For most Covered California consumers there will be only one PPO health plan to select. Blue Shield is the only health insurance company participating in Covered California that will offer a PPO health plan in the major metropolitan regions of California. While the PPO plan design signals to consumers that they have some freedom to use out-of-network providers, the Blue Shield benefits may be very restrictive.
Since the beginning of Covered California, many individuals and families have complained that some doctors refuse to accept health insurance purchased through Covered California. Most health insurance companies have stated that contracted network doctors can’t refuse to see Covered California members. However, Blue Shield of California seems to have changed their position on doctors refusing service. They are now stating, as of November 7th, that doctors can discriminate against individuals and families who have Covered California plans.
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.
The big headline in August was that Aetna would not be expanding their Obamacare individual and family plans in 2017. The smaller headline from a week earlier was that Aetna was seeking approval to become a Medi-Cal manage care health insurance provider in California. Just like other health insurance companies have found, welfare pays better than work when it comes to health insurance.
As is typically the case with enrollment disputes, Covered California says it is a Blue Shield problem and Blue Shield points the finger at Covered California. Blue Shield further states that they must wait 30 days before they request another transfer of the enrollment data from Covered California. So where does this leave the family? They have paid for health insurance in July for which they have no enrollment.
Blue Shield has been sending confusing letters to their members that seem to indicate that the individual or family has lost their Covered California subsidy and they will now have to pay the full premium amount. These premium rate scare letters are automatically generated and do not necessarily reflect the full premium amount will be the consumer’s responsibility. Unfortunately, these confusing letters are throwing consumer’s into a panic generating phone calls to Covered California, Blue Shield, and insurance agents.
As of April 2016, when a consumer makes their first month’s payment for their Blue Shield health plan, the money is never applied to their account.
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.
Blue Shield of California’s billing system that created major headaches for individuals and families in 2014 continues to stumble into 2016. Even through changes to the enrollment website, the simple tasks of determining an applicant’s eligibility and properly applying a premium still seems elusive to Blue Shield in several instances. For whatever reasons, several of the Blue Shield units – underwriting, eligibility, billing, member services, and IT- don’t seem to talk to one another.
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.