In addition to paying a $2.8 million fine, Anthem Blue Cross has agreed to a Corrective Action Plan (CAP) that represents a fundamental shift in how the plan handles enrollee grievances.
Posts related to health insurance for individuals, families, small groups, enrollment, eligibility in California, plans, coverage, benefits.
The HIPP program pays the medical insurance premiums, coinsurance, deductibles, and other cost-sharing obligations for the individual. The annual cost of the premiums and member cost-sharing is compared to the estimated cost of an equivalent set of Medi-Cal services. Outlined in in an ACWD Letter 09-02, DHCS uses a specific formula to determine the cost-effective nature of the private insurance over Medi-Cal FFS.
If you think regular health insurance is filled with loop-holes and caveats to avoid paying health care claims, read the fine print on the HCSM. It can be difficult to know if the HCSM will pay on certain claims under certain conditions. Then there is the wild card of denial because of how the injury or illness occurred that is not explicitly included or excluded in the plan. For example, if you are at a gay bar and are dancing, then trip and break your ankle, will it be covered if the HCSM does not approve of activities involving the gay community?
The single payer proposals I have read deal mainly with the consumer side regarding access to care and reduced patient costs. What seems to be missing is recognition that medical groups and hospital have built their budgets around the existing health insurance plan reimbursement rates. There is no mechanism in the single payer proposals to limit the costs such as the cost of labor (nurses) which is a significant financial element for hospitals. Until we get a handle on the cost of health care, health insurance rates will continue to rise and a viable single payer proposal, where you have more than one or two hospitals participating, will only be a dream.
If you have to move out of your county because of the wildfires you may be entitled to a Special Enrollment Period. California is broken into 19 different rating regions. Los Angeles County is actually two regions, 15 and 16. If you move to a different region, you have a qualifying event for a Special Enrollment Period IF you already have health insurance.
This enforcement action is a result of 21 cases involving 63 consumer grievance violations that occurred during 2014 through 2017. In these cases, L.A. Care deprived enrollees of their rights to medical care. The plan has acknowledged its failure to comply with the law, and the Department has determined that an administrative penalty and Corrective Action Plan are warranted. The corrective actions include employee training and increased oversight of the grievance and appeals system.
The Health Net PPO, not to be confused with the EnhancedCare PPO offered through Covered California, is the only plan that will give plan members access to both the Stanford doctors and hospital. These plans are only sold off-exchange or directly from Health Net. Plan enrollment is limited to certain regions and counties within California.
Not all family members have to have the same carrier either. Some family members can enroll with a more expensive PPO plan while other individuals enroll in an HMO from the same company or completely different carrier. I have clients where some family members have chosen the Blue Shield PPO plan and other household members are with a less expensive Kaiser plan.
You can’t assume that all hospitals part of a larger network are all in-network with the same carrier if one is in-network. In Butte County, Blue Shield contracts with all the Enloe associated hospitals. But Anthem Blue Cross only contacts with Enloe Medical Center – Esplanade. The converse is also true. Blue Cross doesn’t typically contract with Sutter hospitals for their individual and family plans. However, in Amador County, Sutter Amador is an in-network hospital for Blue Cross.
By paying for prescription drugs out-of-pocket, and not having them accumulate toward the maximum out-of-pocket amount for the health plan member helps the insurance company, not the consumer. Not having the drug costs go through the health plan could cost the consumer thousands of extra dollars in health care expenses because they did not meet their maximum out-of-pocket amount for the year.