Kevin Knauss: Health, History, Travel, Insurance
Posts related to health insurance for individuals, families, small groups, enrollment, eligibility in California, plans, coverage, benefits.
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.
Health insurance, at a basic level, is asset protection similar to car, life, and home insurance. Most health plans have an annual maximum out-of-pocket amount that limits your liability to outrageous health care bills in the event of an accident or sudden illness. Once the maximum out-of-pocket amount is met, the health plan covers all in-network health care expenses for the rest of the year.
Neither Covered California nor the sample Blue Cross letter being sent to members explains why the UC hospitals are no longer in-network. Someone, Blue Cross or UC, pulled the plug retroactively to January 1. Fortunately, Blue Cross expanded their EPO network to include Sutter doctors and hospitals for 2022.
The entire process of gender affirming surgery is intimate. Perhaps the most important relationship that you’ll want to secure is with your surgeon. Your health plan (Medi-Cal, Medicare, individual & family, employer group) will have a network of surgeons in the network. With luck, your preferred providers and surgeons will already be in the network of your health plan. Each health plan maintains an online list of providers for members to search. Healthcare networks are still learning and catching up with how to provide services to the transgender community.
It is doubtful that in California individuals who remain unvaccinated would be slapped with a surcharge to cover the risk of future medical claims associated with treating a Covid-19 infection. That is not the way California approaches health insurance rates. However, the health plans can increase rates in regions that have demonstrated elevated health care costs and reasonably predict the higher cost trend to continue because of unvaccinated adults.
The BlueCard program allows members to receive some health care services outside of California. This is an important feature for individuals who routinely spend weeks or months outside of California on business. With the exception of emergency services, if an individual needed small health care service in another state, they were almost forced to buy two health plans; one for California and one for the other state.
Most consumers would be surprised to learn that their health plans are being rated on how well their doctors treat them. Consumers don’t want their health plan involved in their health care decisions or interactions with their doctors. Consequently, some health plans are paying for the sins of some providers by being labeled with a low star rating.
There is a reasonable expectation that Bright HealthCare individual and family plans will fulfill all of their contractual obligations for paying claims and adhering to the member cost-sharing structure of the health plans. The weak spot for some health plans is the customer service department. An understaffed customer service unit can lead to long wait times on the phone or emails not being promptly returned. There can also be issues with prior authorization for medical procedures, durable medical equipment, and prescription medications.
The Sutter providers will mostly benefit counties where Blue Cross is expanding their coverage in the North Bay, East Bay, and Central Valley. A few counties in the Central Valley and most of Southern California will only be offered the Blue Cross HMO plans that do not include the Blue Card Program. Of course, Blue Cross offers additional EPO plans off-exchange, direct from Anthem, with a few extra plan designs that are not offered through Covered California.
