<p>
</p>
<p>Fang, the article posted by Flossy looks to be a case of Blame Everything on Obamacare Syndrome. This is a malady in which anything that anyone dislikes about any aspect of the American healthcare delivery system is automatically blamed on ACA. The Syndrome has been rampant since the law was passed, and seems to be reaching epidemic proportions.</p>
<p>The opposite syndrome would be “Nothing bad is the Fault of the ACA.” That syndrome is spreading, too.</p>
<p>The ACA is complicated and has changed nearly 20 times since being made the law of the land. </p>
<p>Some of those changes have happened just since rollout in October. </p>
<p>If journalists or consumers are confused or write sloppily, blaming it on partisanship alone is kind of absurd. While some people will never like it, even those who supported the idea of it are reeling from the realities of the law. Like higher costs for some or changed networks or whatever. </p>
<p>We have spend 535+ pages trying to figure this out with a group of what, fewer than 50 people posting with probably hundreds more lurking? </p>
<p>Even the insurance commissioner for Washington DC was fired for criticizing a last minute change executive change back in November. Several other state insurance commissioners have pushed back on fixes that sound good politically, but can take months or even years and a lot of work to implement throughout the insurance companies. </p>
<p>We are all impacted by this. Maybe not today if we are insured by our employers, but that can change in a heartbeat with a lost job or changed circumstances. We will not even know what happens whith the employer mandate completely until that deadline happens. It could change again. </p>
<p>Everything is not politically motivated. At a certain point, most of us are just trying to figure out how it affects us, and how to minimize the impact to ourselves and our families. I am not here reading this thread everyday because I need to buy my own policy today. I am here because I am a citizen of this country and may have to buy it in the future and I want to know what I am doing. It is confusing. I am sorry to say that I think I am more comfused in December 2013 about this law than when I first read about it back in 2010. It is hard to keep up. </p>
<p>It might have been easier to write a simpler law initially with rollouts phased in gradually. But that didn’t happen. The confusion will continue in the foreseeable future as the kinks are worked out. That is simply reality.</p>
<p>This is a great thread. We have educated posters like calmom and cardinal fang.</p>
<p>We have posters like GP that bring up issues (some issues are not issues necessarily). That’s ok. </p>
<p>I am learning a lot about individual insurance. Posters have helped me learn about my plan. </p>
<p>I think I am getting an understanding of my plan at Anthem. :)</p>
<p>With all the talk about shrinking networks, my network with Anthem in California is great. That means others have great networks. I dont know what GPs local network is like but his statewide network if he chooses Anthem is awesome. The UCs. Stanford. Cedars is in network. Ws dont know the costs because some of these hospitals may be Tier 2. (UCSF is tier 1).</p>
<p>Because these hospitals are in network, our costs are limited. If our doctors are in network and we dont know this yet, our costs could be limited to over a little over $11,000. We can have a 250,000 surgery and pay 11,000. Is that so awful?</p>
<p>I know. I can hear the complaining. My doctor is not covered. Well… I heard that UCLA and Cedars werent in network and it turned out… If you buy an Anthem plan…these hospitals are in network. All that complaining and the hospitals are in network. Just had to have some patience. :)</p>
<p>I figure if I have to go to a UC, Stanford or Cedars, having those hospitals as tier 2s is not going to be an issue. My costs are going to be over the out of pocket maximum if I have to go to one of those places. </p>
<p>I am curious. I like information. I would like to know which hospitals are tier 2.</p>
<p>I saw a Calpers Anthem list of hospitals and the tiers. The list was an Anthem Select PPO list. My local hospital is a tier 2 under that Calpers plan. Marin General. Now I wonder if Marin General is a tier 2 under my pathways network. I never thought Marin General would be a tier 2 but who knows? </p>
<p>Well Anthem may know. 
