<p>The way it has been explained to me is one would have to stay w/i ones home region. Friend’s hubby was told by Covered California today NO out of area coverage. So, unless there is another way to phrase the question, it seems that the only place this family can receive non emergency care is within the confines of area 9.</p>
<p>They are really panicked - son has been undergoing some expensive testing at Stanford. Their out of pocket costs will more than eat up the saving they planned on via the subsidies. They have to decide whether or not to have S undergo a colonoscopy with the docs that have been following his condition for the past few years or whether to do it local. Even if the do it in network locally, they’d still want the expert to evaluate results. It’s sad to watch them struggle with this.</p>
<p>Maybe the folks in the northern regions where the light blue areas are contiguous are able to move between regions. But as you can see from the map the more central EPO areas are somewhat isolated from each other.</p>
<p>The missing link: <a href=“Be Well | Blue Shield of CA”>Be Well | Blue Shield of CA;
My point was: a look at the benefits summary is like looking at a spec sheet for a car, you’d see the spare or not. I’ll skip the words and say it;s worth a look at several EPO benefit summaries, if one hasn’t.</p>
<p>Yes, from that map page’s words, it “seems” to mean EPO area versus PPO area.</p>
<p>I went back to Dec in this thread and found this post by me.</p>
<p>“All providers in EPO regions are available to all members who live in PPO regions. So UCSF, UCLA, and any other Anthem EPO in-network provider will all be in-network if you live in a PPO region. Interestingly, the reverse is also true. Anyone in an EPO region can go to any Anthem provider in a PPO region. That kind of surprised me. The only difference between an EPO and PPO is that you cannot go out of network in an EPO plan. I think this issue got resolved in the last 24 hours. My inquiry may have brought it to a head.”</p>
<p>Apparently, the Anthem executive told me this. It is possible he was wrong or maybe the rules are different for Blue Shield’s EPO networks. He was struggling trying to answer my questions so I wouldn’t take his understanding of how this works to the bank just yet. </p>
<p>LF; Here is what happens if you follow that link (I’m very familiar with it).<br>
Select your plan (Covered CA EPO Bronze)
Sends you to the standard comparison chart
Click on the link which sends you to participating providers
Now it asks you to enter the ZIP code</p>
<p>SO…the mom would enter the ZIP code for her S in Davis…low and behold up pop the providers in Davis!!! Except these are not in network for Santa Cruz. The system does not ask you for your home area ZIP (or zip of the address for the main subscriber) </p>
<p>Actually, you’ve just proved the whole point. The BS system when queried for in network providers for the individual EPO plans will list them based on the ZIP code of interest to you. It does not restrict you in anyway to the geographic area where you live…and to THAT restricted
network. There is no indication, warning or alert which says ‘hey, you can only input the ZIP code for your home area - those are the only providers in your network.’</p>
<p>And…if you select ‘all EPO plans’ then go to advanced search and search for hospitals in Palo Alto…yup…Stanford comes up as in network WTH!!! Which is probably exactly what this family did when doing their due diligence. Now, now doubt neither BS, Covered CA, or the ACA is responsible…just the uninformed and lazy consumer.</p>
<p>Where did you learn that, GP? Dietz may be able to use it, if it is some Blue Shield wording.</p>
<p><a href=“https://www.healthcare.gov/sep-list/”>https://www.healthcare.gov/sep-list/</a>
If it were me, I would consider: "Misinformation… “being enrolled in the wrong plan.” That would rest on the caller having tried to clarify (in all those calls) that the specialists were covered. But while this could be a strategic possibility, we don’t know what the caller has admitted in the later conversations. </p>
<p>In contrast, from <a href=“https://www.blueshieldca.com/producer/ifp/products/networks.sp”>https://www.blueshieldca.com/producer/ifp/products/networks.sp</a> (the page with the map)- “With an EPO plan, members have the flexibility to use any provider in the Blue Shield EPO network without a referral. There’s no need to select a primary care physician, or to obtain services only from a specific medical group. EPO members must use network providers to receive coverage. There is no coverage for non-network providers, with the exception of emergency care.”</p>
<p>Personally, bugs me we have to go to the broker related site to get some little clarity- and that the wording has to be so closely read to glean (if ever) what refers to PPO only. </p>
<p>Dietz, re; 1115pm, are we looking at the same link- mine at 1055 shows benefit summaries. I think you mean the provider list- and I agree it is entirely confusing. I tried it, even with a 100 mile radius. </p>
<p>This from the BS EPO benefits summary - full document </p>
<p>
</p>
<p>So you can see doctors in network ‘where you live’ but the you may need to drive 30 minutes in order to access certain services. This really is getting more and more confusing.</p>
<p>D, I would try to make a case. 1-2-3. The core point that in various end-user documents (not the brokers,) the wording available is utterly confusing (with examples) and led to misinfo or misdirection, then compounded by answers from reps. Leading to the wrong plan choice. A request for the current charges to be treated as in-net and the right to change plans. ? I wouldn’t (want to) talk to any more common reps, might line up my ducks, all of them, and go for a supervisor. Or the formal appeal. GP’s info from the exec could be helpful.</p>
<p>I can argue both sides- but at this point, you want some steps that might help. I’m out of here for now, but hoping for something to work out.</p>
<p>I found a list of hospitals that are in the PPO and EPO networks for BS. Every hospital, including those in the EPO network, are in the PPO network; however, all the hospitals in PPO regions are not in the EPO network. This would suggest that if you live in an EPO region you can’t go to any provider in a PPO region. I could see where this would be a huge problem in Santa Cruz because it is in a small EPO region isolated from the other EPO regions in Northern Ca.</p>
<p>I noticed that there are two hospitals (Washington and Valley Memorial) in Alameda County, an EPO area, which are not available to anyone who lives in an EPO region but are available to people who live in PPO regions. If this isn’t nuts, I don’t know what is.</p>
<p>Dietz, another question for your friend: prior to these charges being incurred, did your friend inform Blue Shield that son was living in Davis to attend college?</p>
<p>Also, has your friend inquired as to whether Blue Shield offers Blue Card or the Away from Home Care programs to EPO members, and if so – what steps are needed to enroll the son?</p>
<p>If the answer from BS is no-go (no away from home care available to EPO members at all). – then I would have these 3 suggestions for your friend: </p>
<p>1) appeal the insurance company determination, following Blue Shield’s internal process
2) have son apply for a separate policy via Covered California in Davis, using his Davis address, on ground that he has moved and is not eligible for insurance under his parent’s policy (he won’t be eligible for subsidies, but as he is younger his premium will be comparatively lower, and he could get into a BS PPO that way – so he would be able to see Santa Cruz doctors under the PPO plan)
3) get in touch with your congressman.
