<p>What a network for Anthem Blue Cross…</p>
<p>Now wth is pathways?</p>
<p>[Anthem</a> Blue Cross Negotiations Update](<a href=“For Patients | Sutter Health”>For Patients | Sutter Health)</p>
<p><a href=“http://news.sutterhealth.org/2013/12/16/agreement-reached-anthem-blue-cross/[/url]”>http://news.sutterhealth.org/2013/12/16/agreement-reached-anthem-blue-cross/</a></p>
<p>See? Nov links are dated. ;)</p>
<p>Dstark – Blue Shield still has grandfathered plans, from way back. The plan that I had was grandfathered, but I didn’t have grandfathered status because I had come onto that plan from something else at some time after March 2010 – but I do know someone who has the same plan with grandfathered status. </p>
<p>So there may be differences in networks between the old, grandfathered plans, and the new qualified ACA plans. But there wouldn’t be any difference between PPO networks of any of the PLANS which begin in 2014, whether they are on or off network.</p>
<p>It is theoretically possible that the same insurer might offer both an EPO and PPO plan in the same region, and in that case by definition there would be a difference in networks. I don’t think that is happening in California – but I know that Blue Shield has also had a HMO in the past, and that my doctor would accept the BS PPO but not the HMO plan.</p>
<p>Thanks for the Sutter link, DStark – I think the basic gist is:</p>
<p>
</p>
<p>[Anthem</a> Blue Cross Negotiations Update](<a href=“For Patients | Sutter Health”>For Patients | Sutter Health)</p>
<p>And,
</p>
<p>[Covered</a> California Frequently Asked Questions](<a href=“For Patients | Sutter Health”>For Patients | Sutter Health)</p>
<p>You can find a list of all Sutter facilities here:
[Sutter</a> Health Affiliated Hospitals | Northern California Hospitals](<a href=“About Sutter Health | Our Network”>About Sutter Health | Our Network)</p>
<p>So basically, all facilities take the Blue Shield plans, but currently only about a third of the hospitals are taking the new Anthem Blue Cross plans. </p>
<p>I happen to live in an area where the facility nearest me is NOT listed as taking Anthem patients – hence my decision to stay with Blue Shield. Maybe things will be different next year – one nice thing about ACA is that we all have the option to change plans each year, and I am sure the kinks will be ironed out and network information more clear in a year’s time.</p>
<p>
</p>
<p>“Pathways” is the name that Anthem has given its qualified ACA plans. (“Qualified” means certified to be subsidy-eligible - but the same plans are sold on and off exchange). So if you buy one of those plans, on or off exchange, Anthem calls it “pathways” and you would use the “pathways” link in the drop down menu of their provider directory to find the doctor or facility you were looking for. (Except that you can’t, because that option hasn’t yet been programmed into the Anthem online directory.)</p>
<p>dstark, the networks for BS and Anthem are the same for both exchange and off-exchange plans in Ca… To me, this is a huge problem for the many people stuck in the individual market. They have become second-class citizens to their fellow Californians in group and grandfathered plans, except for those people who are receiving coverage for free (or almost free). If you don’t have to pay or pay very little for your insurance, you probably don’t have a right to be all that particular about your insurance. Prior to 2014, I preferred the individual market; in 2014, I will do anything to get out of the individual market.</p>
<p>I have had coverage with BS and Anthem over the years and Anthem is the superior company. BS requires preauthorization for many procedures and tests, much more so than Anthem. I have also spoken to numerous doctors who have told me that Anthem is easier to deal with than BS. I also believe the lawyer who told me that BS is much more reluctant to overturn rescissions and is far more pugnacious in dealing with their subscribers. Their non-profit status does not translate into better service for their customers.</p>
<p>I am not selling this guy. I dont know this guy. </p>
<p>But I like part of his web site…</p>
<p>I am in Pathway 1. I think I get Cal Pacific is in my plan. </p>
<p>Stanford is a tier 1. Across the bridge in SF, Stanford is a tier 2 hospital and costs more.</p>
<p>[Anthem</a> Blue Cross ACA Plans 2014 » IMK](<a href=“http://insuremekevin.com/anthem-blue-cross-aca-plans-2014/]Anthem”>http://insuremekevin.com/anthem-blue-cross-aca-plans-2014/)</p>
<p>This is from calmom’s link…</p>
<p>"Why aren’t Sutter doctors and hospitals participating in the Anthem Blue Cross Covered California products?</p>
