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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.


Changing Doctors?

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Question: I live in Amador County and my only 2 options thru Covered CA were Anthem PPO or Blue Shield EPO. The doctors/imaging specialists I saw all last year were in network with my Blue Shield PPO. Despite telling me they would take the EPO, turns out they don't and they don't accept Anthem. Can I get a PO Box in Sacramento and use that as my (mailing) address so I can have the option of getting the Blue Shield PPO next time around? Or do you know of any other way around such a dilema?

Answer: Putting aside the fact that you would be breaking the rules, using a Sacramento mailing address to enroll on a Blue Shield PPO will not accomplish what you want. The "old" Blue Shield PPO network that was available in Amador County is not the same as the "new" PPO network available in Sacramento county.

I have no doubt that this will touch a nerve with some of my readers and I invite you to comment to this post with your opinions, but I wonder if keeping the same doctor and imaging facility you used last year is of such great value. Obviously, using a different imaging facility is no problem at all but what about the doctor? How much does he know about you that could not be passed on to another equally competent doctor? Seriously, what's the big deal?

13 Comments

You have mentioned that the Dr.’s have to mirror an off exchange plan with a plan that is on the exchange. Are you just referring to someone who signs up on the CC network as opposed to someone who signs up directly from the form the Blue Shield network?

The reason I ask is because my Dr. accepts Blue Shield PPO but does not accept my Blue Shield PPO because it is covered california. They tell me that they “opted out” of all of the CC plans.

I assumed that my Blue Shield PPO purchased on or off network is not the same as the Blue Shield PPO he accepts.

Is this correct?

I almost signed up for Blue Shield of California when I saw I could choose from something like 60,000 doctors. Now I’m learning that the actual amount is substantially lower for the plan I wanted. I’m looking for an alternative to Kaiser.

We agents are small business owners and one of the resources we invest in our businesses is our time. So only you can decide how much of that resource you are willing to invest in any given situation. An agent I know, whom I respect as an astute businessman, draws the line on providing extra service to Kaiser clients (for example, resolving billing issues). He reasons that Kaiser does not pay agents to service their individual plan members (only a one-time application fee). He tells the client something like this, “Kaiser has decided that they want to provide customer service themselves, so here is their customer service number”.

With the smaller commissions we are now getting, are we able to provide the same level of service as before? … like taking an hour drive to complete an application, Looking up 10 MD’s on every Companies Provider list, that don’t really work, tracking if the company actually got the premium payment, etc. If not, how do we explain that “nicely” to the prospect?

My point is that your doctor or medical group is choosing to risk losing you as a patient based on compensation rates. The choices are running both ways. However, the patient will be the one who has to put their money where their mouth is if they really want to “keep their doctor”.

I second everything Sally says - well expressed. Phil, just because “the system was broken” doesn’t mean that this well intentioned but incredibly over complex and far reaching way of dealing with it was all great. While a great many people are benefiting from free expanded medicaid and substantial premium subsidies and many others outside the individual market are seeing little impact, there are many of us who have been responsibly paying for the best cover we can afford for years and are only seeing negative impacts in terms of premiums, coverage and ultimately taxes. For example you told Anonymous “For those not covered by their employers, many couldn’t get coverage at any price and those who could saw their premiums double over the past 4 or 5 years”. Well I am glad this legislation has attempted to deal with preconditions although I think it could have been better done with the taxpayer subsidized high risk pool system (which saw minimal take up even though in 2012 the CA high risk pool would have sold me a policy for virtually the same premium as my Blue Shield HSA and with a lower deductible: that suggests that the low take up had more to do with general affordability of insurance suggesting that the issue of preconditions may have been assumed to be a bigger impediment to the numbers covered than it was). However, the reason my premium and so many others went up so much in the past few years had as much to do with the cost of the various Obamacare mandates that became effective before 2014 as anything else. Meanwhile the legislation did not do anything radical to bring cost down - quite the opposite. Phil you also asked Anonymous “Should we all pay more for our insurance so that you can continue to see this doctor?”. In fact under Obamacare those of us who previously responsibly paid for insurance for genuine illnesses are now being forced to pay more not just to pay for the genuine preconditions of others but so that everybody coming into the system can have benefits for things like substance abuse, smoking cessation, weight loss counseling/treatment and mental health services whether we wanted them covered or not. Is it not reasonable to expect that in return we should at least be able to keep our doctors without (for those on EPOs through no fault of their own) having to consider paying 100% ourselves on top of our premiums? There is too much hiding behind “it was all broken” going on - that is no excuse for this broken piece of legislation.

Obamacare is a broken system because it continues to let the insurance companies decide how to set customer prices, set doctor reimbursement rates, network rationing, and cherry pick the counties they want to do business in. Letting insurance companies use county lines to segregate premiums/networks/customers should be abolished under Obamacare.

