Kevin Knauss: Health, History, Travel, Insurance
Posts related to health insurance for individuals, families, small groups, enrollment, eligibility in California, plans, coverage, benefits.
There are non-standard benefit design health plans offered by carriers off-exchange. You cannot enroll in a non-standard benefit design plan through Covered California. The off-exchange non-standard benefit design plans are usually in the Bronze and Silver metal tier categories. There are more High Deductible Health Plans (HDHP) that are health savings account compatible offered off-exchange.
Blue Shield PPO members can schedule a visit by calling the Blue Shield Nurse Hotline or contacting Dispatchealth directly via website or telephone. Blue Shield HMO members must call their Primary Care Physician for a referral for an in-home visit to treat a medical condition. In-home visits are grouped into 5-hour windows corresponding to morning, afternoon or evening. Appointments can be as early as 7 AM or as late as 10 PM, sometimes on the same day as the request. Care is available in English and Spanish.
Where households realize a dramatic increase in Blue Shield PPO Covered California premiums is when the SLCSP has a small increase or negative rate change. Consumers in regions 2, 3, 4, 6, 7, 15, 16 and 18, where the SLCSP rate increases were in the low single digits will see a smaller subsidy. In other words, the Blue Shield PPO plan rate increases in those areas was greater than the SLCSP that the subsidy is based upon. The subsidy did not keep pace with the Blue Shield PPO rate increase like they did in regions 1 and 10.
Covered California has taken some of the guesswork out of selecting a plan by allowing only standard benefit design health plans on the market place exchange. First, all plans must cover the same health care services from routine office visits, maternity, to mental health services. You will not find plans that are lower cost because they do not cover maternity or cap the benefits for cancer treatment.
The one wildcard with outpatient services is the coinsurance. Coinsurance is a percentage of the invoiced services that the health plan member is responsible for. For outpatient procedures, the coinsurance is not subject to the medical deductible for Silver plans. However, you may find yourself getting billed for coinsurance when you thought the health service had just a set copayment. For example, imaging with the injection of a dye to enhance image contrast. The machine imaging scan will have a set copayment, but the injection of the dye is considered an outpatient procedure subject to coinsurance.
As of October 2022, there were no announcements that Stanford Health Care primary physicians would be in-network with any other individual and family plans. Blue Shield HMO states that Stanford hospital is in-network, but not the physicians. Valley Health Plan can make referrals to Stanford specialist doctors, but not for primary care.
The extraction, storage, and manipulation of your personal online data is akin to the wild west. There are few rules in this relatively young industry and what rules there are, the app gleaners ignore until they are caught violating the law. You can’t see the digital portrait you have created by your own actions on your mobile device and captured by the health insurance apps. In a sense, they own your image. Usually images you create are protected by copyright laws. In this new industry of digital surveillance and capture, you don’t own your own image.
While prior authorization is not required, Blue Shield of California members should become familiar with all of the conditions of the program for proper reimbursement. The abortion services must be provided by a licensed practitioner in a state other than the member’s residence where pregnancy termination can be lawfully provided.
Does my Medi-Cal insurance cover my abortion? Yes. Is my private insurer required to cover my abortion? Yes for most people. California law is clear that abortion care is basic health care, and most insurance plans must cover basic health care services. This requirement does not apply to employers that provide “self-funded” health care coverage or grandfathered plans.
The plan was in violation of the law when it failed to properly exclude certain office visits from enrollee deductibles. These office visits included primary care, and behavioral health office visits. The plan agreed to corrective actions including identifying and reimbursing impacted enrollees, which includes reimbursing nearly $9.2 million to 6,561 enrollees.
