Who is confused by the Affordable Care Act and Covered California? We havent heard of anyone who knows it all, inside and out. In fact, since these programs started, it seems that lots of erroneous information is going around and no one seems to be able to make heads or tails of it. Here are some important things to know: First, know your health plan. Know what youre signing up for -- what your premiums cover, what is your deductible and shared cost, what doctors/hospitals/labs are in-network and which are out-of-network. Know what is covered for well visits (physicals) and sick visits, what the interval has to be between the well visits to have them paid for by the insurance company, what services they (the family) will pay for in addition to their premiums, etc. It is impossible for us to know every nuance of every insurance plan. There are tiers upon tiers just within one company. As a courtesy, we run your insurance the day before an appointment to make sure we dont see any red flags which would end up costing you more, but ultimately, this is something you are paying for and should know. Second, understand that Garden Pediatrics does not accept or not-accept insurance companies. We accept any patient* and we are either contracted with your insurance or not. Or another way to say it, we are either in-network or out-of-network. Some insurance plans will pay a certain percentage of your visit to a physician who is out-of-network, some will not. Whatever they will not pay is the insurance holders responsibility to pay. (*We see a limited number of patients covered by media-cal and IEHP who are lovely and we enjoy taking care of. However, we have a strict panel limit as to how many we can see. The payments are so low from the state we cannot see a large number of patients with this insurance). Third, the Affordable Care Act and Covered California programs designed exchanges to help get more people covered by health insurance. What they failed to do was improve access to health care. If a doctor signs up to be a part of these exchanges, they are often paid 30% less (or even a higher percentage). When we looked into it, the rate offered to us was less than what medi-cal pays. We simply cant afford to sign on with these programs. We would have to make the office visits shorter and have to see more patients in one day in order to pay our staff and keep the lights on. So we are unable to contract with them. The big problem is that it is difficult for you as a consumer and us a practice, to even tell if you have a standard PPO or if you have one of the Covered California exchange insurances. Tonight we were even informed of one patient whose health insurance advisor assured them that that we were in-network and we actually, are not. While we are in-network with the insurance company itself, the PPO as a whole, we are not part of the ACA exchange so even the experts are giving wrong advice. Finally, we care about your child and you and your family. We know that it is a stressful time financially for many. The cost of health insurance continues to rise while it seems the things that are actually covered continues to decline. Further, WE (doctors) continually see the amount we are paid by the insurance companies declining so we understand the pinch. Your familys health and well being is important to you and you want to make sure that the decisions you are making are the best ones for your families health and your wallet. We get that. If you have any insurance questions or concerns, please email us at info@gardenpediatrics and we will do our best to help sort out these issues with you. Additionally, we are currently preparing a lecture (possibly series) around understanding your health insurance plans and wed like to know what would be most helpful for you to learn about. Attached is an article in the San Francisco Gate in January, explaining some of the frustrations in California from a patients perspective.
Posted on: Thu, 01 May 2014 06:07:31 +0000
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