Where is that 2014 provider list? :)</p>
<p>Calpers list. Tier 2s are not new.</p>
<p><a href=“http://www.anthem.com/ca/national/f0/s0/t0/pw_b149849.pdf[/url]”>http://www.anthem.com/ca/national/f0/s0/t0/pw_b149849.pdf</a></p>
<p>Anthem is certainly superior to BS statewide and also in my region. I like that most of the best hospitals are in-network, although it isn’t clear what tier they are. However, many specialists are excluded, and for those tier 2 hospitals I have had a very high level Anthem administrator tell me that none of the doctors at these hospitals are in the network.</p>
<p>I also don’t like that Anthem has excluded out-of-state providers with the Blue Card program. The biggest problem may be the formulary, which hasn’t received much coverage in the press. The drug I take is not in it. In the past non-formulary drugs were covered, no longer in 2014. </p>
<p>Another problem with Anthem is that they don’t have a functioning provider directory. The one on their website is not accurate. So at this point it is anyone’s guess who is covered by Anthem.</p>
<p>A brilliant computer scientist who has done some fabulous “one-step” search enhancements for genealogy buffs like me has now turned his attention to ACA plans.
Website is [One-Step</a> Webpages by Stephen P. Morse](<a href=“http://stevemorse.org/]One-Step”>http://stevemorse.org/) and then click on the link on the page for Obamacare. </p>
<p>It supposedly covers all 50 states. It has links to provider directories on the insurer’s website, but you need to remember your insurer’s plan name (and sometimes make some guesses as to what category it is in…Anthem’s was obnoxious this way).</p>
<p>Decades ago I worked for a firm that maintained databases of insurance plans doctor by doctor – and the lack of awareness in the doctor’s office as to which plans the doctor did/did not participate in was huge. The folks at the front desk think in generic terms “We take United Healthcare,” while the person who does insurance billing (often in a separate office) knows that they’re a participating provider only with certain United Healthcare plans. </p>
<p>D currently works for a firm that maintains a similar database (and how weird is that?) – and says that the problem still exists today and it is the cause of huge patient unhappiness when it turns out that the doctor they saw last week isn’t really in the plan that they have. (And this is, of course, before ACA.)</p>
<p>I would not rely on what I was told by a doctor’s office about their status as a provider.</p>
<p>Arabrab, “D currently works for a firm that maintains a similar database (and how weird is that?)” :)</p>
<p>Love your post. Great link. I can not find the provider link from your link.</p>
<p>GP, you need to get your doctor to fax Anthem and get that drug somewhere on the list. There isnt an alternative drug?</p>
<p>dstark, don’t have Anthem insurance (yet).</p>
<p>
</p>
<p>If you’re addressing me, I have never said that ACA is perfect, or anything close to perfect. But it is enabling millions of people to get insurance who were previously shut out. And as those millions begin to experience the peace of mind and improved health that comes with insurance, yes, I would expect the ACA fan base to grow.</p>
<p>dstark: try this link [Viewing</a> ObamaCare-Compliant Heath Plans in One Step (Affordable Care Act)](<a href=“http://stevemorse.org/obamacare/obamacare.html]Viewing”>Viewing ObamaCare-Compliant Heath Plans in One Step (Affordable Care Act))</p>
<p>Once you’ve input your state/county/age stuff it will populate a screen with all the plans available to you. The far right hand column of that screen is the link to the provider directories – but not every plan has their directories available. You’ve got to make some notes as to which plan you’re in because once he throws you to the insurer’s site you could be asked the specific name of the plan.</p>
<p>
</p>
<p>Probably yes. </p>
<p>An insurance company with an EPO has probably negotiated a different set of rates with its tier 2 providers, which is in turn reflected in the different copays. Anthem wants to encourage its subscribers to go to the less expensive Tier 1 providers – so it sets up a lower copay for those. The math also has to work out on an actuarial basis – so if they project that on average a given patient will run up $500 worth of Tier 1 out-patient billings and $800 worth of Tier 2 billings, and they are offering a Silver plan that is supposed to have an actuarial value of 70%… then they’ve got to come up with a copay for Tier 2 that fits that model. </p>
<p>Keep in mind that in an EPO model, the insurance company will NEVER reimburse the patient for non-emergency out-of-network care. In the PPO model, the insurance company reimburses any out-of-network provider at a rate that is likely somewhat lower than the in-network rate, and the patient is potentially subject to balance billing – but there is reimbursement. </p>
