Sorry, I don’t know the answer about the labs.
Calmom: Thanks for that info. I will have to go back and review the EOB’s for H’s procedure. Time all mushes together these days but I’m sure H had that last colonoscopy within the past 12 months. So, maybe I need to ask the docs office for a refund. However we have a grandmothered group plan which is not fully ACA compliant. Maybe that makes the difference.
Informative article
http://www.governing.com/topics/health-human-services/gov-health-exchange-lowest-premiums.html
Calmom, that is exactly the scenario I was afraid of. If it’s not a problem I guess he should sign up! Today!!
On my Facebook page, I’m seeing other friends decide to go to Kaiser. This nonsense between Sutter and the insurance companies is backfiring, to the benefit of Kaiser. My friends are saying, We just want to go to the doctor, we don’t want all this hassle.
. I’m going to wait a few weeks, but if things are not resolved by February, I’m definitely switching to Kaiser. Worse case scenario is that I have Kaiser for a year, decide I don’t like it, and then switch to another plan for 2016,
I’ve got another EOB for labs that my doctor ordered last summer- I think that some of the labs should be paid for as preventive and Blue Shield has applied them all to my deductible instead. I’m not worried on the financial end because went to Quest & they billed about $680 – and Blue Shield has tagged my patient responsibility at $87… but I’m still spending time reading the procedure codes and trying to make sense of it all. Somehow I think or hope that if everything is done in-house at Kaiser there might e less of a problem with reconciling everything. The Quest submission is complicated by the fact that I got the services in July, but they didn’t submit to the insurance until November – and then they resubmitted in January-- so that’s just more stuff I have to chase down.
Followup – I’m on the phone to Blue Shield, the $87 lab bill mentioned in my previous post is covered under preventive & the claims agent is fixing it for me. This one is due mostly to the lab’s error – what happened is that I had the labs in July, but Quest didn’t submit to insurance until November, and when they did they failed to include diagnoses information (it should have said “routine” but instead it was left blank – so the claim was processed with my share applied to my deductible. Then Quest resubmitted, with the corrected diagnostic info – but because it was the same services on the same date, it was denied as being a duplicate. Probably should have been caught and corrected by Blue Shield at that point, but I can see why that might have happened. Anyway, I still have the direct phone number for claims stored, so no wait time – and it is fixed now. I’ll pay -0- & Blue Shield will pay Quest whatever they have agreed to pay under the circumstances.
And to @Cardinal Fang - yes, I do think that the insurance companies probably do have things set up to systematically to make these sort of money-saving (to them) errors-- that is, I think their computer data entry systems probably have default settings that assume that all services are NOT preventive – so my guess is that the 2nd submission from Quest was automatically rejected by the system computer without a human being ever looking at the difference in diagnosis info, and without the computer flagging that as significant. And yes, I probably would have not bothered to call and instead paid the bill if I didn’t have a heightened awareness right now…(Actually, I wouldn’t have remembered to call today during business hours, except that I got an email from PAMF with an update on the Blue Shield coverage situation – but the news from PAMF is no-news, except that they say they want to come to an agreement and are blaming the problem entirely on Blue Shield).
Calmom: Any chance you could publish that email? I haven’t received one, but then again, we’ve been avoiding PAMF.
I’ll PM you – it’s not that I’m trying to hide anything, it’ s just that it’s not particularly informative & I don’t want to clutter up the board with a private company’s bulk email.
Here’s an article with some more background on the Blue Shield/Sutter issues: http://blogs.kqed.org/stateofhealth/2015/01/16/blue-shield-sutter-impasse-about-more-than-money/
The article confirms that in most cases, people insured via the exchange need to make any changes by Feb. 15th. There are some exceptions - Covered California summarizes qualifying life events here:
http://www.coveredca.com/individuals-and-families/getting-covered/special-enrollment/qualifying-life-events/
It also looks like I could keep PAMF/Sutter if I buy a HealthNet PPO off exchange – on-exchange they are offering only the EPO. But I think that’s something I definitely need to verify – it wouldn’t make much sense to jump to HealthNet only to find that a similar change gets pushed through a few months down the line.
Calmom: I’ve looked at the off exchange HealthNet PPO and from my rather limited digging it seems that the PAMF/Sutter folks are within that network.
