<p>"scuse me, 6 more articles won’t do it. 4 million would be half the enrollment. </p>
<p>dstark, that’s the best possible news @ expanding healthplans. That means that the people with the most to lose – the insurers – have looked at all of the data available, including the mix of young/healthy enrollees, and decided that they want more of the action. That speaks louder than all of the chicken littles combined.</p>
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<p>This. </p>
<p>It seems to me that some of these cases should be dealt with using existing laws and regulations. It is not legal in California to sell insurance plans that pay for people to go to the hospital, only as long as they don’t see any doctors while they are there. That is not an adequate insurance policy. </p>
<p><a href=“http://m.bizjournals.com/twincities/morning_roundup/2014/04/unitedhealths-sticker-shock-in-ny-rices-are-too.html?r=full”>http://m.bizjournals.com/twincities/morning_roundup/2014/04/unitedhealths-sticker-shock-in-ny-rices-are-too.html?r=full</a></p>
<p>Dietz, how big is this group that is non network? There is nothing in network in certain fields? I don’t think insurance companies can leave areas out of network…</p>
<p>Dietz, page 2…</p>
<p><a href=“http://marketplace.cms.gov/getofficialresources/publications-and-articles/what-you-should-know-provider-networks.pdf”>http://marketplace.cms.gov/getofficialresources/publications-and-articles/what-you-should-know-provider-networks.pdf</a></p>
<p>You can cause some problems if there really is no network coverage. </p>
<p>LasMa… Yeah… I think things are looking good. </p>
<p>Calif has already gone from the big 3 to the big 4. Kaiser had the higher prices and they dropped to 4th. Health Net was aggressive and they are third in marketshare now. </p>
<p>Calif had 600,000 sign ups during the last 6 weeks. 600,000. </p>
<p>I hope these insurance companies are thinking very hard before they increase rates too much. :)</p>
<p>CF: Do you have any info on the law? I have every intent of pursuing this issue until I get an answer. Being able to cite a law would be very very helpful if the resistance continues…</p>
<p>I hope Anthem is thinking hard about their execrable customer service, and how people can vote with their dollars to go to another provider next year. </p>
<p>Kaiser deliberately had prices that were higher. Think about it-- if you own your own facilities, you can’t handle a big influx of customers in one year. </p>
<p>Fang, we’ll probably go to Blue Shield next year, for that very reason. Now that Anthem’s customers can leave if they want, there’s no excuse. That’s how the infallible free market works, right Flossy? :)</p>
<p>CF, yeah. We arent married to these insurance companies. We can switch.</p>
<p>Dietz, if you are really correct about this in network issue, I would contact Dave Jones. We have two regulatory bodies in Cal. He is head of the dept of Insurance. He is running for reelection. I dont know how busy he is. When Anthem raised my rates 39 percent, I emailed Dave Jones on a Friday night. He emailed me back at 5 in the morning. Saturday. He was great. I would try Dave Jones.</p>
<p>ds: There are two major groups in our area, Sutter (PAMF) and Not Sutter. PAMF Drs are being employed (put on staff, have privileges, have facilities access… or whatever term the industry uses) at the one and only hospital in Santa Cruz. PAMF Dr’s are not in the BS EPO network which is the least expensive CC plan. They are also excluded from one of the other (Aetna and Health net) PPO options. The specific physicians in question are cardiologist…who will ‘take call for each other’. So, if a non Sutter/in network doc is scheduled to do say…angiogram but for some reason is unavailable for the schedule procedure…a patient would then be assigned the next Dr in line. Now, if that Dr is out of network…??? This used to be an issue with ER docs who were contracted differently than staff physicians.</p>
<p>I see one way out of this…and I hope someone in the know will actually return my call. I could see a physician being in one network when serving at location A but in another network when serving at location B. However, I’m not holding out much hope for that solution.</p>
<p>There was an interesting article about that 39%- wasn’t it that some outside group proved the need for that amount of hike had been miscalculated? </p>
<p>Question: dietz, do you think you mean hospitalists- who, in many cases, are covered same as the facility? They can be specialists (eg, cardiologists,) but usually charged with med care, not surgery. Needs some digging. I see PAMF is hiring these. It’s a different thing than “privileges” and there are several uses of “staff” or “on staff.”</p>
<p>Dietz, I am not a fan of EPOs. Lower costs—smaller networks that is the deal. No out of network coverage.