<p>So lets say that I go to the hospital for planned surgery at a covered facility, and it turns out that the anesthesiologist is not in any network, and submits a bill for $750. (I have no clue what an anesthesiologist charges these days, so I’ve just made up a number as a hypothetical). Let’s also say that the insurance company will allow $275 for service, for its in-network providers, and let’s assume that I’ve already met my plan out-of-pocket maximum so I can reasonably expect all expenses to paid by my insurer. If I am on an EPO, then my insurance pays 0 – out-of-network means out-of-luck. I’m on the hook for $750, although of course I am free try to negotiate a lower price with the anesthesiologist.</p>
<p>If I had a PPO instead, then I’d get an EOB from my insurer saying that the anesthesiologist was out of network, and perhaps because of that they will pay only $225. So now I am dealing with a $525 bill from that particular doctor. Worst case scenario I still owe money, but its less than I would owe with the EPO.</p>
<p>So the EPO is using the tiered system to expand its network – we can imagine a scenario where the doctor who is out-of-network in the PPO is Tier 2 within an EPO – and you can see why Anthem or any other company might find it useful to use the EPO and tiered network system as a way of expanding its network to include more expensive facilities. But there is also something that the patient is giving up with that system, and of course there is no way in advance to know what the future will hold as to provider networks.</p>
<p>It’s obvious why a doctor would not want to be part of an insurance plan that had low reimbursements. </p>
<p>What’s less obvious is why an insurance carrier wants a narrow network. Why would they cut out some doctors or hospitals who may want to be part of their network? They control the cost of an office visit for example. Doctor A and Doctor B will be paid the same for the same type of office visit. The only reason I can think of as to why Doctor B might be cut out of a network is that Doctor B prescribes more or orders more tests or admits patients more often to the hospital. The insurance companies likely know this from looking at their records. Doctor B may have sicker patients who need more tests, but I wonder if the insurance company looks at it that specifically.</p>
<p>arabrab – I think that the site you link to is a good effort, but the problem is that Anthem does NOT have its provider directory for any of the new plans (“pathway”) on line yet – so the link is worthless. I think we Californian’s know how to find the provider directories on the insurance company web sites – the problem is that Anthem has been less than diligent about getting its data posted and available to consumers. Blue Shield has its information up and easily accessible, but it may or may not be complete or up to date. (Kaiser is a known quantity, and apparently none of us want to deal with HealthNet – so it pretty much comes down to Anthem vs. BS for the Californians looking for PPO’s)</p>
<p>Linking to the provider web site search tool is a good idea, but it won’t help if there is no there, there.</p>
<p>
</p>
<p>They don’t want a narrow network. They want a cheap network, and one way to get a cheap network is to have a narrow network. In some cases, providers are accepting lower payments in exchange for exclusivity. So, Acme Insurance talks to Cutt & Nife Cardiac Surgical Group, and says, will you accept 90% of Medicare reimbursement? </p>
<p>Cutt & Nife’s beancounters look at the books, and figure that if they can see a bunch more patients they can afford to see them for 90% of Medicare; the new patients will help pay off all the new equipment they just bought. Most of Cutt & Nife’s patients are on Medicare, so 90% of Medicare isn’t that bad for them. So they say, OK, as long as you don’t also send patients to Blud Cardiac Surgeons too.</p>
<p>Weird. In Colorado, the link to Anthem does let you pull up providers.
Bronze Direct Access has 633 providers in a 10 mile radius of me who are supposed to be open to taking new patients, including all my local docs, and 8 derms (which is often a tight specialty) and opthalmology included both generalists and retina and corneal subspecialists.</p>
<p>They can only see ‘a bunch more patients’ if the 10 minute visit is cut to 5. </p>
<p>That could be part of what the carriers are doing, but I bet they are looking at how often particular doctors send patients for MRIs, lab work, etc. they may be looking for the doctors that don’t utilize these expensive tests. That seems to be why they are cutting out the expensive hospitals.</p>
<p>“Keep in mind that in an EPO model, the insurance company will NEVER reimburse the patient for non-emergency out-of-network care”</p>
<p>That is the biggest difference I see with Anthem PPO and EPO plans because these plans have the same in network providers.
