Kevin Knauss: Health, History, Travel, Insurance
One of the first filters in selecting an EPO or PPO individual and family plan, either through Covered California or off-exchange, is determining if your current doctor is in-network. For all the enhancements to online doctor directory search tools, they still suck. They are not consumer friendly. Consumers are given either too many conditions to select or the provider search tool offers too little information.
The Department of Managed Health Care (DMHC), who regulates most of the individual and family plans offered through Covered California, has developed a website to allow consumers to compare health insurance companies. The Health Plan Dashboard website does not assign any performance review ratings. But it does give consumers a high level view of some of the data collect on the health plans such as enrollment, complaints, and enforcement actions for medical, dental, and vision plans.
As of January 12, 2016, I cannot recommend any individual or family enroll in a Blue Shield of California health plan either directly with them or through Covered California. As an insurance agent I have been dealing with Blue Shield’s nightmare enrollment, eligibility, and billing fiasco for over three weeks.
While Covered California standard benefit design health plans have very specific limitations on member responsibility for in-network health care services, the coverage for out-of-network services can vary greatly between PPO health plans. The insurance carriers that offer PPO health plans through Covered California (Anthem Blue Cross, Blue Shield of California, and UnitedHealthcare) with out-of-network coverage seem to have made up their own rules for this PPO benefit. Because the Covered California individual and family health plans have such narrow networks, many families are finding that they must go out-of-network to receive certain health care services.
New for 2016 is a Blue Shield individual and family health plan that offers $7 primary care office visits. The new Blue Shield of California Silver Seven 3750 PPO also has $7 lab tests as well. The trade-off for the low $7 office visits and other health care services is $3,750 deductible and 30% coinsurance for services subject to the deductible.
Covered California Certified Insurance Agents assisted 429,365 individuals for possible enrollment into the expanded ACA Medi-Cal health insurance from January 1, 2014 through July 31st, 2015. The Medi-Cal assistance enrollment figure comes from a Public Records Act Request that I submitted in early October of 2015 to Covered California. As the $58 compensation to agents for Medi-Cal enrollments ceased over the summer I felt it was important to learn the level of agent involvement with funneling Californians in Medi-Cal health plans.
Individual and family plans offered through Covered California in 2016 will include new pharmacy prescription drug benefits. The benefit, also mirrored in many off-exchange health plans, caps the amount a consumer must pay every month for a particular prescription. While that sounds straight forward, the rules surrounding any pharmacy deductible and tiered drug formulary can be complicated and confusing.
Whenever a health insurance company or health plan wants to change their health insurance rates in California they must submit a justification for the rate change in the monthly premium amounts to the Department of Managed Health Care or Department of Insurance. Regardless of which agency they must submit their rates to, the agencies just […]
A review of Covered California Navigator enrollment and payment data for 2015 reveals that a majority of organizations awarded grant money to enroll individuals and families in qualified health plans failed to meet their enrollment goals stipulated in the grant award agreements. Fifty-five of the Sixty-five organizations listed that received Navigator grants failed to meet […]
At the end of June 2015 the Centers for Medicare and Medicaid Services (CMS) announced that they had boosted the reimbursement for high cost health care claims to health insurance companies participating in the ACA reinsurance program from 80% to 100% for 2014. The increase in coverage resulted from fewer requests for coverage of high […]
