Column 68: Reader questions and Medicare Rx website up to date!

Column 68: Reader questions and Medicare Rx website up to date!

 A reader writes: I like reading your articles in the R/S regarding the ACA. I've had an Anthem Blue Cross "silver" plan since last spring.  So what!  I haven't figured out how to enter the system.  I wish you might do a series of articles describing how one accesses a primary care physician under the ACA.  ACA access 101, if you will,

Per your request I will address your specific questions as follows:

1.            How do I use Anthem's physician list to find a "primary care" doctor?

I am assuming that you are insured in one of the northern counties that offer only PPO plans.   Preferred Provider Plans (PPO) means simply that you received the highest level of benefits or lowest share of cost out of your pocket if you use a preferred provider. Anthem, like most health plans has multiple ways for you to find out who is a Preferred provider.  You may call the customer service number on your card and they can assist you.  Be advised, this may require  wait time on the phone.

 

Another option is to use their "find a provider" tool on the website.  Just be very careful to choose the right network for your plan.  If you have an individual plan (not employer sponsored and not a Medicare Plan) you are in the Pathway PPO network.  This is the same regardless if you are on the Exchange (through Covered CA) or off the Exchange.

 

It is always a good idea to confirm with your provider before you access service if they are member of the Pathway PPO plan.  Since providers change status and the website may not be updated, this gives you additional assurance.

 

It is important to be aware that you may also contact customer service for an out of network referral if there is not a Preferred provider within your geographic area.  Call the 800 number on your card to begin the process before you receive services such as surgery.

 

It is quite frustrating that it is so difficult to obtain timely and accurate provider network information.  We had hoped this would be resolved in time for 2015 open enrollment.

2.            Can I refer myself to a specialist?  

On a PPO plan you may self-refer to a specialist.  If the provider is in the network you will receive the highest level of benefits.  But be aware that due to the high patient volume, some specialists may request that you have  a referral from a primary care provider to effectively pre-screen your medical situation.

3.            Is chiropractic covered?

Chiropractic benefits are not covered on the Anthem Individual plans.   You may look at the Evidence of Coverage (EOC) document or call the customer service number to verify.

4.         Are there any resources such as County, State or agents, such as yourself, people might consult for assistance regarding the ACA?

Certified enrollment counselor, Certified Insurance Agents and Health and Human Services departments can all provide assistance.  The web page www.coveredca.com has a button that says "Find Help Near You" where you can locate these resources. Most agents will only have time to help their clients as this is a rather busy time for us.  You may also call 800-300-1506 and read "War and Peace" while you are on hold...only kidding.

A reminder about Medicare Part D Rx open enrollment.  It starts 10/15/2014, but the website has the 2015 information up as of 10/1.  You may look at the site and research all the plans for 2015.  Go to www.medicare.gov and input your medications.  You can find a comparison of your total cost, including deductibles, premium and copays based on the medications you are taking today.  This is the best way that I know to evaluate the plans. 

It is a very valuable website and to date has been quite accurate. Just be sure that you are looking at 2015 reports, not 2014!

 

Note: All information in this column is provided" to the best of my knowledge" subject to final regulation by the respective agencies.