That is what I have been told. That is what GP has been told. </p>
<p>Calmom, what you wrote is probable in some cases. Maybe even Blue Shield in Cal. </p>
<p>I dont know if there is a geography issue. A usage issue. I agree that because EPOs dont cover out of network costs except for emergency care, there is a built in cost advantage with EPOs. </p>
<p>I dont know why SF is an EPO market while Marin is a PPO market. Maybe The SF population is more expensive to treat and EPOs are a way to cut costs? </p>
<p>I dont know.</p>
<p>One thing I do know is that Anthem’s network across the state is becoming broader and broader.</p>
<p>
Blue Shield has told me, more than once, that they are not “cutting out” anyone. Any and every doctor who was part of their previous network is free to join the new one - the doctor just has to take the affirmative step of signing up. I believe them. </p>
<p>I also believe that it is very possible that my doctor, who never has demonstrated any facility whatsoever for handling paperwork, hasn’t yet taken that step. So I will stop by sometime in the coming week, drop off my new insurance card, and see what happens. I do have a minor medical issue, so if that doesn’t clear up on its own in a few days-- I might make an appointment to take care of that as well-- which would provide an early test of the system, assuming my doctor gets around to trying to bill the insurance company for the visit. </p>
<p>As I posted before, I think a lot of doctors who already have busy practices might either be consciously taking a wait-and-see attitude, or may simply have not paid attention to whatever mail they might have gotten from the insurance companies about the new networks. I don’t know how long the process is for a doctor to get added to an insurance network - it might be something that can be done very quickly – so it may be that many doctors are in the habit of waiting until they actually have a patient present an insurance card for a particular plan before they sign up for something new.</p>
<p>
Probably because there are more providers overall within SF, and at the same time SF has some higher cost facilities that are in high demand. So it is very possible for most patients to have all of their medical needs met within city limits by Tier 1 doctors at Tier 1 facilities, but some patients will prefer the Tier 2. In any case, no need for anyone to leave town.</p>
<p>Marin is very different – the population is geographically, with Marin General being the primary, centralized facility. (According to its web site, it is the “only” full-service, acute care hospital in the county). So a multi-tier system doesn’t make sense-- if someone lives in Bolinas and needs to see a doctor, that patient isn’t thinking about costs - that patient is thinking about how long the drive is. It may also be just as easy for that patient to drive into San Francisco to see a specialist as to find one in San Rafael. </p>
<p>But the geography/distance factor is also going to help Anthem when it comes to patients choosing unnecessarily expensive facilities. The patients are more likely to try to choose a local provider as their primary physician than set themselves up to have to cross a bridge every time they need to see a doctor for a routine issue. </p>
<p>Anthem is trying to strike a balance between its own pocketbook and what it feels that the patients in a given area want. For them, the EPO model doesn’t work well in Marin, but clearly works well in SF, where geography is a negligible factor – SF is very small geographically, and rather big in terms of population and resources.</p>
<p>My understanding is that BS is receiving almost as many enrollees as Anthem on the exchange. That is too bad. People have no idea what they are signing up for. Anthem’s network is hundred times better than BS (appropriate initials) and probably not more expensive either. If everyone voted with their feet and signed up with Anthem, it would force BS to broaden their network; but people are too uninformed to properly analyze the insurance plans they are buying. One reason for this is because the exchange doesn’t reveal this information. Although you can compare plans on Covered Ca., you can’t compare networks. You don’t even know which plans have out-of-network coverage, as well as the deductibles and out-of-pocket maximums for this coverage.</p>
<p>If anyone is still trying to determine which insurance company in Ca to go with, please choose Anthem. Don’t reward BS for their lousy networks. They don’t deserve your business.</p>