Santa Monica, CA – Beginning on Saturday consumers may enroll in new health coverage or switch plans for 2015. Consumers should be cautious when choosing coverage because health insurers continue to throw up roadblocks to quality care, said Consumer Watchdog.  

“Federal health reform has dramatically improved the health care landscape, including important consumer protections that bar insurers from discriminating against those with pre-existing health conditions,” said Consumer Watchdog lead attorney Jerry Flanagan.  “But from ‘EPOs’ to ‘narrow networks,’ consumers face threats to their health and financial well-being under new practices adopted by health insurers.”

Consumer Watchdog attorneys were joined by health insurance consumers to announce ten facts and potential pitfalls consumers purchasing health insurance should be aware of during the upcoming Open Enrollment period.

1. You Have 90 Days to Decide.

Under federal health reform, consumers may only enroll in new coverage or switch coverage during designated Open Enrollment periods except for a few narrow exceptions.

The Open Enrollment period for 2015 runs for 90 days beginning on November 15, 2014 and ending on February 15, 2015.

Californians may purchase health insurance either through the state health insurance exchange, known as “Covered California,” or directly from health insurers.  

After the Open Enrollment period, consumers can only enroll in health plans if they experience a “qualifying event.” For example: change in marital status, birth of a child, or change in employment.

2. If You Want Coverage on New Years’ Day, Your Deadline is December 15.

For coverage to start on January 1 you must enroll in coverage through Covered California by December 15.

If you are currently enrolled in a health plan, from now through December 15, 2014, you can decide to keep or change your current health plan, add or remove family members to your coverage, and report other changes such as a change of income that may affect the premium assistance you receive.

If you take no action, you will be automatically renewed with the same health plan, except for plans that will no longer be offered through the Covered California exchange such as the HealthNet PPO and Contra Costa Health Plans.

3. The “Exclusive” in Exclusive Provider Organization Means “Limited.”

EPO stands for “Exclusive Provider Organization.”  An EPO plan uses a specific network of hospitals and doctors.  Like an HMO, there is no coverage if you see doctors who are not in the network, except for emergency care.  Unlike an HMO, you do not need a referral from your primary care physician before seeking covered services.  

A PPO plan (“Preferred Provider Organization”) also utilizes a specific network of hospitals and doctors.  However, unlike an HMO and an EPO plan, a PPO plan provides some coverage for out of network physicians albeit at a lower rate than for in-network physicians.

Several class action lawsuits filed by Consumer Watchdog attorneys outline some of the pitfalls of EPO plans, including rampant misinformation about which hospital and doctors are included in the plans’ networks:

•    Download the class action lawsuit against Blue Shield here: http://tinyurl.com/l2k4aq7
•    Download the class action lawsuit against Anthem Blue Cross here: http://tinyurl.com/l6wpwcz
•    Download the class action lawsuit against Cigna here: http://tinyurl.com/k7lyacj

As discussed in the lawsuit against Anthem Blue Cross, Anthem enrolled consumers in EPO plans unilaterally and without notice, resulting in large unpaid medical bills.

“Anthem Blue Cross refuses to cover my wife’s preventive care because according to them, I have an EPO. But clearly, my insurance card says PPO. If I knew that Blue Cross changed my coverage from PPO to EPO, we would have visited a doctor who is a member of the EPO network,” said Paulino Pelejo of Diamond Bar. “When I asked Blue Cross to change my coverage back to PPO, Blue Cross refused because they said it is not Open Enrollment anymore. It is really frustrating! We are already paying over $600 monthly for our insurance and the least Blue Cross can do is cover my wife’s preventive care!”

4. Just Because Your Insurer Says Your Doctor Is “In-Network” Doesn’t Mean She Is. Call Your Doctor Too.

A “Narrow Network” refers to the practice of health insurance companies dramatically reducing the number of in-network physicians and hospitals.  Consumer Watchdog has received hundreds of complaints from consumers who have reported difficulty identifying in-network doctors and hospitals.  

These Narrow Networks have dramatic consequences for consumers’ pocketbooks if they cannot identify in-network doctors when they need treatment. If you are enrolled in an HMO or EPO you must pay the full-cost of services provided by out of network doctors.  If you are enrolled in a PPO plan you will receive some coverage from your health insurer after you meet your annual deductible, but you must still pay up to 50% or more of the cost of services provided by out of network physicians.

The class action lawsuits listed above outline some of the pitfalls of Narrow Networks, including rampant misinformation about which hospitals doctors are included in the networks.

“When my wife and I enrolled in our new Blue Shield health plan it was important to us that our long-time physicians were included in our plan’s network,” said Kevin McCarthy, the lead plaintiff in Consumer Watchdog’s class action lawsuit against Blue Shield.  “Before enrolling we confirmed through Blue Shield’s website that our doctors were ‘in-network’ and we even called our doctors to double-check.  It was only after we visited our doctors for routine check-ups that the bills started rolling in informing us for the first time that our doctors were in fact out of network and Blue Shield was only covering a fraction of the cost.  Adding insult to injury, when we called Blue Shield to complain we experienced hold times of two to four hours each time we called. I feel Blue Shield is trying to get away with a blatant ‘bait and switch’ and I won’t stand for it!”

