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San Francisco Marin Medical Society Blog

Covered California: What San Francisco Physicians Should Know for 2016

In 2015, Covered California, California’s health benefit exchange, enrolled approximately 1.3 million individuals in qualified health plans. With Covered California estimating to add an additional 300,000 enrollees during the 2016 open enrollment period (running November 1, 2015, through January 31, 2016), it is critical that physician practices understand their participation status, which products are being offered, and what changes to expect in 2016. SFMS has compiled the following guidelines to assist physician members with Covered California in 2016.

Changes to the Covered California Plan Offerings for 2016

Anthem Blue Cross and Blue Shield of California, both of which offered an EPO in certain geographic areas previously, will no longer be offering an individual/exchange EPO product in 2016. Instead, both plans will be offering PPO plans.

Blue Shield of California sent notice of the change to its Exclusive EPO provider network on October 15, 2015. The notice states there will be no change to the provider agreements or reimbursement rates. While the product type is changing, the provider network will not change. Patients who select the PPO product will only have access to the narrowed individual/exchange network, rather than the broader provider network. Enrollees who chose to transition the Blue Shield individual/exchange PPO product will receive new ID cards reflecting their new PPO plan.

Anthem Blue Cross will no longer be offering its EPO network in California for individual/exchange enrollees. There will be no change to the provider network or reimbursement rates.

Re-verify Participation Status and Review Provider Network Tied to Various Products

With the change in some product types and the addition of two new health plans offering coverage for 2016, SFMS encourages practices to re-verify their participation status. Practices also should re-verify the participation status of the physicians and other providers (e.g., physicians, facilities, etc.) to whom they may refer patients using the plan’s online provider directory search.

When searching the provider directories, ensure the correct product type has been selected. You will need to check your participation status for each product type offered in your area (e.g., PPO, HMO, EPO, HSP), but you do not need to search every metal tier. For almost all product types, the “Bronze 60” metal tier can be selected as the default. Many plans are utilizing narrowed networks for the exchange, so the search results in a provider directory for a standard commercial PPO plan will likely differ from those of an exchange provider directory.

Practices can contact the plans directly with questions or concerns regarding physician participation status.

Anthem Blue Cross and click “Find a Doctor”  Under “Select a plan/network,” select the category of “Medical Networks on Exchange” and select the appropriate product type (e.g., HMO, PPO). For a complete list of Anthem exchange/mirror product names, click here Network Relations (855) 238-0095 or 
Blue Shield of California and hover mouse over “Explore” in the blue ribbon at the top, then click on “Find a Provider.”  Click “Explore” in the blue ribbon towards the top of the page. Under “Step 1” click the green “Select a Plan” button. Under “medical plan and network,” click the drop down arrow and select 2016 Individual and Families PPO Plans (including Covered California)” then select the “Sub Plan” based on metal tier. Practices can select the “Bronze 60” product as the default. Then click the green “set plan” button. Next, under “search by doctor name” enter the physician’s last, then first name, select a specialty, and enter the practice zip code under “located near.” Click the blue “find now” button.  Provider Services (800) 258-3091 
Chinese Community Health Plan Click here for CCHP Provider Directory. Network is primarily using Chinese Community Healthcare Association (IPA).  Via the Chinese Community Healthcare Association (415) 216-0088 x2806 
Health Net and click on “Provider Search” toward the bottom. 

Click “Provider Search-Find a doctor.” After selecting a plan year and a location type, under “Filter by Plan/Network” Under “Covered California” select one of the following:

• EPO – PureCareOne Small Business (this is the SHOP product)

• HSP – PureCare Individual & Family Plans

• PPO – Small Business (this is the SHOP product)

In the search box under the green ribbon towards the top right of the page, enter the physician’s name and select “in Doctors.”

Provider Services (800) 641-7761 or 
Kaiser Permanente  Click here to select your region and click “Go”. All providers are included in all product types  

2016 Covered California Qualifying Health Plan Naming Convention

[carrier name] + [metal tier name] + [actuarial value (AV)] + [product type (e.g., EPO, HMO, PPO)]

For example, Anthem Bronze 60 EPO is the Anthem EPO plan offered under Covered California’s bronze tier.

Re-verify Patient Eligibility

SFMS is urging all physician practices to verify patients’ eligibility and benefits effective January 1, 2016. The beginning of a new year means exchange/mirror product calendar year deductibles and any visit frequency limitations start over.

Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan). With open enrollment, there may also be changes to patients’ benefit plans, or patients may even be insured through a different plan. This reinforces the importance of verifying eligibility each time the patient is seen. Additionally, verifying eligibility will alert the practice as to whether the patient is delinquent on paying their premium and/or is in the federal three-month grace period.

Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice, as your ability to collect decreases significantly after the patient leaves the office.

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