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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.

My Doctors not in Network? Now What?

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Question: When I enrolled in Covered California Anthem Gold PPO in December, I first called all my doctors offices, twice, and asked what CC plans they would be participating in. Each time they all told me if I picked a “Blue PPO” I’d be fine. As Anthem is the only PPO available in Alameda County (Blue Shield is an EPO), I signed up for Anthem. Yesterday I looked on the website and my large internal medicine group had dropped. I emailed them and my doctor confirmed, saying it would “Be Prudent” for me to find a new doctor ASAP. What are my options? I could try to get back on my HealthNet high-risk pool plan ($1080/mo, $4000 deductible, cancelled Nov. 1 then reinstated, but it’s so infuriating when I’m eligible for a significant subsidy on the exchange. I work 3 jobs to be able to pay for health insurance. What do you recommend as a pathway to finding the cheapest insurance that does cover Alta Bates Medical Group, Hills Physicians Med Gp, Sutter East Bay Med Fndn, or multiple of those groups)? Advice welcome.

Answer**; You seem to be someone who is receiving ongoing treatment for multiple conditions. So I understand that changing providers is a bitter pill to swallow. However, think of it as a trade-off. You couldn’t even get regular health insurance a couple of months ago because of pre-existing conditions - paying over $1,000 monthly for a high deductible risk pool plan. Now you can get covered for the same rate as a triathlete. Now you are “eligible for a significant subsidy” making a no-deductible Gold plan available at a fraction of what you were previously paying for substandard coverage. Narrow networks are necessary to keep costs down - one of the trade-offs for all the good stuff you now enjoy. You welcomed advice - pick new providers in-network for the plan you selected and move on.


I have a comment….I have found doctors, facilities etc…charging for an office visit with preventiveexams. It clearly states on the Blue Shield CA plan that it is covered 100% including officevisits. I’m afraid that the consumer is getting charged for this at many places.

Before joining coveredca, I contact my doctors. None knew if they would be accepting any policies, but thought they would accept Blue Shield. It turns out all but one of my Drs. doesn’t accept Blue Shield EPO, the only Blue Shield offered in my county. Unfortunately most of my doctors are in the next county over where Blue Shield offers a PPO. I’d have signed up for Kaiser CoveredCA if I had known I would need to switch virtually all my doctors. Can I switch now or would I need to wait for open enrollment.

I have submitted at least 20 Cov Cal/Blue Shield applications. All are enrolled and most are effective 1/1/14. To date, Blue Shield does not show me as the agent on any of them. Blue Shield blames Cov Cal. Covered Cal blames Blue Shield. In the meantime, we are limited on how must we can help through Blue Shield with their issues and we do know when we will be receiving commissions. HELP! Any insight on when this will be resolved?

Would you mind clarifying whether an insurer’s in-network providers for CC will be the same as those for their off-exchange plans? For example, can an in-network BS PPO provider decline to treat you through your insurance because you purchased it through CC and not off-network?

Hi All - I purchased “Anthem BlueCross Pathway PPO (Anthem Core DirectAccess cacj)”. Does anyone know of a surgeon in the San Francisco Bay Area that 1) accepts my insurance and 2) also has priveleges at a hospital that accepts my insurance? Preferably at El Camino Hospital in Mountain View, Ca? Thanks, Johnny

Phil, I have been on line and on the phone very frustrated for the same reason (having signed up for blue cross only to find that my medical group only made an arrangement with blue shield epo, living in one of the 7 blue cross exempted zip codes. However, I checked in my medical group and several doctors, including those I want to see, accept the Covered California Blue Shield EPO plan. I evened called the business office to confirm. So hopefully you’ll find another doctor you like who is in the medical group you will like and trust. -MB

Phil, if keeping your doctors/hospitals in network is a high priority, and premiums is less a factor, than Cigna is worth looking at. The person is already paying $1080 per month for a $4000 deductible plan. After a cursory review of the Cigna plans, the person should be able to get a much better network, lower deductible, and lower premium with Cigna. While the Cigna LocalPlus network is also a slimmed down network compared to Cigna’s old PPO network, every doctor/clinic/hospital I checked, that was not in the Anthem PPO network, was in the Cigna LocalPlus network.

My wife and I have the Anthem Silver 87 plan, and she is currently facing the same network problem. She has numerous doctors/clinics that are not in the Anthem CC PPO network. Worse is the Select Drug List, which is costing her over a $1000 per month. We are currently in the process of trying to obtain prior authorization for all the drugs not on the Select Drug List. Cigna’s Drug List is also similar to Anthem’s list, so there is no advantage to Cigna when it comes to drugs.

Lin, in my case, Blue Shield EPO is not available in my zip code, 94539. Crazy as it sounds, there are seven zip codes in Alameda county where Blue Cross will not sell policies.

This article explains why. http://www.bizjournals.com/sanfrancisco/blog/2013/11/narrow-networks-obamacare-california.html?page=all

Because of my zip code I can only buy policies from Anthem (PPO), and Kaiser. There should be a law against this zip code discrimination.

Sorry Phil, but your answer is a bit harsh. You must realize how frustrating it is to be told one thing and then to discover it is not the case. CoveredCA could have and should have published providers for each network from the beginning and not made it so difficult and confusing for the consumer, the providers and the agents trying to help these folks.

CIGNA is not a CC qualified health plan. That’s means no subsidy or cost sharing reductions. That would be an expensive option in this situation.

I am in the same boat. I live in Alameda county and dropped by Healthnet. Only available subsidized PPO policies are from Anthem. But my Healthnet plan was never reinstated, so I don’t understand that part of your comment/question.

Your only possible option to get a plan with your doctors/hospitals in network is Cigna. Cigna sells PPO policies in Alameda county. I am 59 and their plans range from $650 to $1000 per month. Check them out. http://www.cigna.com/ In the middle of the page, click on GET A QUOTE

Cigna is the one insurer that didn’t leave the California market and didn’t participate in the exchanges. For whatever reason, their networks are much better than the Anthem in/out of exchange networks.

I have Blue Shield EPO for alameda county and I go to the Sutter East Bay Medical Group on san pablo avenue in Albany. they are in my network. Would this work for you? My hospital is Alta Bates in network.

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