Both DMHC and CDI make their rate review process as transparent as possible to the public. This is not the case for Covered California. The reason Covered California gets to negotiate rates in secret is because the health plans are considered contractors and the rates are considered bids. I learned this after I filed a Public Records Act request asking for the rates submitted to Covered California.
California Health Insurance
Posts specifically related to California health insurance, enrollment, premiums, plans, termination, Covered California, Medi-Cal, Medicare, small groups.
Finding out if your hospital is in-network with your new health plan
The California individual and family plan market place will be changing quite a bit in 2017. Next to confirming if your favorite doctors are covered by the new health plans, many consumers want to make sure their chosen hospital is in-network as well. From information provided by Covered California and the health plans, I have put together a table of California hospitals by region and the health plans they accept.
Covered California health insurance rate proposals may be incorrect
A really nice tool for agents and consumers to compare health insurance plan rates is the Shop and Compare Tool. Within this website you can also download a proposal that lists the available health plans by metal tier level for the household information entered. Unfortunately, I recently found that the proposal created may not always match the website results shown.
Covered California to verify Qualifying Events for Special Enrollment Periods
Covered California has come under pointed criticism from the health insurance companies for their lack of verification of a consumer’s Qualifying Life Event (QLE) for a Special Enrollment Period (SEP). That will change as of August 1, 2016, when Covered California will start a program to randomly sample consumers who have enrolled in health plan outside of Open Enrollment under a QLE. Selected consumers will have to provide verification that they actually do have a QLE that makes them eligible to enroll outside of Open Enrollment such moving into California or the loss of minimum essential coverage like Medi-Cal or employer group coverage.
The secrecy of Negotiated Rates and Allowable Amounts
While the Affordable Care Act has brought transparency for consumers to compare health insurance plans, it has failed to lift the veil of secrecy surrounding how much health care services actually cost. This is particularly important for consumers who have high deductible PPO Bronze plans who would like to learn the health plan’s negotiated rate for a health care procedure.
Encrypting emails to protect health insurance consumers
For independent health insurance agents, such as me, who don’t have access to an already established secure network through a large agency, we have to be more diligent in securing all the different parts of the internet communication puzzle.
Calculating the value of the maximum out of pocket amount for health insurance
All individual and family health insurance plans include a maximum out-of-pocket amount that is the most an individual will pay on in-network health care services for a calendar year. This is particularly important for sole proprietors and self-employed people as one emergency room visit can easily top $20,000, and without health insurance, can imperil the person’s business. The value of the maximum out-of-pocket benefit can be measured and compared between different metal level health plan tiers and carriers as one guide in selecting a health plan.
Health Insurance companies tackle fraud and abuse with new verifications
Health insurance companies are deploying a variety of measures to reduce fraud and abuse such as only accepting paper applications or requiring proof of residency and identity.
Bronze 60 100% coinsurance after the deductible confusion
One of the most baffling health plan descriptions is the 2016 Bronze 60 health plan that states that the member is responsible for 100% coinsurance after the deductible. Most people who read this immediately shake their head and think, “I have to pay for all of my health care services EVEN AFTER I meet the deductible?” There really is no reason to buy health insurance if it never helps with the costs. The second part of the equation, not always referenced, is the calendar year maximum out-of-pocket amount of the Bronze plan which does limit a health plan members health care expenses.
Out of Network costs vary greatly among California PPO health plans
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.