Confusion with the Affordable Care Act

With the implementation of the Affordable Care Act, there has been some widespread confusion among San Diegans about what the new plans entail and which providers people can see.  Similar to many other locations across the nation, provider access is more limited, especially for individual policies. Companies like Health Net have decreased the number of individual providers compared with their employer benefit plans due to costs and other other limitations. In San Diego, Health Net has only 204 doctors in their provider network for the Covered California individual health plans.

Furthermore, recent news revealed that only 30-35% of San Diego doctors will be participating in the Covered California network. Many doctors opted not to be involved with Covered California because of the low reimbursement rates. Reimbursement rates for some doctors on Covered California can be almost as low as Medicare (56%). That is almost half of the typical reimbursement rate which is 95-120% of Medicare rates. Why would doctors want to participate if they aren’t getting paid as well?

This shift in the limited number of providers has caused many insurance agents to change the way they provide benefit plans. The priority question is no longer which plan do you want but rather who is your doctor and do you want to keep them. If the doctor is the most important factor to the client, then agents will try to find plans that have that physician within their provider network despite differences in cost and benefits.

In addition, many people in San Diego are perplexed by the new product offerings and partnerships created amongst carriers and hospitals.

“Blue Cross in San Diego has contracted with Sharp and UC-San Diego, so members signing on with one of the Blue Cross plans being sold through Covered California will face new limits on the physicians and hospitals they can use. “So if you’re a Scripps person, you’re not going to be having Blue Cross. Blue Shield only takes Scripps, Palomar and Pomerado,” Gussin said.”

Many doctors foresee issues with patients calling their office to set up an appointment claiming they have Blue Cross insurance. When the doctors ask which Blue Cross plan they have and the patient is unsure, the doctor may have to notify them that they aren’t covered in their network anymore because they chose a plan on the exchange. This is frustrating for both the patient and the provider.

Are you confused about your plans and need help understanding what your benefits entail, which doctors are covered, and which hospitals are in your network? If so, give us a call and we’d be happy to review your plan and assist you.

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