<p>A number of Sutter-affiliated hospitals participate in the Anthem Blue Cross Covered California individual product called Pathways. They are: CPMC and St. Lukes, Alta Bates Summit Medical Center, Novato Community Hospital, Sutter Amador Hospital, Sutter Lakeside Hospital, Sutter Coast Hospital and Memorial Hospital Los Banos. We are open to participating in new health plan products where it works for both parties."</p>
<p>So… Texaspg’s comment about doctors charging more for different plans from the same insurance company…</p>
<p>Makes sense if the insurance company is in different regions in Cal.</p>
<p>Cities with EPOs in Calif probably do have different pricing than areas with PPOs. The out of network costs arent the same either.</p>
<p>[Purchasing</a> Individual Coverage - Cedars-Sinai](<a href=“http://cedars-sinai.edu/Patients/Insurance-Exchanges/Options-for-Purchasing-Individual-Coverage.aspx]Purchasing”>Purchasing Health Insurance on Your Own | Cedars-Sinai)</p>
<p>Looks like Cedars Sinai is in network in my plan…Tier 1. I dont know about the doctors at Cedars though. :)</p>
<p>"Anthem Blue Cross’ new individual and family plans for 2014 will exclude the majority of Cedars-Sinai physicians from its new narrow network of providers.</p>
<p>Cedars-Sinai Medical Center is offered as an in-network hospital in PPO plans and as a Tier 2 facility in Exclusive Provider Organization (EPO) plans.</p>
<p>If you curently have an individual or family plan from Anthem Blue Cross that includes Cedars-Sinai, you may be able to keep that plan through a process called grandfathering."</p>
<p>dstark, how do you know that Cedar Sinai is tier 1 in your region? Is this in writing somewhere?</p>
<p>Also, how do know that Stanford is tier 1 in your region? I can’t find anything on the site you referred to which tells you what tier Standford is.</p>
<p>“Meeting the deductible before most coverage kicks in is common in the individual market, but it differs sharply from job-based health insurance. More than three-fourths of the insurance plans offered to Americans with coverage through their jobs pay a substantial chunk of the cost of doctor visits without the workers having to meet the annual deductible first, according to an annual survey of employers by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)” </p>
<p>This is what I have found so hard to grasp. For instance, in the last month I have racked up over $1000 in medical bills between doctor’s visits and lab tests. The negotiated rate reduced it to $359 - which my insurance will pay. My co-pays come to $150. I don’t believe I have paid anything towards my deductible ever.</p>
<p>In California, all the health plans and insurance companies had to agree to sell plans outside the exchange that look virtually identical to the plans inside the exchange. There will be some slight modifications, but the plans will still meet the stated actuarial value of 60, 70, 80, or 90%.</p>
<p>For example, an off exchange Anthem Blue Cross Silver plan may have a $1750 deductible as opposed to the traditional $2000 deductible of the exchange plan, at a lower monthly premium. However, that off exchange plan with the lower medical deductible may have a higher pharmacy deductible than the on-exchange plan. </p>
<p>Prescription coverage is expensive for the health plans. But if you are on prescription medications, having a $250 pharmacy deductible could more than make up for the extra cost of the $2000 Deductible Silver plan or even a Bronze plan</p>
<p>“Flossy, if you’re around, yesterday you said that if a doctor took a patient who had bought an exchange policy, the doctor would have piles of paperwork that wouldn’t exist for other patients. Can you point me to any documentation of that? I figured that if a patient comes in to the doctor’s office and they have insurance, the doctor’s office bills them in the usual way no matter where the insurance came from.”</p>
<p>[Local</a> physicians expect Obamacare to cause pain](<a href=“http://www.theoaklandpress.com/general-news/20131222/local-physicians-expect-obamacare-to-cause-pain]Local”>Local physicians expect Obamacare to cause pain – The Oakland Press)</p>
<p>Kevin, I may have misinterpreted how tier 2 facilities charge Anthem customers.</p>
<p>“Cedars-Sinai Medical Center is offered as an in-network hospital in PPO plans and as a Tier 2 facility in Exclusive Provider Organization (EPO) plans.”</p>
<p>Is Cedars-Sinai covered under a tier 1 plan if a patient has a PPO and a tier 2 plan if a patient has an EPO plan?</p>
<p>Or is Cedars a tier 2 facility for both PPO and EPO coverage?</p>
<p>Is there Tiered coverage under PPO plans?</p>
<p>What part of that article says that doctors have more paperwork for patients who bought on the exchange than other patients?</p>
<p>This part makes me suspicious of the entire article:</p>
<p>
</p>
<p>This “qualified physician” stuff appears to be referring to the electronic health records (EHR) rules. Doctors who don’t meet certain standards for electronic medical records will see their Medicare reimbursement reduced. </p>
