I am happy to share some good news for Blue Shield of CA (BSCA) subscribers, as well as the rest of the individual market! BSCA has contracted with the following medical centers and medical groups of the University of California system for three years: UC Davis, UCLA, UC Irvine, UC San Diego and UC San Francisco.
North state brokers have had concerns about enrolling members in the BSCA individual EPO plans because of the network. While Stanford and the Sutter systems have been in the network, the absence of the UC system has been an issue.
Much of our physician referral activity for advanced care in the north state has been to the UC system. Since the Blue Shield individual product is an EPO (Exclusive Provider Organization) this network gap could create some big problems.
In an EPO the participant must use a network provider or no benefits are paid. The Anthem products is a PPO (Preferred Provider Organization) which means that it provides benefits should the participant go to a non-network provider. It’s important to note that out of network provider services are subject to a separate additional deductible and coinsurance. This results in substantial additional coverage for those providers, so it’s not a huge benefit, but it is still different.
Network adequacy continues to be a big problem for those enrolled in individual plans in northern California. A search of physicians who accept the plans reveals that there are still about 1/3 or less of the other PPO network lists.
Most people are not aware that there is no difference in network for individual plans issued whether they are purchased on the Exchange (through Covered California) or they purchase the individual product directly form the carrier. Employer sponsored Group Insurance plans do not have the same network adequacy issue because the Group PPO networks are more comprehensive.
However, beware that Anthem uses multiple networks for the small group market. The “Select” network is not the same as the full Anthem Blue Cross of CA PPO network.
If your group is looking at changing plans, be sure to get a look at the current network list. Of course, the lists are always subject to change. The insurance companies have been chastised about the fact that their websites are not always accurate or up to date.
It is my opinion that Provider departments of the insurance companies would be well served to make this a high priority. I am not a computer programmer, but it seems to me that there could be closer to “real time” updates of the system.
I understand that credentialing can be an issue for insurers. Credentialing is the process by which the insurance company verifies that the provider meets the contracting criteria. In addition to agreeing to the insurer’s pay scale, the provider must agree to other provisions such a utilization protocols and maintaining certain standards of practice. Quality issues including absence of sanctions from regulators and maintaining adequate malpractice insurance are other factors.
As an aside, I have heard from numerous providers that the reason they do not participate in the in Medicare Advantage plans for seniors due to the “hassle factor”. They don’t find the reimbursement rates to be that much different, but they do not want to jump through the burdensome hoops required by the HMO type plans that represent Medicare Advantage. They much prefer the Medicare Supplement products that coordinate with Medicare and pay deductibles and coinsurance due from the insured. So, it’s not “all about the money!”
In fact, most Medicare Supplement plans are not even a PPO plan. They pay standard benefits that are tied to Medicare’s reimbursement. Medicare has already done all the price negotiation so that is not an issue.
Network adequacy will continue to be an issue as we approach the 2016 individual open enrollment season. But at least we in the north state can have access to the UC system in both of the major players’ plans.
