How You'll Pick Your New California Exchange Plan

http://www.calhealth.net/Pick_California_Health_Plan_by_Provider_Network.htm

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The commoditization of health plans and specialization of networks

That's a mouthful but it fits. The new Exchange plan benefits are mandated at certain levels (Platinum, Gold, Silver, Bronze, and Catastrophic) which we've discussed in detail across calhealth.net The rates are somewhat constricted by MLR requirements and in indeed, the preliminary rates are all pretty range bound as expected. As we discussed over a year ago, if the benefits are mandated and the rates are constrained by MLR and political pressure, where's the give? The doctors and hospitals. It's akin to squeezing a baloon and the only way it can go it towards reimbursement to providers.

Early volleys at provider reimbursement

We heard rumors during the summer of 2013 that letters were going out to doctors and hospitals from carriers with intent to reduce reimbursement sizably for the new Exchange plans. Essentially, the providers were going to take the hit for guaranteed issue and increased health risk. The doctors had two options...accept a much lower reimbursement for care or choose not to participate in the networks. Either way, there was going to be big changes in the California health insurance networks. So what did we find out yesterday?

Exclusive contracts and shrinking networks

On the Individual and Family market, the carriers are signing exclusive contracts with hospitals and hospital groups. For example, the UC's signed a contract with Anthem. Blue Shield signed with Sutter. Scripps...Shield. Sharp...Anthem. We don't have information yet on Health Net's approach. The new PPO and EPO networks will probably have 50% of the current PPO doctor networks and 75% of the current PPO hospitals. Different areas will have PPO while others will have EPO within a given carrier.

So what does this mean to California health insurance shoppers and members

Unless the choice of doctor and more importantly hospital doesn't matter to you (assuming there's an alternative in your area), come Jan 1st, 2014, you will likely choose a plan which contracts with your chosen hospital and doctor. The real question is how people without a subsidy will react to paying much more for health insurance and getting about 1/2 of the prior network to access. We're not looking forward to those calls.