Kevin Knauss: Health, History, Travel, Insurance
Posts related to Preferred Provider Organizations, PPO, health plan networks, in and out of network benefits.
The value of dental insurance is questionable in the minds of many consumers. And I don’t necessarily disagree with that evaluation. However, the importance of regular dental exams, cleanings, and hygiene cannot be disputed. If dental insurance keeps a person on track with good dental hygiene and habits, they will be spared the expense of expensive dental procedures in the future.
Blue Shield individual and family plans also come with Teladoc for phone call consultations, NursesHelp 24/7 online chat, and the BlueCard program that allows member’s access to providers when they are travelling out-of-network. The plans also include a physician home visit. The home visit, Heal on-demand house calls, is subject to the member’s location. There is also Telebehavioral health benefit that helps members with mental or substance abuse challenges access therapy online with mental health professionals.
The health plans don’t recognize the invoiced amount of the health care services from out-of-network providers as either accruing toward the deductible or for their cost-sharing of 50% before the maximum out-of-pocket amount is met. The health plans apply a Usual and Customary Rate (UCR) or the Allowable Amount. This limits their responsibility for payment and increases the health plan members costs.
Before I start gathering coverage information, I create a table with preferred or “must have” providers, hospitals, and drugs in rows, with the available health plans across the top columns. I then mark which health plan has the providers in-network and if the drugs are covered and at which Tier.
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.
Anthem Blue Cross is terminating many of their 2016 PPO and Tiered PPO plans across different regions of California. They are being replaced with an EPO version in 2017. Covered California has misleading information placed on the consumer’s accounts that the new EPO is the same as the old PPO plans.
With the loss of the Anthem Blue Cross PPO plans in most of California and the double-digit rate increases on many plans, consumers are starting to look at the HMO plans available to them. There was a time when HMO plans were always more expensive than PPO plans. In the new health insurance landscape of Obamacare, HMO plans are becoming less expensive. But is a HMO plan right for you and your family?
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.
Health Net of California is sending letters to current members in their IFP PPO plans that they can keep the health plan they purchased through Covered California but they won’t be able to receive the ACA tax credits in 2015. Health Net will no longer offer their PPO plans through Covered California. In their place […]
A significant change to the plan types offered for individuals and families through Covered California for 2015 will be Health Net dropping their Preferred Provider Organization (PPO) plans. In place of the PPO health plans, Health Net will offer Exclusive Provider Organization (EPO) health plans. This change may be particularly significant for members who relied on […]
