[quote=citydweller]BG, thanks for pointing out the arrows, I had thought there were only 4 choices in each metal group, but you’re right, it looks like there are about 9 choices in each group. Now I have to do some more research 🙂
What is the difference between an EPO and PPO?[/quote]
citydweller, I posted this link explaining what an EPO is earlier in this thread:
I’m reading it to be that EPO’s “Exclusive Provider Networks” tend to be small, localized networks around where the plan holder lives. Unless the plan’s documentation states otherwise, they don’t offer any coverage outside of that network.
Sharp individual plans (their HMOs offered on CoveredCA) feature the bulk of providers to choose from as being their own employees except for 225 (private practice) Sharp Community Medical Group providers to choose from at the Gold and Platinum level:
The rest of Sharp’s providers work directly for them (Sharp is one of the biggest employers in SD County with ~30K employees). Their POS Plan (they stop short of calling it a PPO because it more resembles an EPO … at least locally) is only offered to large groups and NOT on CoveredCA. Their Performance Plan is the ONLY one of their plans which is a “POS Plan.” Their other three plans (featured on CoveredCA at the Silver, Gold and Platinum levels) are HMOs.
As I stated before here, my children were covered by Sharp HMOs and could not get coverage out-of-county with Sharp. As SK noted earlier here, all carriers’ plans will now have to, by law, cover emergency services to the extent they state they will on the plan documents.
This still doesn’t completely fix the problem of a SD-based college student under age 26 who is living out-of-county or out-of-state and who might want to seek routine or specific care in the location of their campus.
I stated earlier that all of my own five (very experienced) local physicians (ages 65-73) appeared to accept “Health Net.” Upon further research, I determined that only one of them will accept a HealthNet Plan offered on CoveredCA. This is because none of the Health Net Plans offered on CoveredCA are PPOs. They are all HMOs. I requested a provider directory for my region (SD County) last night from HealthNet, which was in my e-mail this morning. As NSR stated earlier in this thread, it is very small. As does Sharp’s local provider network, several medical specialties in HealthNet’s network have only 1-2 local providers to choose from (in SD County).
[quote=no_such_reality]There is one PPO available, Blue Shield in the San Diego region.
It covers 50% for out of network providers.
The Anthem EPO, also covers 50% for any out of network providers for emergency purposes.
In LA, the Anthem EPO has 8839 doctors in network. HealthNet, a much smaller competitor has 2316.
In San Diego, HealthNet isn’t a viable option, IMHO, they only have 216 primary care doctors in network.[/quote]
Thus, the Blue Shield of CA PPO is the only plan on CoveredCA which all my current providers will accept. From my research, it appears to be the only “true PPO” provided on the CoveredCA exchange for the SD Region (19) and is only offered at the Platinum level.
My current Aetna HDHP (beginning at just $93 per month in 2004, when I signed up) has gone up 385% since then. Since my carrier is leaving the state, I have no choice but to sign up with coveredca or a carrier off the exchange (sans any tax credit I am eligible for on the exchange). However, it has always had/has ALL the best doctors under its Aexcel designation available to me at all times, without referral.
That is truly a sad commentary because I am (reluctantly) giving up an “affordable” HDHP with a HUGE nationwide provider network which included thousands of the very best doctors in the country who are in private practice. Although much more robust, my *new* plan’s rate will now (much) more than double what I am currently paying, that is, if I want to retain my longtime providers. But I can’t afford its monthly premiums without the tax credit :=0 because the only option for me on CoveredCA to keep those providers is to sign up for one of the most expensive plans on the exchange, the Blue Shield (Platinum) PPO.
I was perfectly happy with my 5000/3000 plan HDHP with copays of 40/50 and “free” preventative care as long as I could see a provider of my choice, at any time.
I wonder if the PTB who cobbled together the ACA really intended to double ++ the relatively-healthy insured’s HDHP individual premium by insidiously forcing the best carriers out of the biggest state’s market in the US and then disguising that exchange’s 100%++ “rate hike” with a “tax credit” of varying amounts (only for those who qualify for one).
The way I see it, since there are no longer any plans available ANYWHERE which are comparable to my “grandfathered plan,” the above is essentially what happened here in CA.
Study everything carefully, citydweller, to make SURE if you sign up on CoveredCA that you won’t be severely “watering down” your current coverage with a plan which will end up being unpalatable if something major should happen to you. Keep in mind that those plans on the exchange (especially the ones which end up being “free” or “nearly free” to the masses after tax credits and premium assistance) are subject to rate hikes for 2015 and beyond.
If you become really sick or gravely injured, CHOICE of providers is key and can mean the difference between life and death, IMO.
There are no longer any plans available which directly compare to “grandfathered” plans, citydweller. I just feel that those few individuals lucky enough to keep their “grandfathered” plans will not experience rate hikes to the degree of the plans on the exchange because hardly anyone is going to sign up for them (due to lack of tax credits being available). Also, the “sickest” people who will sign up on state exchanges are currently uninsured for a reason. That reason is that they were denied coverage in the past or were offered coverage but couldn’t afford the premium so declined it.
These aren’t the same subset of people who will now sign up for coverage OFF the exchanges (where your “grandfathered plan” comes from), IMO, as it is likely that the vast majority qualify for a tax credit (however small) to reduce their premium on an exchange plan. So, since the “grandfathered plans” (with all medically-underwritten insureds) are groups with far less risk, they likely won’t experience as high of or as many rate hikes from here on out, even if their carriers also offer plans on state exchanges.
