Column 78 Covered Shasta Covers Shasta Population

Covered Shasta Covers Shasta Population



I am most grateful for the opportunity to be included in the Covered Shasta group.  This groups expands my knowledge across the lines of the safety net programs, like MediCal and how they serve their populations.  They have a great website:


The most recent meeting provided further insight into how the MediCal expansion is doing.  Partnership Health Plan, has grown to over 57,000 members.  This is up from 44,248 in January 214.  MediCal has doubled its case size from 12,000 to 25,000 in our area.  A case size could be one or more actual participants.  Partnership Health Plan reported that their membership is up from 44,248 in January 2014 to over 57,000 members.   So if the goal of the ACA is to expand coverage, then it is being met in this segment of the population.


Kelley Sewell, Northern Region Director of Member Services and Provider Relations reported a rather unique experience.  They received multiple calls from physicians who were questioning recent payouts.  What made it unique was the fact that the physician offices were pleasantly surprised with the amount of the quality care bonus.  "They called to ask if the amount was right, because they thought it might be too high".


Theresa Bible, a Certified Enrollment Counselor was formerly with Dr. George Domb's office.  In her new role it has been a challenge to work with the network inadequacy in the area.  "I don't like enrolling people in plans, when they feel there aren't any doctors to take care of them", she said.  She struggles with the fact that Dr. Domb, (ENT) had good experience with reimbursement rates from the new Pathway network, yet so many physician offices are refusing to take Covered CA patients. 


My own experience has been similar, at least with primary care.  Dr. Jack Kimple of Redding Family Medical Group told me that the Anthem reimbursement rates were not a problem, yet others have told me they simply cannot afford to take these patients.  


Another issue facing specialists, particularly those involved with procedures, is the extended grace period for Covered CA insureds.  These insureds have a 90 day grace period, so the doctor can pre-certify a procedure, only to find that the insured did not pay the premium and were no longer insured when the procedure is complete.  If they re-certify on the day of the procedure and find out the patient is cancelled, then they are left with a gaping hole in the schedule.  I have opposed this 90 day grace period from the outset and this is a perfect example of why!


Preferred Provider (PPO) networks have become more complicated and frustrating for clients.  Anthem has 3 primary networks: Prudent Buyer, Select and Pathway.  Blue Shield has their primary network and an EPO (Exclusive Provider Organization) network.  Assurant rents the Aetna Signature network for the individual product in our area. When you research the provider lists on line they are often inaccurate.


Further, many of the provider offices are still not clear on their own network participation. Often the receptionist will say "We don't take Covered CA", not realizing that their contract is active with Anthem Pathway PPO.  So consumers are faced with the challenge of accessing care in the network and verifying provider status.


Peter Lee, Executive Director visited Redding on his recent photo op bus tour, but did not even bother to address this issue.  I would love to see a letter writing campaign from our area.  Letters could be directed to Mr. Lee asking for a reliable source to locate provider lists for the plans as well as a review of the network adequacy for our area. The physical address is: 1600 9th St Sacramento, CA 95814, should you care to write. 


My advice to any politician looking for a path to the hearts of many constituents: Take on this issue with enthusiasm!


Covered CA update


A tip for entering income information on the Covered CA website.  Do not put a beginning and end date unless the income had a specific date.  You should leave those fields blank to report steady monthly income.


Surprise!  CoveredCA extended the deadline for the first round of open enrollment for "service partners" until midnight tonight (Sunday 12/21/2014).  This will extend the processing time for those that want insurance effective 1/1/2015.  Otherwise, open enrollment continues until 2/15/15, but insurance effective dates are dependent on enrollment dates.  Kudos to those agents working today. I am taking the day off!