Ask Emily: Change and no change at the exchange

08/22/2014 3:28 PM

08/22/2014 3:29 PM

I’m sure you’ve heard that premiums for plans sold through our health insurance exchange, Covered California, will go up an average of 4.2 percent next year.

Just remember, “average” means just that. Your premium increase (or decrease in some cases) will depend on a variety of factors, including where you live and what plan you choose. I’ll delve into that below.

Plus, you shouldn’t obsess over premiums alone. Satisfaction with your health insurance depends on so much more than your monthly bill. Consider the following questions, based on issues that many of you have struggled with:

Was it easy to enroll in your new plan (or Medi-Cal)?

Did the Covered California website work for you?

Have you been able to see a doctor who will accept your new coverage?

If so, how long did it take?

How much do you pay for prescription drugs?

Have you been hit by unexpected medical bills?

Many of these critical topics were left out of Covered California’s announcement. In today’s column, I’ll explain what you can expect from next year plans, beyond the premiums.

If you buy your health insurance from the private market, you should pay attention to this, too. All plans sold through Covered California must be sold on the private market at the same price.

ENROLLMENT: Let’s start with a piece of good news. If you have a Covered California plan, you can keep it without reapplying.

You will receive letters from Covered California and your insurer with details, but just keep paying your bill and you’ll keep your plan, says Covered California executive director Peter Lee.

If you’re not happy with your plan, you can switch. Open enrollment runs from Nov. 15 through Feb. 15, 2015.

PLAN CHOICES: Ten plans will be offered around the state, with options varying by region. They’re the same as this year’s, minus the Contra Costa Health Plan, which announced in June that it won’t participate in 2015.

NETWORKS: Among the biggest challenges many of you faced this year were “narrow” networks, in which some plans significantly limited the number of participating doctors and hospitals (assuming you could even locate accurate information about which doctors and hospitals participate).

Lee said Covered California is working with plans to ensure their provider directories are accurate and have encouraged them to expand the number of participating doctors, hospitals and medical groups.

The day before Covered California unveiled 2015 rates, Anthem Blue Cross announced that it has added 6,300 doctors to its Covered California plan network since Jan. 1.

Lee also pledges that Covered California will analyze the plans’ health care utilization data to ensure that consumers are receiving care.

“How many people actually got preventive care visits, actually saw doctors?” he asks. We want to “put numbers behind the access issues.”

Meanwhile, the state Department of Managed Health Care is investigating Anthem and Blue Shield of California’s networks, an audit triggered by consumer complaints. The department hopes to release its findings before open enrollment begins, says spokesman Rodger Butler.

But shouldn’t this work have been conducted last year, before consumers started trying to use their new health plans this year?

“When reviewing Covered California networks for 2014 the department did not have good cause to believe these plans had violated the law,” Butler says.

Once officials identified a pattern of complaints “and had good cause to believe the plans may have violated the law, the department initiated these surveys,” he says.

PLAN BENEFITS: If you had any beefs with your plan benefits and hoped they would change next year, you’re out of luck, with one important exception.

Dental insurance for children will be embedded into all plans, which wasn’t the case this year, Lee says. Supplemental dental insurance for adults also will be available, he says, but as an add-on item.

Otherwise, benefits remain the same, such as the potentially expensive prescription drug pricing tiers (which include up to 40 percent cost-sharing for “specialty” drugs) and some plans’ exorbitant (or nonexistent) out-of-pocket maximums for out-of-network use.

“We’re going to pause and look at changes to benefit designs in 2016,” Lee says.

RATES: About half of Covered California participants will see their rates go down, stay constant or rise less than 5 percent; 36 percent will see premium hikes of 5 percent to 8 percent; and 13 percent will see rates rise more than 8 percent.

As I mentioned earlier, so much of pricing is local, and California is chopped into 19 different pricing regions. The average increase for San Francisco County is 6.6 percent, whereas the average increase for a region that includes five Central Valley counties is actually a decrease: -1.9 percent.

Within regions, rate increases can fluctuate wildly by plan. In the Sacramento region, the lowest increase is a decrease of 1.8 percent, but the largest increase is 16.7 percent.

Want to know what your rate change will be? Go to CoveredCA.com and click on the “Shop and Compare Tool,” which has been updated with 2015 prices.

To comment on the still-tentative rates, go to DMHC’s website (you have 60 days starting Aug. 1): http://wpso.dmhc.ca.gov/ratereview

The state Department of Insurance regulates Health Net’s Exclusive Provider Organization plan. Comment at http://bit.ly/1ogvUpb

The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation

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