“What doctors we were able to find ‘in network’ were not even in the same county where we lived!,” added Kevin McCarthy. “Our choices were highly limited and we were locked into the Blue Shield plan for all of 2014 with no choice but to pay excessive out of pocket costs to see our own physicians. We were scammed, plain and simple.”

5. Medical Services May Not Count Toward Your Deductible if You Go Out Of Network.

In order for covered treatments and services to accrue toward your deductible and annual out of pocket limit, you must seek treatments and services from an in-network physician.

Once you have met your plan’s annual deductible, you will share the cost of services with your health insurer. You will either share the cost through a co-payment, which is a fixed dollar amount, or through co-insurance, which is a percentage of the amount listed on your health insurer’s negotiated fee schedule with each doctor and hospital.

However, if you seek treatments from out of network physicians or hospitals:

•    Negotiated fee schedules are not available;
•    Payments made to out of network doctors and hospitals do not accrue toward your in-network annual deductible; and
•    Payments made to out of network providers do not accrue toward your annual out-of-pocket limit.

6. Fewer PPOs On Exchange.

Federal subsidies are available to you and your family if your income is less than 400% of the federal poverty level. To access those subsidies you must enroll in health plans through Covered California.

However, there is only limited PPO coverage available through Covered California.

Blue Cross and Blue Shield sell PPO coverage in only limited areas of the state.  For example, Blue Cross does not sell a PPO plan in Los Angeles County.  

HealthNet will no longer sell any PPOs through Covered California in 2015.  HealthNet will sell PPO plans outside of the Covered California exchange, but consumers who enroll in those plans will not receive any subsidies even if they qualify for them.

If you are currently enrolled in a HealthNet PPO through Covered California you must sign up for new coverage by December 15 to have coverage on January 1.

7. Keep an Eye Out for Health Status Discrimination.

A centerpiece of federal health reform are new rules barring a health insurer from denying coverage or charging more for coverage due to your pre-existing health conditions or health history.  You may no longer be charged more or denied coverage due to your pre-existing health conditions.  But be on the lookout for other discriminatory behavior and report it to Consumer Watchdog immediately.

“Insurance companies are still insurance companies—they want to cut their costs and your coverage but boost their profits.  Consumer Watchdog has received a number of reports from consumers of continued health status discrimination by insurers, albeit more subtle than in the past,” said Jerry Flanagan.

If you believe you have been discriminated against due to your health condition or health history please contact Consumer Watchdog here: http://www.consumerwatchdog.org/node/add/complaint

8. The Cost of Prescription Drugs May Be On You.

The cost of some generic medications is skyrocketing and some brand name medications may cost you more than others. Several news organizations have reported dramatic increases to some generic drug costs and the U.S. Attorney General’s office is investigating the problem:

•    Wall Street Journal: http://blogs.wsj.com/pharmalot/2014/11/10/justice-department-probes-generic-competition-after-price-hike-reports/
•    San Francisco Chronicle: http://www.sfgate.com/health/article/Prices-soar-for-some-generic-drugs-5105538.php
•    CBS Chicago: http://chicago.cbslocal.com/2014/10/31/prices-soar-for-some-generic-drugs-why/

“We were astonished to discover that generic prescription drug prices have gone through the roof,” said Maria Feldman, an Anthem Blue Cross subscriber living in Long Beach.  “For example, one of my children takes a generic medication that cost $15 last year, but now costs $115.  We were shocked to learn that a new generic medication prescribed by our doctor cost $341 for just 50 grams of medication. Hopeful for a better price, we researched another generic version of the medication.  Unfortunately, that generic medication cost $321. We were lucky – instead of paying those excessive prices, we found an over the counter medication that costs just $7 that seems to be working well.  I worry about other consumers that don’t have an over the counter option.”

Some consumers have also discovered that the brand-name medications they take are no longer included on their health plans’ “preferred drug” list. As a result, consumers are paying more than they used to for the same brand-name medications prescribed by their physician.

9. Premium Increase Information May Not be Available Until You Renew.

Some consumers may not know what their 2015 premiums charges will be until December, possibly after they renew their coverage. According to the Covered California website:

Your plan will not have any information about your renewal until December. In early December, you will receive a billing statement for the coverage you have selected for 2015.
…
[Y]our premium will likely change. Your health plan will send you an invoice showing your new monthly premium amount for 2015.

Source: https://www.coveredca.com/youre-in/questions-about-renewal/

10. Help Consumer Watchdog protect consumers.  Report any health insurance problems.

Please help us help you and other consumers by reporting any problems with Open Enrollment or your health insurance plan here: http://www.consumerwatchdog.org/node/add/complaint

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Consumer Watchdog is a non-profit and non-partisan consumer advocacy organization. Find us on the web at: http://www.ConsumerWatchdog.org