Doctors in Southern California not accepting " Covered California" plans, even PPO's

[Salty]

Doctors in Southern California not accepting " Covered California" plans, even PPO's

My spouse and I currently are retired ( 63 and 54) and are considering a relo to Orange County Ca, for both family and weather reasons. We currently live in Massachusetts where we have purchased our health insurance on the Obamacare website for Ma ( Massachusetts Health Connector) for the past two years. While the " Silver " level coverage is expensive, has high deductibles etc, it is virtually accepted everywhere including the Boston top doctors and hospitals. While it is technically an HMO , my primary care Dr is excellent and getting referrals anywhere I need to is not an issue. Overall it has been a very positive experience except

In considering a California relo, I have noticed ( and read on various blogs) that people are having trouble getting doctors to accept their health insurance purchased on the Covered California website, even a PPO! My spouse had an issue a few years ago that required us to seek emergency care with a retina specialist while visiting in California a year ago. I noticed a sign in the Doctor office that stated " We no longer accept plans purchased through Covered California" ( Ca Obamacare website). In doing my research I called that office this week, and they confirmed they do not accept the plans, even the PPO plans. In doing further research on various cardiologists, primary care doctors etc, I am discovering when they DO accept Obamacare plans, it may only be ONE or two of the 5-6 plans offered-

Has anyone in California had issues with their Doctors accepting Obamacare ( Covered Ca) plans??
I want to thoroughly research this issue before I put our " easy" access to insurance in Massachusetts at risk!

Any insight is appreciated.





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[LOL!]

Suppose a doctor & their office only takes cash. Does that mean that your plan will pay you back some "out-of-plan" amount after you pay the bill out of your pocket?

 

[Accidental Retiree]

When we lived in NorCal and started CoveredCA in 2014 with Anthem, neither my doctor nor my husband's would take our new insurance. (Our previous insurer, Aetna, left the individual market in CA at the end of 2013.)

When we kept the same Anthem plan but relocated to SoCal, I made an appointment with a dermatologist listed on the Anthem site as accepting my plan. I also called the office to make sure I'd be covered; however, when I arrived at said doctor's office and handed over my insurance card, I was told they didn't accept CoveredCA.

For 2015 we switched to Kaiser and have never run into any problems since.




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[LitGal]

Tread Very Carefully and Do Lots of Homework

I have not lived in CA since 1996, nor do I have experience with ACA. However, DH and lived there for 25 years. During the last 12 years his health declined because of a progressive, genetically inherited lung disease. We had excellent insurance, and he worked in the pharmaceutical industry so he knew all his docs (who provided for him the best care available). He always was referred to the "doctors' doctors."

Bottom line: during those 12 years, we watched health care become increasingly rationed. The doctors and hospitals did their best, but the health insurance companies found more and more ways to implement "managed care" algorithms for payment. In short, a patient gets just so much care. Then that's it.

We thought our care there had been fine, until we moved to Ohio. What an eye opener. "Managed care" had not yet made inroads here, and doctors had little to no experience in being told "no" by an insurance co. We were accustomed to asking-- before any treatment-- would the ins. co pay for it? With the frequent "no's" in CA, we took the habit with us to OH. Doctors in OH would look at us quizzically, "Of course, they will pay for it. I am going to write it." And the ins. co. did pay for 20 years of aggressive treatment, right up until DH passed away in Jan. '15. After his passing, one of our favorite docs approached me and said, "You know, don't you, that your DH was a patient with 9 lives....."

But I attribute his prolonged life to the quality of health care he received in OH, even in this era of ACA. Before his passing, DH said to me once, "You know, I don't think I would have lasted this long in CA." And I agreed with him. During our last 12 years in CA, 911 had to take him to the ER at least 5-6 times with life-threatening emergencies. In OH, that happened twice in 20 years.

Now, the experience of dear friends, still in CA.

None are on ACA; all have PERS, Kaiser, or an employer-based ins. Despite the quality of their care, all face rationed care. It seems that--- no matter what condition they present to the doctor--- specialists, medication checks, and (especially) an aggressive pursuit of the best treatment available are strikingly limited. Physical therapy is limited. Then you are done, whether improved or not. One friend has severe side effects from a couple medications (for which there are many alternatives, with fewer side effects); but the dr. doesn't bother to pursue it. Her mother struggles with depression and was recently hospitalized after two suicide attempts. Dr. has no recommendations.

My brother is a corporate CFO with commensurate insurance. He rarely goes to the dr. because his deductible is so high.......and he already has 3 stents in his heart. (But that's another story....)

IMO my mom is the one who gets the best care. She is 89, on Medicare and an Anthem Blue Cross supplement (cost is about $320/mo., including her Part D). She has no deductibles and no co-pays, though it can take a while for her to see a doc.

Clearly, there are infinite variables involved. Though I can't speak to any ACA policies, I thought you might find it helpful to hear some CA-Health-Care anecdotal experiences, which may convey a bit about the medical climate there.

Best of Luck!!