4) get in touch with the state insurance commissioner.</p>
<p>Here is where I see a legal issue: One of the benefits of the ACA is that young adults can remain on their parents’ plan through age 26. It is common for young adults to maintain separate residences from their parents, and for young adults to attend colleges in different areas. So logically, an insurance policy should provide a mechanism for coverage for those young adults. </p>
<p>So if in fact that is the situation, this is a very big issue that needs addressing.</p>
<p>If, on the other hand, there is a mechanism for getting “away from home” care for the son --but the parents didn’t do whatever paperwork was necessary because they didn’t know they had to – that’s an issue that might be resolved via Covered Cal-- it may depend what’s in the written paperwork the parents received with their policy that could arguably have put them on notice. (And I don’t mean small print buried 10 pages deep. The insurance companies should anticipate this issue when coverage is for young people age 18-26 – so I think it is on the insurance company to notify the policy holders of this possible issue). </p>
<p>Dietz, as I understand it, if proper care cannot be provided in network, the patient can appeal for out of network care (at network cost). Has your friend looked into that? </p>
<p>I don’t live in CA and my only exposure to EPO had been this thread, but my sense was that an EPO was designed to create something cheaper than a PPO so the price is probably a good indication of the difference :)</p>
<p>Ergo, it would make sense to me that a PPO can go to an EPO area, but not the reverse. Since my son’s gf is from CA and since son has an intent to move there I had asked a lot of questions of BS about his interim coverage etc. and concluded that he’d need a PPO too, though a permanent move to CA will be a qualifying event and he’ll still ultimately have to change his plan. </p>
<p>That said, I’d personally argue with BS in the case of Dietz’s friend that there was an opportunistic failure to disclaim or describe coverage limitations and that they should therefore move kiddo into his own PPO to be covered at home and away, and pay his current claim. While this will add a few hundred to their monthly insurance cost (likely bringing it up toward PPO level) it should still be more cost effective than having all three on a PPO and if BS agrees to pay the claim, might be worth the shenanigans. </p>
<p>By way of example, my PPO was $1196 with mcson on the plan, $979 without. His stand-alone PPO is $230. Dietz’s friends were paying $600/mo for all. I’m betting the college son could sever for about a $250 differential, some of which would drop the parent’s premium. However, these numbers are not subsidized numbers as we do not qualify.</p>
<p>If the family is receiving subsidies then moving the son off will change their subsidy eligibility. It’s worth a look to see is BS will clean up the mess. They may not be in the mood for a formal commission inquiry about their transparency :)</p>
<p>^And in terms of cheerleading, while I support the tenets of ACA, I think we all should be making a distinction between ACA and the private insurance market’s RESPONSE to ACA and conduct around compliance. Making this distinction indicates a capacity to reason, not blind cheerleading…</p>
<p>Someone knew way back in August 2013 that a Family plan EPO is not a good option if one has a student who is at college in another county in CA. Not saying this means Deitz’s friend could figure it out from her plan documents (though I will say from Deitz’s post of BS EPO benefits summary I understood was it was saying.) </p>
<p>Thanks for all the insights and suggestions. At this point I know just the higher level details of my friends situation - the primary driver in all this being the CC rep statement ‘no out of area coverage’. They did ask if they could put the S on his own policy and were told no because they were claiming him as a dependent. I don’t know if they’re aware of the appeals process but I will bring this to their attention. </p>
<p>If it were me I would have gathered all the info presented here, along with screen shots of the BS documents and the results of provider searches via the BS website. The first volley would be to BS and then to the DOC (that used to be the final arbitrator…does Covered Ca. now have it’s own board?)</p>
<p>So, I’m not so sure you can make a distinction between a law and the consequences of a law. Laws do have consequences. ACA is good but it makes businesses do bad things. Hmmmm.</p>