I don’t like that deal. </p>
<p>Out of network in a ppo plan is a different deal. You should be covered at a higher cost and a higher out of pocket maximum. </p>
<p>I think your example is very interesting. I don’t know the answer. The answer may depend on specific cases. Specific doctors. </p>
<p>LF: I am trying to get details. The writeup was cardiology specific so I don’t think these physicians will be functioning as hospitalists. Two independent cardiologist recently retired. What is the most disconcerting is the question of coverage has stumped the provider facility (or…if I want to go down the other thought path…they know the answer but figure it’s not a good thing to make public).</p>
<p>It doesn’t seem to be an isolated instance. We’ve been …um…surprised by ER bills which included a completely separate Dr. bill from an out of state group. But ER coverage always came under a different heading. In this case, from what I can tell, the out of network PAMF cardiologist will be providing non ER services at a BS contracted facility. Maybe I have this all wrong and the
details have been worked out…but the radio silence is not giving me a warm a fuzzy feeling.</p>
<p>CF: If we were to choose an EPO (which is not in the plans), I’d read the fine print and abide by the details. However, this situation is different. We had an issue with an in -network PPO provider giving my S a sling for a fractured arm. The supplier of the sling was not an approved vendor and I received a separate bill from this vendor for what was about 6X the cost of the same sling at the local medical supply drugstore. When I asked the provider (oh surprise - PAMF), the answer was…hmmm…that’s a bummer (okay, I paraphrase). So, the details here are very important to me.</p>
<p>FWIW: I fought the sling bill and the ER doc bill and won’ By won I mean I wound up paying an in network rate. Those were isolated instances - up until now. It looks like the problem is spreading, I’m older and I just don’t enjoy the fight all the much anymore.</p>
<p><em>Cue violins</em> <a href=“Sad Violin (make you emotional cry) - YouTube”>Sad Violin (make you emotional cry) - YouTube;
<p>“There are people all over the country who will have the same experience as the Staten Island woman. It doesn’t take a degree in physics to know that limited networks with narrow formularies are going to generate thousands of these stories.”</p>
<p>“My husband’s plan was cancelled and Anthem offered him another, very expensive plan. He went with an exchange plan which was considerably cheaper and with his expected usage, will cost us much less overall.”</p>
<p>LasMa, this is what you said about your husband in a previous post. If he is not receiving any subsidies, I don’t see why he is getting a better deal through the exchange. The plans are pretty much identical in pricing. The very expensive plan you were offered by Anthem is pretty much what you are going to get unless you increased the deductible, which you could do off the exchange.</p>
<p>The reason why Dietz has not heard of EPO’s is because they were rarely used in Ca before Obamacare. Now much of the state (Los Angeles, San Francisco, San Diego, etc.) has EPO’s for insurance companies like Anthem. Under Obamacare trying to figure out if the physician at a hospital is covered is going to be a painful exercise.</p>
<p>Dietz, if you do get an answer from Dave Jones about the networks in Santa Cruz and the adequacy of the networks as to what is legally required, let us know. The Sutter monster is difficult to deal with for everybody.</p>
<p>Oh please, Dave Jones doesn’t know cr*p. He is not going to tell her anything she doesn’t already know. That guy is useless.</p>
<p>dietz, have a look at this:</p>
<p><a href=“http://www.statenetwork.org/wp-content/uploads/2014/02/State-Network-Georgetown-ACA-Implications-for-State-Network-Adequacy-Standards.pdf”>http://www.statenetwork.org/wp-content/uploads/2014/02/State-Network-Georgetown-ACA-Implications-for-State-Network-Adequacy-Standards.pdf</a></p>
<p>The networks are required to be “sufficient in numbers and types of providers, including providers that specialize in mental health and substance abuse services, to ensure that all services will be accessible without unreasonable delay.” That’s vague, but obviously a plan that doesn’t provide hospitals and doctors in those hospitals is not providing “all services.” Looks like the states are responsible for enforcing the network adequacy requirement. </p>
<p>Calmom, is there an opportunity for a consumer lawsuit here, in areas where the networks are clearly inadequate?</p>
<p>“Calmom, is there an opportunity for a consumer lawsuit here”</p>
<p>How about a lawsuit against Obamacare.</p>
<p>I’d bet you could find one, GP. But I don’t want to lose my insurance. I can’t afford the prior cost. Things had changed in our situation. We aren’t in the financial position you may be. If things changed back, you’ve got posters right here who would be the sort of sad tales you like to quote. Would you care? There’s either empathy and understanding or there isn’t. Not selective, at safe distance. </p>