A health plan without your preferred doctors is not health insurance. It can be a challenge to determine which health plans include your doctors and hospitals among the various individual and family plans in California. A good starting point is the Covered California provider search.
Whether you purchase your health insurance through Covered California or off-exchange direct from the carrier, you can use the Covered California Shop and Compare tool to search for doctors and hospitals. The Covered California provider search tool will display the network status of the doctors and hospital you select for all the different plans offered. However, the Covered California provider is not perfect and may not return accurate results.
Covered California Shop and Compare Tool
The first step in the provider search is to go to www.coveredca.com. There are lots of websites brought up in an internet search for Covered California that are NOT Covered California. If the website requires you to enter an email to get results, run away from it. Once you are on coveredca.com, click the Shop and Compare button in the upper right-hand corner.
The next page determines your location by zip code. Enter the zip code that you want to search doctors. For the income field, just put in any income over the Medi-Cal limit. For the household size, you can just use 1 and any age you want to be. Then click See My Results in the lower right-hand corner.
The next page informs you that you are eligible for Covered California. Click on Preview Plans.
The next page is used by Covered California to filter plans based on your use of health care and prescription drugs. Skip through it by clicking Next.
You have finally arrived at the provider search portion of the system. Type in the last name of the doctor you are searching for. If the doctor is listed, click on the box and it will be added to your list. You may have to expand the distance from the zip code for some providers to be displayed.
Doctor and Hospital Health Plan Network Status
When you have selected all of your doctors and hospitals, click the Next button.
Covered California will display all the plans – you can filter metal tier level – and your preferred providers you selected. If there is a green circle with a check mark, the provider is in-network. If there is a red circle with an X, the provider is not in-network.
The Covered California results are only as good as the information provided by the health plans. I run the provider search multiple times per day when I working with clients. My experience is that the provider search results are about 95 percent accurate.
There are 3 errors I have encountered. 1. Some doctors are never displayed in the search to even select. 2. Doctors are inaccurately displayed as out-of-network, when they are in-network. 3. Some doctors show in-network when they are not. The last condition can be a function of the location selected. Some doctors are in multiple medical groups. They may in-network with a plan at one location with a specific medical group, but across town they are practicing under a different medical group that is not in-network with the health plan.
You can compare up to 3 health plans. The interesting tidbit of information on the compare page is the estimated number of doctors in each plan within a specific radius of the zip code. The number of doctors, if accurate, is of limited value. The contracted doctor population may be an indication that you may have more choices and options outside of your preferred providers.
Perhaps the least reliable information about the network status of a doctor is to call the doctor’s office. The front office staff usually does not have a good knowledge of health insurance. You will usually get answers like, “We take all PPOs.” That response is worthless. Another reply is the doctor’s office will take Blue Cross plans. The problem is that all health plans maintain different networks of providers for Medi-Cal, Medicare, individual and family, Small Group, and Large Group health insurance.
Another misinterpreted response from a doctor’s office is, “We don’t accept Covered California health plans.” This leads people to believe the doctor will accept off-exchange individual and family plans. What the office is really informing you is that they are not contracted with the individual and family network of providers for any health plan. The network of providers for the ACA health plans is the same whether you enroll through Covered California or direct with the carrier off-exchange.
Health Plan Provider Finder Websites
The best source of the health plan’s provider network is to visit the carrier’s website and select Find a Doctor link. Two of the providers in the Covered California provider search showed out-of-network. That seemed odd, so I decided to check the carrier’s website to verify the network status by selecting Doctors and Specialist area.
Regardless of which health plan you are searching, you must select the correct criteria to get the correct results. Crucial is selecting the plan type. There are usually multiple network and plans. In this situation, we must select the correct year and then Individual and Family. It is really important to identify if you are searching in the PPO or HMO network of providers.
When I search for this doctor, he showed in-network with the carrier when the Covered California system showed him out-of-network. However, check that the address is correct for the location that you would be visiting the provider. Also important is the medical group.
This doctor was also determined in-network for the HMO health plan on the carrier’s provider search, but shown as out-of-network on Covered California. Also note that Dr. Suja is with the Mercy Physicians Medical Group whereas Dr. Willems is with the Scripps Clinic Medical Group.
With an HMO you must select a Primary Care Physician (PCP.) Your PCP will refer you to specialists within their medical group. A PCP with Scripps Clinic Medical Group may not be able to refer you to a doctor in the Mercy Physicians Medical Group. The result is that even though the doctor shows in-network, if the doctor is not in the medical group of your PCP, that doctor may be out-of-network for you.