why I ditched Covered California — for now


In late 2013 we signed up for BlueShield through CoveredCA. Turned out, BlueShield had fed CoveredCA and us a crock of lies: almost none of our doctors signed up with the CoveredCA/Exchange version of BlueShield.

BS, as I like to call them, had advertised their doctor list using the previous year’s non-Exchange list. However, their Exchange reimbursement rates were so low that none of our individual doctors signed up. Not one. Only the big hospitals and biggest medical groups were able to negotiate reasonable (i.e. pre-Exchange) rates with BS. And, by the way, that’s only because of the Obamacare provision that forces the insurers to provide enough doctors for a given geographic area. If it weren’t for that provision, we’d have had no doctors at all in our area.

As an example, when I search for a dermatologist within 15 very crowded miles of my home, I find only one! [Actually, I found three, but two seem to have left the area or couldn’t apparently afford a phone answering service]. And we’re in the crowded Bay Area. It ain’t exactly a doctor desert.

So even though we were paying for Platinum coverage, all of the individual doctors we saw from January through March were considered Out Of Network. We ended up paying the full doctor rate, and were reimbursed by BS at 50% of the rate that BlueShield would have paid the doctor if the doctor had signed up for BS.

Read that sentence again. When you sign up for insurance, they make it look like Out Of Network charges are covered at 50%. Not so. You and I only get reimbursed at 50% of what the insurer would have paid to the doctor, not 50% of what you and I had to pay.

Take the image above, for example. The doctor bill that we paid was over $110, and that was AFTER we renegotiated with the person in the billing department! From the $110 that we actually paid the doctor, BlueShield cut us a check for a whopping $5.60. We ate the difference. Multiply that by all of the doctor visits we made from January through March. There were several. Strep throat, an eye infection, something that we thought was the flu but wasn’t, etc.

In this instance, my wife needed a medical test because of a potentially serious  problem (that luckily turned out to be easily treated because she caught it early). She was at the doctor’s office for over an hour, and saw a nurse practitioner plus the doctor. For this 1+ hour visit, BlueShield would have reimbursed the doctor’s office $11.20. Is it any wonder that the doctor didn’t agree to that reimbursement rate? Who would?

Do you want fries with that?

So I went back to my original dollar analysis for Covered California, and updated my spreadsheet (which you can use with Google apps or Excel) to again compare the options between different plans.

Now that it was February, I was able to re-contact all of our doctors to find out what plans they had actually signed up for. Guess what? The ONLY CoveredCA/Exchange plan that all of our individual doctors (and the medical groups and hospitals) had signed up for was HealthNet. They’d signed up for HealthNet both Exchange/CoveredCA and private (non-Exchange).

Why? Because HealthNet, at least for 2014, kept the reimbursement rates the same regardless of Exchange or private. So the doctors knew they’d get reimbursed the same as before. Hence they signed up.

So my original calculation, that HealthNet was the most expensive, turned out to be exactly backwards. With the exception of Kaiser HMO (which employs its own doctors and so completely controls everything), HealthNet was the cheapest real option, because it was the only option that actually offered us In-Network doctors.

Bah! So since it was pre-deadline, I switched us all over to HealthNet. Total cost for a family of four on the Platinum plan in the ultra-expensive Bay Area: over $2000 a month. Ack! But the math showed that this (or the Silver plan) were the cheapest. In our case, our usage pattern for medicines and doctors was moving very close to what I’d predicted, and the spreadsheet showed that the Platinum plan would end up being the cheapest.

Unfortunately, the CoveredCA site doesn’t make it easy to switch from one CoveredCA plan to another one within the year. I may have been able to do it given enough time and stress, but I was afraid that the terrible experience of signing up in the first place might screw us out of coverage altogether, so I signed us up for private covered through the HealthNet website. Took about a half-hour, and we were approved within a day or so. DONE.

Canceling BlueShield took nearly two hours just for them to answer the phone, and another 45 minutes on the phone with them. Everything about the BS experience was just that: BS. Website, the way they reimburse, the info you get. All BS.

Hopefully we made the right choice. It was certainly an expensive one. If my small business doesn’t show signs of life this year, I may be priced out of the private market and need to look for another corporate job just in order to get my family insured.

I remain grateful for Obamacare: without the changes in the law that prevent us from being excluded, we’d never get care at all for several of my family members without getting and keeping a job at a major corporation. But the prices of healthcare (which weren’t properly addressed by the law as it eventually came into being) are so out of whack, that the reality still only gives us decent coverage because we’re lucky enough to be able to afford it.

This year. For a while.

2015 Update: I checked CoveredCA again for 2015. The plans had changed, and they no longer even offered the HealthNet plan that would cover our actual doctors. So once again I stayed with private insurance. Now don’t get me wrong: I’m very much in favor of the Obamacare provisions that have allowed us to have insurance regardless of pre-existing conditions. Otherwise some of my family would not be insurable, even at the current high prices. But I’m disappointed in the actual results. Families can indeed get CoveredCA insurance at reasonable rates, but only if they’re willing to take any doctor, and potentially different doctors every year (given the changing available plans). So in reality, this isn’t much different from an HMO. That’s my takeaway: if you’re going with CoveredCA, you might as well compare prices against a cheap HMO option, because unless you’re willing to pay out-of-network rates, that’s effectively what you’re going to get.


2 thoughts on “why I ditched Covered California — for now”

  1. Doug, thanks for sharing this complex experience. It’s so difficult to find this kind of information, I’ve looked! Good health to you and yours. 🙂

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