I live in Alameda county, zip 94539, and can only buy an Anthem PPO plan, or Kaiser HMO plan. Anthem’s network is way too small. All of my/wife’s doctors (except one) are no longer in Anthem’s network. While we have an insurance card, it is useless for seeing our doctors/clinics that we have been seeing for 15+ years. Example - Menlo Medical Clinic, Palo Medical Foundation, and Stanford Doctors all used to be in Anthem’s and Healthnet’s PPO network. All of these doctors/clinics are no longer in Anthem’s ACA Pathway networks. Healthnet stopped selling plans to Alameda customers in 2014, for unknown reasons, which forced me into Anthem’s PPO plan.

Here are some of my ideas that could fix the in-network access problem: 1) Do not let insurance companies sell policies by counties.
Require the insurance companies treat the entire state as one big risk pool. 2) If Number 1 isn’t feasible, do not let insurance companies “cherry pick” the most profitable counties.
If they want to do business in California, require they sell policies in all counties. 3) If an insurance company sells polices to businesses in a county, require they sell policies to individuals in that county. 4) Allow insurance companies to sell policies with a greater network of doctors/hospitals. Right now Anthem can only sell policies that have the same network as the Covered CA network. Pathway X PPO is the Covered CA on-exchange network. Pathway X is the Anthem off-exchange network. Let Anthem offer a more expensive insurance plans with a larger network.
Give us consumers the option to have/pay for a wider network.

Often times it’s the foundation or larger medical group that decides whether to accept the insurance payment terms, not always the individual doctors. Please tell me how it is I can “pay the difference” when my insurance doesn’t contract with this medical group? I think what you mean is I can pay out of my own pocket if I really want continuity of care, which I’m going to do. By the way, this would be in addition to the premiums I pay for insurance that doesn’t meet my needs OR I can choose to not have insurance and pay a penalty. Either way from my perspective, I’m being penalized.

I understand the system is broken and I agree. I’m just saying that we are in a new limbo now. I would just as soon have a completely socialized program than what the ACA provides right now. To know that if my zip code was different (only 1 county over), I could have access to the doctors I have been using, regardless of the cost, is frustrating. If I had known in 2004 when I moved here that access to medical care would be based on my zip code and that would be an issue, I might have chosen a different zip code!

I’m happy the country is trying to make progress on this front. Right now, I am someone caught up in this change in a negative way. I know I’m not the only one.

Phil has bought up a good point by reminding us that doctors are making choices too. Doctors are choosing not to do business with certain carriers and/or provide care in certain plans where they find the compensation too low. They aren’t discontinuing service to their existing and long term patients. Rather they are saying no to insurance compensation that doesn’t work for them. The patient can pay the difference, or the doctor can accept a lower fee. Doctors are equal contributors to the inability to “keep your doctor” debacle.

Dear Kasey, “What’s the big deal?” is a question and there should be nothing shocking about asking it. Here’s one you asked, “Why don’t we move to a system where you never see the same doctor or hospital twice and just get whoever is available that day at one big central unaccountable hospital like the British system?” I haven’t had any experience with the British system but I am very familiar with the Kaiser Permanente system. It works very well, perhaps better than anything else right now, yet it has some of the characteristics your questions alludes to (minus the hyperbole). I think you’ve missed the point and that is, we can’t go back to a system that proved not to work except for some.

Dear Anonymous, your desire to continue care with your existing doctor is a “big deal” for anybody under your circumstances. Neither the Affordable Care Act (Obamacare) nor the Covered California exchange intended to do this to you. Our healthcare system was broken. For those not covered by their employers, many couldn’t get coverage at any price and those who could saw their premiums double over the past 4 or 5 years. Your insurance carrier asked your doctor to accept lower payments to remain in their network in 2014. Your doctor has refused to provide care at that price and opted out of the network. He knows he’ll lose some patients, but that’s a cost of doing business. Should we all pay more for our insurance so that you can continue to see this doctor?

Am I the only one a little shocked by this response? Like the questioner, I had also paid for a quality policy for years and am now suffering forced changes thanks to the reduced networks. And no, I don’t get a subsidy so I am getting nothing out of the new world of “Affordable” care other than paying 50% more premium than before for the nearest equivalent HSA policy from the same carrier (Blue Shield) and reduced doctor choice. And who knows what next year and the year after will bring? Forced enlargement of networks by the Department of Health or further narrowing by providers to try to compete with the lowest prices - oh and higher prices of course? Tell me, should I just choose new doctors and other providers every year and forget all about continuity of care? Why don’t we move to a system where you never see the same doctor or hospital twice and just get whoever is available that day at one big central unaccountable hospital like the British system? That would save money and “surely it would not be a big deal”? Well it is a big deal to me and like the original questioner would prefer none of this had happened. Phil, I think you’ve missed the mark on this one.

The doctors I refer to are specialists who provided great care to me during a life-threatening disease treatment last year. In this rural community where I live, we have limited local access to cutting edge, potentially life-saving care and technology. I’m not saying it’s bad care, just very limited care.

If you needed follow-up care for a life-threatening illness/disease and you couldn’t access the care you wanted because of your zip code, how would you feel? THAT is why it’s a “big deal”! Apparently, you have not been in such a position and do not understand how relationships and trust form between patients and doctors and how important this is to successful outcomes.

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