Santa Cruz Provider Networks Tighten in 2017 and Kaiser Comes to Santa Cruz

StethoscopeAccording to Santa Cruz health insurance specialist, Kathleen Brewer de Pozos, more individual subsidized ObamaCare health plans offered by Covered California in Santa Cruz County will be limiting the number of doctors you can choose. The physician networks contracting with each plan may not be finalized until October or November, possibly later. (Blue Shield, for example, did not reach agreement with one of its major providers two years ago until January, two months after the beginning of open enrollment.) Nevertheless, carrier websites continue to offer regularly updated search functions that will assist members in selecting network providers.

Only One PPO for Santa Cruz County

Blue Shield will be the only carrier offering a PPO (Preferred Provider Organization) in Santa Cruz County in 2017. PPOs have bigger networks and fewer controls on getting specialty care. PPO plans will also allow members to go out of network, but they will face higher up-front deductibles for those services and be left with paying the difference between what the PPO will pay and what the out-of-network doctor charges.

Two EPOs for Santa Cruz

Anthem and Health Net are offering EPO (Exclusive Provider Organization) plans for 2017. EPOs are more restrictive and may have smaller networks. Members do not need a referral from their primary care doctor to see a specialist. Because they have smaller networks and don’t pay for any non-emergency services outside of the network, EPO premiums are generally lower than those for PPOs.

Kaiser Comes to Santa Cruz County

The Kaiser Foundation Health Plan will offer its HMO (Health Maintenance Organization) plan to Santa Cruz County residents for the first time in 2017. Many local residents have been lobbying for Kaiser to come to the region for over 25 years. Kaiser almost always contracts with its own doctors, The Permanente Medical Group (TPMG).

HMO plans are sometimes called gate keeper plans because members must have a referral from their primary care provider (PCP) in order to consult with a specialist.

Provider Search Functions Available at Carrier Websites

Watch for physician network information in October and November. This year (2016) Physician’s Medical Group and certain solo practice doctors contracted with Health Net. Dignity Health (Dominican) contracted with Anthem, Blue Shield, and United Healthcare, as well as some other smaller groups and solo practitioners. The Palo Alto Medical Foundation (PAMF) contracted with Blue Shield.

Provider networks change, so be sure to confirm that your doctor(s) are in-network for the plan you select.

Open Enrollment Begins November 1

Open enrollment for new members as well as existing plan members begins November 1 and continues through January 31, 2017. For a plan effective date of January 1, 2017, it is essential to complete an application by December 15, 2016. Start early to avoid the rush! The last few days and hours before each monthly deadline typically get a bit crazy and waits for help are long.

Need Help?

For questions or help anywhere in California call Kathy Brewer de Pozos at: 831-713-6438 or email her at: KathyPozos2000@gmail.com

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Blue Shield / Sutter Health Agreement Reached

Blue Shield announced today that the company has reached an agreement on a two year extension of its contract with Sutter Health, including the Palo Alto Medical Foundation (PAMF). This agreement, whose terms are not  public, protects both carrier and clients according to Blue Shield.

Sutter Health and the Palo Alto Medical Foundation are major players in the Northern California health care scene. In some  counties, including Santa Cruz, Blue Shield will be the only carrier whose network of providers for individual policies includes Sutter and PAMF, in contrast with 2014 in which these providers contracted with both Health Net and Blue Shield. Patients who had already moved from their Health Net policies to Blue Shield effective January 1, 2015 in order to keep their providers were facing the possibility of having to find new doctors anyway. News of the agreement will be welcomed.

The lack of a contract between Blue Shield and Sutter Health/PAMF affected both individual and group members of the plan.

Open Enrollment for individual and family health insurance continues through February 15, 2015. Contact us today for a free consultation and help enrolling in a plan to meet your needs.

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