the new carriers which provide the new ACA-compliant Individual/Family health plans.

I just helped Daniel who posted here at this site previously. His selected medical group which insisted in it providing absolutely no coverage to those with Covered California plans, had it completely wrong. I helped that medical group get on the right track, and Daniel as well. That medical group now understands that it in fact DOES cover those who have plans as enrolled through Covered California, as the medical group does cover new Individual/Family ACA-compliant plans as offered by the insurance carriers… which are the exact same plans and networks as offered through Covered California.

These doctor’s offices and/or medical groups think that Covered California itself, as an entity is offering health coverage, when in fact it is not. They do not understand that Covered California is only an intermediary for the sake of financial tax credit subsidy (or Medi-Cal) assessment, and that an Individual or Family still purchases coverage (though through Covered California) from a private health insurance carrier like Anthem or Blue Shield.

Or doctors simply are unaware that networks have changed. This is still quite common.

Worse is that the insurance carriers, which automatically rolled over their members into new ACA-compliant plans from their cancelling previous non-ACA-compliant plans, did NOT tell their members that their access to providers would be pared down radically, and that many continuing members would lose access to their providers partially or altogether. Seems like malfeasance in doing so.

And do NOT trust the Covered California provider search. Last time recently it was resolving to provider/doctor/medical group results from Anthem’s full network and not Anthem’s Pathway PPO or Pathway Tiered EPO networks.

Search for providers from each carrier’s main website only. And I suggest doing this first!

www.Anthem.com/ca www.BlueShieldCA.com www.HealthNet.ccom

And rely upon this information first, and THEN call your doctors offices to inquire and/or verify additionally. Do both, but I suggest using the health insurance carriers’ provider network search tools as the BASIS for comparison and determination of a provider’s in-network status. Doctors and medical groups very often do NOT know correctly whether they are or are not in-network providers.

And when searching for providers you MUST select the correct plan and/or network from Anthem, or from Blue Shield, or from Health Net, or any other carrier.

Phil, That happened to me yesterday as well. I thought maybe their system showed that the children’s father had an employer plan and thus no subsidy for the children. The children were already in Medi-Cal system so I redid the app with kids not wanting coverage. Now I’m thinking maybe it was a glitch in the system. My question is: Can children still apply for Medi-Cal if one of their parents had an offer of coverage from their employer?

I have submitted 2 CC family apps today where the children under 18 are said to be ineligible for APTC, CSR and Medi-Cal. The family income is clearly in the APTC range. On the plan selection screen, they are listed apart from the parents and siblings over 18 and directed to select a CC plan without tax credits. The Eligibility Determination Factors include:

- Household income is in the APTC program limits.
- Household income is not in the Medi-Cal program limits.
- Household income is not in the CSR program limits.
- You meet all other factors to qualify.

Anybody else experience this?

Thanks Simon for the correction. I wasn’t able to test the “Terminate and change” method fully. I have updated the entry.

Thank you, Joey!!! I called my PCP office this morning, and they said they are no longer in-network for ANY PPO plan. So either I need to change to an HMO plan, or I need to find a new PCP (after more than 12 years with him).

And I wouldn’t have known it without your reply, so thank you very much!

Switching plans by Terminating Participation will not work. It will initially show that the plan has been changed but when you go back a couple of days later, the whole homepage will be non-functional. This has been the case with my clients who wanted to switch and also confirmed by SHOP support (who seemed a little more knowledgeable than customer support). Once I had terminated their participation, I had to create another account in order to enroll them in a new plan. Please check with CC.

Don’t trust the Anthem website. The network info is not accurate. Two of my doctors show in-network on Anthem’s Find A Doctor search. But both doctors have told me they are not in network. Anthem has been very slow at updating their network info. The only way to know for sure is to call your doctors and ask them.

It turns out that Covered CA does not necessarily have accurate information on medical providers for Anthem Blue Cross. Checking the anthem.com/ca site, I learned that my doctor IS in the network of the plan I selected. So I won’t be changing plans after all.

Thank you so much for posting this. I had assumed that the directories would be the same, but as you noted they are VASTLY different. So much for the infamous “you can keep your current doctor”. We can, however, switch to another plan that has our doctor in-network.

I don’t know why I didn’t check when I applied, but I’m glad to have found out now, rather than in April.

Thank you!

I completed my application and submitted my documents required for proof of California residency. My application has been pending for almost a month now and I am unable to reach ANY representative. I can never get through on the phone lines, and the chat always cuts out.

Is there an address I can send my documents directly to? Is there ANYONE I can speak to about my application?

I thought CC was supposed to be accessible and easy to use, but in my experience there has only been complete silence from the other end and no answers, no communication, just ZERO help from their website, phones, chats, everything. I am so frustrated with this!

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