<p>So the posted article (1) appears to be inaccurate and confused and (2) even if it were accurate, says nothing about paperwork differences between patients who bought exchange policies and other patients.</p>
<p>dsark - I agree with calmom’s post 8311. You should read it a couple of times.</p>
<p>Essentially, what I am saying is the following:</p>
<p>BC/BS has contracts with Doctor A under Plans A,B,C,D which are individual, group, grandfathered and whatever else you want to call them. Most of these have equivalent rates that they have been paying until now and it is quite possible BC/BS has a single reimbursement across all of them. These have all been negotiated in the past and the doctors and facilities know what their reimbursements are for the procedures.</p>
<p>Now BC/BS has ACA metal tier plans but since this is considered a much bigger volume than their existing plans, they are going back to negotiate with doctor A for those plans. Doctor A refuses for the lower rate and won’t be listed on the metal plan but will still be on the old plans. </p>
<p>The reimbursements are the same when you buy in exchange or through BC/BS directly but essentially they are renegotiating all prices to bring them down. Some doctors are ok with the new prices and some are not and have not signed up YET. This is the reason GP keeps writing essays about the missing doctors that he would never go to but wants to have that warm and cozy feeling that they exist to serve him as opposed to one or two he will really visit.</p>
<p>So what I am saying is that if you are correct and a doctor is signed up with BC/BS, you should see that doctor in every plan, no matter what plan BC/BS offers. If he/she is not available in every plan, then I am correct and they need to sign separate contracts to be on a plan. </p>
<p>What I foresee happening: BC/BS (or anyone offering a plan) will have a bunch of doctors signed up for the reimbursement rates they have defined and figure out who has not signed up. Next year (2015), they will lower their other rates on their other plans and drop the doctors who don’t agree from their other plans also so they will have a set of doctors who are on all the plans. Unless the doctors go into concierge or cash only practices, some of them will cave and agree to lower prices across board on all plans offered by the insurer.</p>
<p>The question was, “Are some doctors reluctant to sign on to the exchange due to fear of low reimbursements and over-regulation?” The answer is some certainly are. Yes, there is much confusion, everywhere.</p>
<p>texaspg, are you saying that BCBS (or whoever) is going to negotiate one low rate for all their plans including group plans? I’m sure they’d like to. These negotiations have two parties, though. BCBS might find it more profitable to have various levels of reimbursement.</p>
<p>ACA has a bunch of regulations. Whether a doctor joins the metal tier plans or not, the regulations are not going away. Insurance companies are not the regulators.</p>
<p>“going to negotiate one low rate for all their plans including group plans?”</p>
<p>If I was running a business, why would I want to continue paying 90 to someone when I know that person is accepting 70 also for other patients? I am saying it is an eventual outcome over the next couple of years. So those who are staying away today will figure out they would rather stay with BC/BS/Anthem/whoever and get the volume rather than have no one from that insurer which means in a couple of years the doctors are in or out on all the plans.</p>
<p>Texaspg, we dont really disagree.</p>
<p>You misunderstood me. That is ok. I misunderstood you. :)</p>
<p>I never said the below.</p>
<p>“So what I am saying is that if you are correct and a doctor is signed up with BC/BS, you should see that doctor in every plan, no matter what plan BC/BS offers. If he/she is not available in every plan, then I am correct and they need to sign separate contracts to be on a plan.”</p>
<p>Now for 2014… With EPO plans, and PPO plans in different regions of the state of California</p>
<p>Are doctors paid differently when comparing EPO plans and PPO plans?</p>
<p>I am confused about the following…</p>
<p>The labeling of EPO plans as tiered plans while PPO plans have no such label. What does that mean as far as pricing?</p>
<p>The reason I ask this is because I can only buy a PPO plan. In SF, people who purchase an anthem plan can only buy an EPO plan.</p>
<p>Different locations. Different plans. Different costs out of network. What about in network costs?</p>
<p><a href=“http://www.anthem.com/ca/provider/f5/s4/t0/pw_e208745.pdf?refer=provider[/url]”>http://www.anthem.com/ca/provider/f5/s4/t0/pw_e208745.pdf?refer=provider</a></p>