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California health insurance  -  Health Reform Questions  -  doctor network differences

Are Doctor Networks Different Between Carriers?
Real Answers for Real Californian's
Questions on Covered California

 

In a short answer, Yes.  They have always been slightly different but provider (doctor or hospital) networks has been less of a concern over the past 10 years since the networks were so large and for the most part, pretty similar between the major carriers.  That may not be the case going forward after Jan 1st.   Doctor and hospital selection will play a much more important role in choosing a health plan than before if your choice in provider is important.  Let's take a look at what to expect.

The Shrinking Provider networks

We wrote an article in 2012 on how the doctor and hospital networks were going to bear the brunt of cost containment going forward.  That looks to be coming to fruition with the official rollout.  We expect the major carrier PPO networks to shrink by roughly 1/3 and the HMO networks to shrink even more.  There may even be exclusive hospital contracts between carrier and certain hospitals (and/or hospital chains) which is huge departure from prior workings of the health insurance market.  So how should a shopper handle this when comparing plans?

Know your Providers Up Front

Make a list of the doctors and hospitals that are must-have for you or your family.  The hospital is especially important since it represents the significant health bills.  Usually, in a true emergency, the carriers will not hold you to a network but you have to be really conservative with this assumption.  It's best to look at the local and specialty hospitals that you want to make sure to have access to as well as doctors that are important to you. 

How to Use This Information When Shopping for A  Health Plan

If you qualify for a health subsidy, you will enroll in an Exchange plan (which you can quote through our Exchange Plan Quote Page).  Part of this system will allow you to enter the names of providers that are important to you and show plans with their inclusion visible.  We can also guide you through the process of enrolling in the Exchange since the system can be tricky to navigate.  You just need to designate us "Goodacre Insurance Services - Dennis Jarvis" as agent in the "Find Help Near You" when submitting the application.  We will email you simple instructions on how to navigate the online system.  This will save you lots of time and our services are free.

If you do not qualify for a subsidy, a non-Exchange health plan will  make more sense since the enrollment process is easier and the plans/rates are identical.  There may be even be additional plan options off the Exchange.  In our Health Plan Quote page, you'll find provider directories next to each plan in the results.  Our recommendation is to find your ideal plan in terms of rates and benefits and then check the provider listing to see if your doctors/hospital are in the network.  Rates will probably be the primary driver of your decision if you don't qualify for a subsidy since the rates are much higher. 

Either way, please feel free to contact us with any questions regarding plan selection and provider networks.  We are happy to help you in the process at no cost to you.    

 

Please submit your California health reform question and we will reply both to you and add it to the GURU page (anonymously).


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MAGI (Modified Adjusted Gross Income)
For most taxpayers, MAGI is the same as Adjusted Gross Income (AGI) which can be found on Line 4 on a Form 1040EZ, Line 21 on a Form 1040A, or Line 37 on a Form 1040.

Taxpayers who receive non-taxable Social Security benefits, earn income living abroad, or earn non-exempt interest should add back that income to AGI to calculate MAGI.



Federal Poverty Level Grid
(estimate current  year household MAGI)

Family
Members
FPL 138% 150% 200% 250% 300% 400%
1 $11,490 $15,856 $17,235 $22,980 $28,725 $34,470 $45,960
2 15,510  21,404   23,265   31,020   38,775    46,530     62,040
3 19,530  26,951   29,295   39,060   48,825    58,590     78,120
4 23,550  32,499   35,325   47,100   58,875    70,650     94,200
5 27,570  38,047   41,355   55,140   68,925    82,710   110,280
6 31,590  43,594   47,385   63,180   78,975    94,770   126,360
7 35,610  49,142   53,415   71,220   89,025  106,830   142,440
8 39,630  54,689   59,445   79,260   99,075  118,890   158,520

0- 138% = Medi-Cal
138% - 150%: premium capped at 2-4% of gross; Tier 1 Benefits
150% - 200%: premium capped at 4-6% of gross; Tier 2 Benefits
200%-250%: premium capped at 6-8% of gross; Tier 3 Benefits
250%-400%: premium capped at 8-9.5% of gross; no cost sharing

>400%:  no subsidy or cost sharing

For 138%-250% range, apply for Silver in Exchange
For 250%-400% range, apply any Metallic plan in Exchange
For >400% range, apply any Metallic plan off Exchange


Penalty for Not Purchasing 2014 Insurance
$95 per family member or 1% of income, whichever is higher

 


 

 

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