 

[Salty]

Thank you both so much for your thoughtful, personal replies. Litgal, I am so sorry for your loss. When I hear stories like these, they serve to validate some of the reservations I have about moving to Ca. I recently investigated insurances ( auto, homeowners, umbrella etc. In speaking with the State Farm agent, the umbrella policy would be 100% more than we pay in Ma. The agent explained everyone sues in California! In general we LOVE the weather and the beautiful coastline. To be outside everyday would be a gift. I must admit, I DO have reservations though.....the healthcare, the nature of SOME of the sue happy people and the overall congestion.

The other area we are considering is Bucks County Pa ( New Hope, Newtown , Doylestown etc) although expensive as well, it seems as if people deal in a more genuine manner like you describe in Ohio. That is appealing to us!

If anyone else has Cal Obamacare experience OR Bucks County / Pennsylvania experience that would be great to hear about as well!

Many thanks!

 

[photoguy]

I want to thoroughly research this issue before I put our " easy" access to insurance in Massachusetts at risk!

I'm not sure you'll be able to draw a reliable conclusion from anecdotes. What if the percentage of doctors taking your plan is lower in one state but on a numerical count you actually have more doctors to choose from?

However if you do manage to get quantitative data on network size, wait times,etc i would be very interested in that.





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[FUEGO]

I'd check out the networks of doctors for any health plans you might choose. When I looked at a few different ACA options available to me, they all had excellent coverage for primary care docs, a wide variety of specialists, and local hospitals (as in hundreds of docs within 5 miles, at least 2 of the 3 local hospitals in network, and a dozen or more specialists in any specialty you could name). If you want to be certain that the network info is accurate, then try calling a random sample of doc's offices and inquire as to whether they accept the coveredCA insurance plans.

My own personal experience with an exchange plan is that the network is very similar to my old employer provided coverage and possibly the exact same. We kept the same docs, same dentist, same specialists, same hospitals (including the one big hospital that still isn't in network). YMMV and we rarely need medical attention, so don't think too much about how "limited" our network might be.

 

[ivinsfan]

AS I understand it some posters with first hand knowledge are saying coverage and seeing the doctor is one thing. Getting the Calil insurance companies on board for treatment plans is another. You don't know how this affect you until you have to worry about it for yourself or a loved one.

 

[AllDone]

As a recently retired doctor who practiced in Orange County and who now lives in San Diego, I haven't seen a problem. I'm currently using Scripps Clinic for my own health care and the access times are excellent. Riverside and Imperial counties are chronically underserved.

 

[GoodWishes]

We live in nor-cal and have a high deductible ACA bronze PPO plan this year. DH have not used his much. Although not serious, I have several medical issues that got me seeing various doctors, having various tests and prescriptions. I met my deductible a month ago. I haven't had any problem with doctors, labs, etc accepting my ACA insurance.

 

[Scuba]

I live in So CA and none of my long-term docs take Covered CA plans. There may be good docs who take these plans, or you could always go with Kaiser, but I like having choice. Luckily DH has a "grandfathered" plan that he bought pre-Obamacare and he can add me when I RE. The other option that is becoming popular is concierge medicine. If you have the resources, this is a way to get excellent personal service and attention.


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[Bamaman]

Not only does California have high instances of litigation, the courts are completely clogged up and cases often take years to settle. In my travels there, I've noticed that even many restaurant chains cannot be found--due to litigation problems and the high cost of doing business there.

The ACA programs may not be with us in the long run, and they really just cover a very small percentage of the U.S. population. But insurance companies dealing in the ACA are hemoraging red ink. When companies fail to turn a profit and get out of the business, California's going to be the first state they're exiting.

It almost makes one think twice about retiring to the West Coast.

 

[MichaelB]

Will doctors take ACA policies? Thus has been the subject of endless rumor, speculation and commentary around the country, despite the absence of hard data. ACA policies are really Blue Cross, Aetna, United HealtCare, Humana, and others, and to say a doctor does not take an "ACA policy" really means she does not accept one policy from BCBS but does accept another from BCBS, even when she has a contract with the insurer for both plans and they are both part of the same network.

There are currently more than 1.5 million qualified health exchange policies in Califormia. Plenty of opportunity to document this claim. Yet, everybday thousands of policyholders visit to their physicians, who are then reimbursed by the insurer, with no issues. The major insurers use the same networks and network structure for their individual and group policies and make it very clear which network you get when enrolling in a specific policy.

Insurers are required by law to allow anyone to search their provider network to look for specific providers or facilities. This makes it very simple to check whether a specific provider is part of the network. A phone call is then all it takes to confirm make an appointment.

This claim, that physicians are not taking ACA policies, is codswallop.

 

[ShokWaveRider]

This claim, that physicians are not taking ACA policies, is codswallop.

+1 I agree 100%. But having not walloped a Cod lately, I would use the term "Rubbish".

Besides what is wrong with Keiser? We used them for almost 20 Years in Laguna and were MORE than happy. All Doctors and Specialists were under one roof if I remember, at least the ones I used.

