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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.

Same ACA Plans Pay Different Amounts?

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Question: Last year we had a Bronze HSA plan with Blue Shield. This year we have a Bronze HSA plan with Anthem. After several claims this year I have noticed that IDENTICAL procedures are being paid differently to providers by Anthem vs. Blue Shield (and not to our benefit). Why would plans which are considered the same metal (i.e., Bronze) pay differing amounts? I thought the only difference between insurers was the providers that accepted the plans? If that is not the case, how would it be possible to find out this information before selecting an insurer?

Answer: Each health insurance carrier negotiates payment rates with their own network providers. That's how Anthem and Blue Shield can pay the same provider different amounts for the same treatment. The contracted rates between carriers and providers are not available to the public, so a consumer cannot know in advance exactly what a carrier will pay the provider for any specific treatment of procedure.

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I am covered under Kaiser through Covered Cal and am arguing over a plan start date to the current plan I have. It started when I lost my job (and income) and applied for coverage. After enrolling in a plan (not the one I have now) I was able to find a new job, so I called Covered Cal to update my income and change my plan again (still 1st week of the month - April - with the new plan). I downgraded my plan through a special enrollment and was told my new plan would start the 1st of the next month (May). Now I am being told my plan had a retroactive star date (1 April) because I no longer qualified for the plan I enrolled in for April. I received no notice and I know I was told the start date was 1 May along with a premium bill (in excess of what my premium was said to be) to cover the difference between the two plan premiums.

Is Covered Cal allowed to change my plan without notification? If a plan is changed for any reason, is it the duty of Covered Cal or the Insurer to notify the insured?

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