The Department’s General Counsel Opinion Letter, issued pursuant to Insurance Code section 12921.9, was prepared in response to an inquiry from San Diego’s TransFamily Support Services regarding several denials of coverage for male chest surgery for patients under 18 years old who are transitioning from female to male. The Department determined that denying coverage for mastectomy and reconstruction of a male chest based solely on age is impermissible under state laws requiring coverage of reconstructive surgery. Health insurance companies must consider a patient’s specific clinical situation in determining medical necessity.
Posts related to health insurance for individuals, families, small groups, enrollment, eligibility in California, plans, coverage, benefits.
Health insurance is unique in that it not only protects you from catastrophic health insurance bills, it can also help reduce the costs of many routine health care services and prescription medications. It’s as if your car insurance gave you discounts on oil changes, tire rotations, or replacing your brakes. While some of us we need routine maintenance, most people don’t know when their transmission is going to die and it needs to be replaced.
I will note that when selecting the UCLA Medical Group from the drop-down list on the L. A. Care website, it will specify that limited enrollment is available. I don’t know if that means only the participating primary care physicians will accept a limited number of L. A. Care members or if the entire UCLA Medical Group is limited.
Covered California does not pay agents to assist consumers with enrollments into individual and family plans. The insurance plan or carrier compensates the agent. Agents are not paid anything for answering questions about Covered California. They are only paid a commission if the person enrolls into a health plan the agent represents and is appointed with.
Now, it seems they have set up their communication structure in such a way as to thwart any meaningful discussion between them, agents or potential consumers. If I can’t access information for my clients, then I am not providing all the services my clients expect. If the health plan throws up barriers to my access, then it is not a functional health plan in my eyes.
Unbeknownst to many people, most California health plans cover emergency care anywhere in the United States and treat it as if it were in-network. This means that if you have a Silver 70 plan and are rushed to the emergency room of the nearest hospital while on vacation in upstate New York, your copayment will be $400 just as if the emergency services were performed at your local home office.
Not all Blue Shield health plans will be receiving the premium credit. The credits will be applied to fully-insured employer groups (except flex-funded), dental and/or vision plans, Medicare Supplements, and individual and family dental and/or vision plan subscribers. Blue Shield states they are issuing premium credits as permitted by state regulators and Covered California.
Therefore, I request that all health insurance and specialized health insurance companies provide their policyholders with a partial premium refund no later than December 31, 2020. These refunds should be reflected in the November or December 2020 premium statements sent to policyholder or certificate holders, if refunds have not already been issued.
Blue Cross will offer the standard benefit design metal tier plans through Covered California and off-exchange, direct from the carrier. They will also offer a few non-standard benefit design plans available off-exchange. Blue Cross will offer a Silver HMO plan off-exchange with no medical deductible and 0 percent coinsurance for medical services. The copayments are a little higher than the standard Silver 70 ($50 office visit, $85 specialist visit, emergency room visit $750) and the maximum out-of-pocket is $8,550 versus the $8,200 for a standard Silver 70.
California is broken into 19 different rating regions. Sutter Health Plus HMO plans are offered in 9 of those regions. The least expensive rates – based on the Bronze plan for a 40-year-old individual – are in the Sacramento, El Dorado, Placer, Yolo counties service area. The most expensive are found in Santa Clara County, 15.92% higher than the Sacramento region.