Honestly, I think as Americans we have TOO much choice in everything. Choice can be a Boon or Detriment, as far as healthcare is concerned it is a detriment. If we had less choice and great affordable healthcare it would be a lot better.

 

[MichaelB]

What is much more common, not just in California but across the US, is physicians and facilities that are not part of an insurers network. Insurance companies create lower priced policies by designing networks with much smaller numbers of doctors and hospitals. The impact for a policyholder is clear - it is more difficult to find a provider nearby, and the wait time for an appointment is lengthy. To some, this might appear as if "doctors aren't taking my insurance", but in reality, the insurer designed it that way.

 

[athena53]

Insurers are required by law to allow anyone to search their provider network to look for specific providers or facilities. This makes it very simple to check whether a specific provider is part of the network. A phone call is then all it takes to confirm make an appointment.

This claim, that physicians are not taking ACA policies, is codswallop.

The third post in this discussion is the experience of someone who checked the web site of their insurer, found the doc was in the network, called to confirm, and was told when they got there that they don't take that policy. When I lioved in KS and had Coventry, my gyno accepted "my" Coventry policy but said they didn' accept the one written on the Exchange.

As MichaelB said, one of the factors that make Exchange products affordable may be a limited network or negotiated rates so low that docs don't want to take too many patients with those policies.

 

[ShokWaveRider]

I think Florida is an exception to these rules. Florida Blue has all but a monopoly here. We use a HMO version of their plans. We enjoy full coverage everywhere in Florida and emergency everywhere else. So far so good. Everyone I have contacted accepts them here where we are.

We will see if this continues in 2017. I am not sure I am a subscriber to letting companies compete across state lines. I think it would be asking for trouble. It will lead to "less" coverage as companies try to compete with them in their home states by offering inferior packages to what they do now.

 

[MichaelB]

As MichaelB said, one of the factors that make Exchange products affordable may be a limited network or negotiated rates so low that docs don't want to take too many patients with those policies.

My point was not that doctors were not taking the insurance. It was that insurers are excluding the doctors, hospitals and other providers. This is not doctor driven, it is insurer driven. The insurers have always made money by finding ways to limit patient choice, this is no different.

 

[Another Reader]

Reply #11: "I live in So CA and none of my long-term docs take Covered CA plans."

Reply #3: "When we lived in NorCal and started CoveredCA in 2014 with Anthem, neither my doctor nor my husband's would take our new insurance. (Our previous insurer, Aetna, left the individual market in CA at the end of 2013.)

When we kept the same Anthem plan but relocated to SoCal, I made an appointment with a dermatologist listed on the Anthem site as accepting my plan. I also called the office to make sure I'd be covered; however, when I arrived at said doctor's office and handed over my insurance card, I was told they didn't accept CoveredCA."

Yes, this is anecdotal evidence, but it's an accurate description of what is happening in California. Large numbers of complaints about inaccurate provider information on insurer websites have been filed with the state. That's why people are cautioned to verify participation with the provider.

We are seeing the creation of huge health networks like Sutter Health and Stanford that engage in cost cutting and streamlining. These networks take CoveredCA because they can make it work. Independent practices largely do not. There is no requirement for any medical practitioner to take ACA insurance and small practices cannot afford to take it because of the low reimbursement rates and the hassles of dealing with the insurers. Many of these practices also do not accept new Medicare patients for the same reasons.

 

[timo2]

for my reading clarification, I'm assuming that when people in this thread say 'ACA plan' they really mean 'exchange plan'. Because every plan, even employers plans, are technically ACA plans. Or are people including the 'off-exchange' plans in there use of 'ACA plans'?

 

[Sojourner]

A bit OT, sorry... but reading through this thread just makes me really despondent about the future of health care insurance and coverage in this country. What an incredibly byzantine, cryptic, confusing system we have. Just sayin'.

 

[ivinsfan]

The huge number of threads running currently just about healthcare is what I find depressing. I'm 25 months from Medicare and I can't tell you what a relief it will be to me to not have to worry about this for myself.

 

[CaliKid]

I can't speak to ACA plans but we have been covered by HMO plans for years and had excellent care. In the couple instances we wanted second opinions we have been able to get in to UCSF and Stanford without long delays. We are in Nor Cal and maybe it's different than So Cal but I am not aware of doctors refusing ACA plans up here.

As for the decision to move to the OC. Life is so good there you won't even need to worry about your medical insurance! Seriously, weather, food, outdoor activities, life is good in the OC!

 

[haha]

Besides what is wrong with Keiser?

Spelling?

 

[AllDone]

Orange County's MemorialCare page:
Covered California Health Benefits Exchange Plan | MemorialCare Health System | Orange County | Los Angeles County

San Diego County's Scripps Clinic:
https://www.scripps.org/patients-and-visitors__health-insurance-options__covered-california

San Diego County's Sharp Healthcare:
How to Choose Sharp HealthCare Through Covered California - San Diego