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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.

Covered California Plans Not Honored?

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(email: jaynedoe13@yahoo.com)

Question: When I contact a doctor to see if they take our insurance and tell them we have Blue Shield PPO, they say yes. Once I give them my subscriber number they say, "Oh, we don't take Covered California plans." Since my understanding is that all plans on exchange mirror those off exchange, I have asked the insurance company why certain doctors refuse. They said they can't force doctors to take the plan. But, if the exchange plan pays exactly the same as the off exchange one, why would there be so many refusals (and trust me, there are a lot!). It has begun to feel like a plan purchased on exchange (without subsidy at this point) is like a welfare plan that no one wants to touch. Any ideas? Since we cannot switch to another plan at this point (no special circumstance) it has become quite irritating to be shoved off like we have the plague! Thanks!

Answer: When your doctor says they take Blue Shield PPO, that means they are included in the Blue Shield PPO networks for employer-based health plans for the most part. They get higher reimbursement rates from those plans. Covered California fosters competition between authorized carriers to yield the lowest premium rates possible in the current marketplace. In order to compete, the carriers lean on their providers (doctors and hospitals) to accept ever lower reimbursement rates. Many providers refuse to participate in Covered California carrier networks resulting in "narrow networks" with fewer provider choices. Because 90% of patients are covered either by employer-based health plans or Medicare, doctors can opt of out Covered California with minimal downside to their practice.


If you have coverage under a PPO, whether from CoveredCA or not, when a doctor or other health care provider says they “don’t take” that insurance, it simply means they are not a “participating” provider in the insurer’s network. But it doesn’t mean you cannot use that doctor for your health care needs. You simply pay much more out of pocket to use a non-network physician (including deductibles, copays, and coinsurance, and total out-of-pocket exposure per year).

Blue Shield has a large network of participating providers, so you shouldn’t have that much trouble locating a physician. Maybe not within 5 miles of where you live, but certainly within 15-25. Rather than spend time calling doctors, you should use the Blue Shield online provider directory at www.blueshieldca.com/fap. Be sure to select the correct plan before starting your search.

(Can you remove my email from my original post…not sure how I did that!).

Thanks for the response. I guess my confusion is the situation with on exchange vs. off exchange plan. But I guess I’d hit the same problem if I chose an ACA plan off exchange….no one wants a “metal” plan at all.

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