An update regarding Individual and Family plan [IFP] Reimbursement rates.

Question: When I contact a doctor to see if they take our insurance and tell them we have Blue Shield PPO, they say yes. Once I give them my subscriber number they say, “Oh, we don’t take Covered California plans.” Since my understanding is that all plans on exchange mirror those off exchange, I have asked the insurance company why certain doctors refuse. They said they can’t force doctors to take the plan. But, if the exchange plan pays exactly the same as the off exchange one, why would there be so many refusals (and trust me, there are a lot!). It has begun to feel like a plan purchased on exchange (without subsidy at this point) is like a welfare plan that no one wants to touch. Any ideas? Since we cannot switch to another plan at this point (no special circumstance) it has become quite irritating to be shoved off like we have the plague! Thanks!2015-ACA update

Answer: Unfortunately, the joke in the health Individual & Family [IFP] insurance marketplace these days is:  “Now we all (should) have insurance, but very few doctors who will take it.”  [Unfortunately, with every joke there’s a bit of truth  So “getting to keep your doctor,” wasn’t quite as realistic as it sounded” when our government officials mentioned this to Americans.]

The reality is many people on IFP plans have not been able to keep, or choose, the doctors they want to see.  When your doctor says they take Blue Shield PPO, that means they are included in the Blue Shield PPO networks for employer-based health plans, for the most part. Given the mandated restructuring of plans by the ACA, IFP plan reimbursement rates to doctors were reduced.

Thus, for example:  Covered California fosters competition between authorized carriers to yield the lowest premium rates possible in the current IFP marketplace. In order to compete, the carriers lean on their providers (doctors and hospitals) to accept ever lower reimbursement rates. Many providers refuse to participate in Covered California carrier networks resulting in “narrow networks” with fewer provider choices. Because 90% of patients are covered either by employer-based health plans or Medicare, doctors can opt of out Covered California with minimal downside to their practice.  Bottom line, Employer plans currently reimburse at higher rates.


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