Dear Tom and Alan:

I had my family on Blue Shield of California for many years. The rates kept going up each year, as they did for everybody else, but we never had any trouble finding a doctor that took Blue Shield.

A couple of years ago Blue Shield changed the network from a PPO (good) to an EPO (bad). Instead of having a statewide directory of doctors, we were stuck with only the ones that signed on for the four county area in which we lived.

Not surprisingly, many of the previous Blue Shield doctors did not renew their contracts under the new EPO plan. This was completely unsatisfactory to us, so we changed insurance companies.

Beginning the second year of the Affordable Care Act (“Obamacare”), we enrolled in Health Net. We got a top-of -the-line plan for the four of us and paid a premium price for it.

It’s been great to have a full complement of doctors and hospitals, but our “Gold” plan is going up 25.5 percent in 2016.

Is there anything available with doctors on it that doesn’t cost a fortune?

Bert

Tom: The short answer is no.

Your Gold plan is more expensive than the Bronze or Silver plans and less expensive than the Platinum. These metal tiers are all that’s available under the ACA.

Health Net was pretty much the dominant PPO plan during the first year of the ACA. Their Preferred Provider Organization (PPO) kept their network of doctors at least partially because there was no talk of cutting reimbursement rates to providers.

For the second year, Health Net instituted an Exclusive Provider Organization (EPO) for the applicants that went through Covered California rather than directly to the company. Anyway, the PPO network remained intact for those subscribers who avoided the Covered California marketplace.

But as Bert discovered, there is a high cost to a premier plan with a full network of doctors.

Al: It’s pretty clear that the many requirements of the ACA made a good number of insurance company actuaries very nervous.

Blue Shield’s solution was to reduce the scope of the provider network: EPO instead of PPO. After two years of this, we’re told that Blue Shield will be offering a PPO plan for 2016.

One of the strangest reactions to the ACA was that of Anthem Blue Cross. They made up a whole new network for individual and family plans.

Instead of the Prudent Buyer network that had been in place for years, they introduced the Pathway network.

One of the immediate problems in the first and second years of the ACA was that almost none of our local doctors took the Pathway plan. Unfortunately, this is the way it’s going to be in the third year also.

Kaiser was a beneficiary of this upset because their doctors are employees, not independently contracted providers.

Submit questions or reach the Health Insurance Guys at Schrette Insurance, 1556 First St., Suite 105, Napa, 94559; 255-9511; schrette@gmail.com; or alancash@gmail.com

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