Some Good News for Individuals in 2016

blue shieldThere is some good news in 2016 for North State residents that purchase their insurance as individuals, rather than as part of a group. But first let’s be clear.

One of the biggest misconceptions in the public today is that there is a difference in products available to individuals and/or families if the insurance is purchased on the Exchange. In our state the Exchange is known as Covered California. I cannot say this enough: There is NO difference in networks if the plan is considered an individual (not employer sponsored group) plan.

In my opinion, the only reason to purchase insurance on the Exchange is if you are eligible for subsidy. Otherwise there is no reason to add this additional and cumbersome layer of administration to your insurance.

We are told repeatedly that a provider is not taking “Covered CA”. The key issue here is which network the provider has agreed to accept. For example, if they have agreed to accept the Anthem PATHWAY PPO network then they will be considered a PPO (Preferred Provider Organization) member whether the plan is purchased on or off the Exchange.

The good news is that for 2016 Blue Shield of CA will be offering a PPO plan, rather than the prior EPO (Exclusive Provider Organization) plan. This is important because the Anthem Pathway Network is quite skinny when it comes to specialists in the North State. We are told that the entire Blue Shield PPO network will be available with this new product, making it very attractive to members.

However, it is my understanding that the 2016 plans continue to be “in-state only”. This means that treatment is available only for emergency care when you are out of state.

So if you are diagnosed with cancer and want to go to an out of state facility for treatment, the plan will not pay the bills. This is an important provision. Grandfathered plans (issued before March 23, 2010) do not include this “in state only” provision.

We also have a new carrier in the North State individual market: United Health Care. To date, we have not analyzed the network to see if it is a viable plan. It has not had good penetration in the past, but my physician clients tell me UHC is soliciting them heavily.

From what I have seen on the rates, it really depends on age and plan type to see who is more competitive. BSCA seems to be targeting the silver plans until age 55 or 60, then they are “in the ball park” on the bronze plans.

If you want to preview the rates go to and look at shop and compare. If you are not covered on the Exchange, simply enter $250,000 as your income and you will see the unsubsidized rates.

You may also notice that Northern CA rate increases are higher than those in the south. We simply do not have the competition between providers that allows the insurance companies to negotiate rates. Our weighted average increase is 7.8% compared to 1.8% in the south. Of course individual increases will vary.

You will continue to see the “metal” plans: Platinum, Gold, Silver & Bronze. This standardization has really helped consumers when comparing plans. The latest release says that the Bronze plans will have 3 office visits covered prior to meeting the deductible.

Other new benefit provisions will be included. For example, the plans are helping insureds to estimate costs with tools like the BSCA Cost Estimator. Since there is so little transparency in health care pricing, this could be a big help.

Telehealth is becoming much more prevalent. Blue Shield states that this service “offers members who live in remote and urban areas a convenient way to see specialists throughout California, which can save time, expenses and the hassle of traveling far from home.” They collaborate with Adventist Health using local Telehealth offices throughout California to offer a specialized telemedicine cart that includes a high-definition camera, diagnostic scopes and a vital-signs monitor to send accurate images and sound readings for a timely and accurate diagnosis.”

We do not have information on where these service may be made available in Far Northern California. However, I am told that Shasta Community Health Care has one of the largest Telemed Centers in the state. (I have not yet had time to check it out in detail.)

Remember Open Enrollment runs 11/1/2015 to 1/31/-2016. Time to start thinking about your options.

Margaret R. Beck
Margaret Beck  CLU, ChFC, CEBS started her insurance practice in Redding in 1978. As an insurance broker/consultant,  she represents businesses and individuals as their advocate.  She assists in choosing proper products, compliance with complex benefit laws and claims issues once coverage is placed. All information in her column is provided to the best of her knowledge, subject to final regulation by the respective agencies. Questions to be answered in this column can be submitted to Beck's column is also published in the Redding Record Searchlight.
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