Is HealthNet a private insurance company whose policy is not sold on exchange?
By any chance, is Anthem BlueCross PPO on the exchange?
I know I could go to PAMF in the south bay area as well as Stanford med center if my insurance is Anthem BC PPO.
My family mostly go to a PAMF affiliated clinics but I heard if you are an in-patient, you are sent to a hospital out of PAMF. It is so confusing. The PAMF clinics at 701(?) E El Camino, Mountain View (just south/west of I-85 and El Camino) is as large as a hospital and has many specialty doctors. Its walk-in urgent care center is not an emergency care center.
I also do not know the difference between PAMF and Sutter. But it seems there is a hospital called Sutter (Los Gatos on the very south side of the bay area)? Many doctors seem to have a clinics in Los Gatos.
I just look up Health Net. The info is slight old (end of 2013) but it seems Health Net is on CA’s exchange. (Am I wrong here?)
“With few states having unveiled detailed plans for their state-run insurance exchange, all eyes were focused on California, which offers quite the blend of individual and commercial customers, as well as a number of soon-to-be Medicaid participants under the PPACA’s Medicaid expansion. Yesterday, California unveiled the 13 contract winners who will be participating in its insurance exchange in the coming months. There were some very familiar on the list, including Kaiser Permanente, Blue Shield of California, Anthem Blue Cross – which is run by WellPoint (NYSE: ANTM ) , the nation’s second-largest health insurer – and Health Net (NYSE: HNT ) , which collectively make up a big portion of California’s individual insurance market.”
“However, notably missing from the list were UnitedHealth Group (NYSE: UNH ) , CIGNA (NYSE: CI ) , and Aetna (NYSE: AET ) , which all kindly bowed out of being included into California’s health insurance exchange.”
So those who are NOT on the CA exchange are UnitedHealth Group, CIGNA and Aetna. But it seems the health net is on exchange.
I wonder whether Anthem BC PPO is on exchange in CA.
I think it varies from area to area not state to state. In my area there are 4 companies on the exchange offering something but I don’t know the details and it is not everything it is something and it changes a lot.
It varies from zip code to zip code. Certain companies (BC/BS/Healtnet/Kaiser) offer policies in certain zip code. These companies offer different types of plans based on the zip code. So, BS may offer a PPO in one zip and an EPO, HMO or nothing at all in the neighboring zip.
Companies offer on and off exchange plans. In my area Healthnet offers an off exchange PPO plan, but an EPO on the exchange. Off exchange plans are will not receive subsidies.
It changes from year to year. Last year, HN offered an on exchange PPO. This year no company is offering an on exchange PPO. Last year, BS offered an on exchange EPO and an off exchange PPO. This year the ONLY available PPO plan in my zip code is the off exchange HN plan.
Again, area dependent…but Anthem/BC offers a a PATHWAYS PPO…which almost no one seems to accept.
That's my situation -- HealthNet offers the PPO off exchange, only an EPO on exchange. Sutter doctors appear to be included within the PPO, not EPO. Full cost premium not significantly higher - about +$50/month- but the complicating factor is that my income is borderline at the 400% mark for subsidies. So I am paying full cost for the premium rather than opting for a subsidy I might have to pay back in a year -- but at the same time not sure I want to give up the potential of that tax credit, which is probably worth about $5000 if my adjusted income falls below the cutoff.
@mcat2, PAMF is a subdivision of Sutter, the parent company. PAMF has geographical coverages, from Palo Alto to Santa Cruz. Any Sutter subdivision outside this area is called something else, not PAMF.
PAMF is not an HMO like Kaiser is. Your insurance is with Anthem so if PAMF doctors send you to a hospital, make sure that it is covered by Anthem. I believe El Camino Hospital is a PAMF affiliated hospital.
You can also go to doctors (non PAMF doctors) that accept Anthem PPO insurance.
If one has a business with income which varies widely from year to year it is a game of blind mans bluff when trying to decide whether or not to go the subsidy route. An end of the year business action brought us into FULL subsidy range for 2014…but…we didn’t know that in January. So, for that and a host of other reasons, we stayed with our grandmothered BS group PPO.
So, if subsidies must be paid back retroactively, why in goodness name are the not also payable retroactively…hmmm…something a logical person would have put into the law…