Kevin Knauss: Health, History, Travel, Insurance
Posts related to health insurance for individuals, families, small groups, enrollment, eligibility in California, plans, coverage, benefits.
Many people want predictable copayments for routine services and are willing to accept a large deductible and maximum out-of-pocket amount for the rare and unexpected hospitalization. Blue Shield of California has come pretty close to designing such a plan with their 2022 Bronze 7500 HMO individual and family plan. Services with a set copayment and not subject to the medical deductible are:
Adverse selection is wanting to enroll in health insurance under adverse conditions. The health plans, and society in general, wants everyone in the insurance pool from the beginning. When people climb out of the pool – drop coverage after getting treatment – the big health care bills must be covered by the remaining people in the pool. That raises the rates for everyone in the pool, and that’s not fair.
Individuals and families may be eligible for a temporary increase in premium tax credits for this year, with no one paying more than 8.5% of their household income towards the cost of the benchmark plan or a less expensive plan. Meaning, many consumers will be eligible for higher tax credit amounts to help cover their Marketplace health plan premiums.
The 56-year-old San Mateo County resident purchased health insurance through Covered California in 2020 and 2021. The estimated income was $45,000. In 2020, after the Covered California subsidy, the individual paid $109.98 per month for the Kaiser Silver 70 plan. In 2021, the Kaiser Silver plan jumped to $285.71, a 160 percent increase over the prior year.
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.
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.
