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Blue Shield of CA and Sutter Health: Negotiating a new contract

From Blue Shield today:

Blue Shield and Sutter Health are engaged in contract negotiations
Blue Shield of California and Sutter Health are engaged in discussions on rates and terms for a new network contract (HMO/PPO and in some cases, Group Medicare Advantage). The current contract is set to expire at the end of this year and without a new deal, Sutter Health would no longer be a Blue Shield in-network provider starting January 1, 2017.

We are working diligently in good faith to complete a new contract that is fair and sustainably affordable for our customers. If the network relationship terminates, Blue Shield will ensure that members have continued access to care in their area, including continuity of care for those who qualify to continue in their current course of treatment with a Sutter Health provider.

What are the lines of business affected by the negotiations?
The contracts being negotiated apply to all Blue Shield plan types, including HMO, PPO, EPO, POS-HMO Tier, POS-PPO Tier and Group Medicare Advantage.

  • Individual and Family Plans: Grandfathered and Non-Grandfathered Plans (on and off exchange)
  • Medicare: Group Medicare Advantage Prescription Drug (GMAPD) plans
  • Small Business (1-100 employees)
  • Fully Funded Large Employers (101+ employees)
  • Self-Funded/ASO Large Employers (101+ employees)
  • Self-Funded/Shared Advantage (101+ employees)
  • CalPERS
  • FEP
  • FEHBP

Sutter Health providers are located in Northern and Central California (see listing of counties below). In addition, Sutter Health has surgery centers in San Diego County.

Sutter Health Counties
Alameda Marin San Joaquin Santa Cruz Sutter
Amador Merced San Luis Obispo Shasta Yolo
Contra Costa Placer San Mateo Solano
Del Norte Sacramento Santa Barbara Sonoma
Lake San Francisco Santa Clara Stanislaus

The contracts currently being negotiated include the following Sutter Health hospitals:

  • Alta Bates Medical Center Herrick Campus
  • Alta Bates Summit Medical Center Alta Bates Campus
  • California Pacific Medical Center – California Campus*
  • California Pacific Medical Center – Pacific Campus*
  • California Pacific Medical Center – St Luke’s Campus*
  • California Pacific Medical Center Davies Campus*
  • Eden Medical Center
  • Memorial Hospital Medical Center
  • Memorial Hospital of Los Banos
  • Menlo Park Surgical Hospital
  • Mills Peninsula Health Center
  • Mills Peninsula Medical Center
  • Novato Community Hospital
  • Sutter Amador Hospital
  • Sutter Auburn Faith Hospital
  • Sutter Center for Psychiatry
  • Sutter Coast Hospital
  • Sutter Davis Hospital
  • Sutter Delta Medical Center
  • Sutter Lakeside Hospital
  • Sutter Maternity and Surgery Center of Santa Cruz
  • Sutter Medical Center of Santa Rosa
  • Sutter Medical Center, Sacramento
  • Sutter Roseville Medical Center
  • Sutter Solano Medical Center
  • Sutter Surgical Hospital North Valley
  • Sutter Tracy Community Hospital

    *Includes Medicare Advantage

In the event of a termination with Sutter and in accordance with DMHC regulations, Blue Shield of California would notify HMO members assigned to a Sutter Health Primary Care Provider (PCP) 60-days in advance of a potential termination with Sutter Health. PPO members with an out-of-network benefit could receive services from a Sutter-affiliated provider, but the out-of-pocket costs will be at the non-preferred benefit level.

Our commitment to affordably priced health coverage
Blue Shield continues its provider contract discussions with Sutter Health in hopes that new agreements will soon be reached. We appreciate your patience while we work to secure the best possible outcome for our customers and members. Our goal is to provide our members with access to quality health care at an affordable price.

Emergency services
Blue Shield of California members who need emergency services should call 911 or seek care at the nearest emergency room. Blue Shield will provide the full emergency care level of benefits for these services.

Oscar is coming to San Francisco

Oscar is coming in 2017. No, not that Oscar.

A new health insurance carrier will offer plans both on- and off-exchange, in San Francisco, San Mateo, and Santa Clara counties. A little surprising it took this long, considering they are Google-funded, and we’ve heard them described as “great software – with health insurance attached.”

It appears their Bay Area rates and network will be middle-of-the-pack (current word is no Sutter Health/PAMF, though that could change). Will their customer service and user experience be enough to consider Oscar as a viable choice? Stay tuned.

How to save $1,000 in health premiums over the next 4 months

This isn’t a strategy for everyone. If you feel bad for the insurance companies, you can stop reading now. And if you have any significant health issues, this won’t work for you, either. But, if you:

  • Have had minimum essential coverage from January 1 through October 31 of this year
  • Are healthy, with no (or minimal) foreseen health expenses for the next few months
  • Are willing to take a few minutes to understand the rules and exceptions around:
    • Open enrollment
    • Guarantee-issue health insurance
    • Individual mandate to purchase minimum essential coverage
  • Would prefer to pay the lowest possible health premium, without subjecting yourself to financial risk or tax penalty

…then this could be for you.

Read More

Covered California Announces SHOP Plans and Rates – without Anthem Blue Cross

Covered California, the new health insurance marketplace, or “exchange” announced today that six carriers would participate in the 2014 SHOP for small businesses of 2 to 50 employees:

  • Blue Shield of CA
  • Kaiser Permanente
  • Health Net
  • Chinese Community Health Plan
  • Western Health Advantage
  • Sharp Health Plan

The last three are regional carriers.  As expected, Anthem Blue Cross is absent from this list, having withdrawn from the small business exchange last week, as reported by the L.A.Times and The Hill.

Rates are pending approval by state regulatory agencies, and Covered California’s release only gives examples for a single, 40-year old employee.  You can download the booklet and accompanying press release here.

Yet unanswered is the question of whether these plan options will offer limited provider networks, as we have seen with the individual marketplace.

Small employers will be able to choose to purchase health coverage for employees inside the Covered CA marketplace, or they may go directly to carriers as they do today.  Depending on the business demographics and needs, either may be a viable financial strategy to provide competitive benefits to employees.  We look forward to helping small business owners determine the right choice for their business.

What To Do With This Blue Shield Rebate Check?

Small businesses and individuals will be receiving a rebate from Blue Shield by August 1st.  Employers, please review the details here, about valid ways to return these refunded premiums to your employees.  Reducing the cost of future insurance coverage is a legitimate use of the rebate.

From Blue Shield:

Medical Loss Ratio Rebates and Notifications

Last month, we informed you that Blue Shield reported its 2012 Medical Loss Ratio (MLR) by market segment to the Department of Health and Human Services (HHS). We are now sharing our rebate information with you.

Blue Shield did not meet the MLR thresholds for the following market segments:

  • Individual and Family plans regulated by the Department of Insurance (DOI)
    The MLR threshold for this market segment is 80%. Blue Shield reported an MLR of 78.0%. The Individual and Family plan MLR was 2% below the 80% threshold. As a result certain subscribers will receive premium rebates by August 1, 2013. The 2% of premium revenue equals $13.3 million that will be returned to 226,034 Individual and Family plan subscribers who were enrolled in the Blue Shield Life plans that did not meet the MLR threshold. The average rebate amount per subscriber is about $59.
  • Small Business plans (50 or fewer employees) regulated by the Department of Managed Health Care (DMHC)
    The MLR threshold for this market segment is 80%. Blue Shield reported an MLR of 76.6%. The Small Business MLR was 3.4% below the 80% threshold. As a result, certain subscribers will receive dues rebates by August 1, 2013. The 3.4% of dues revenue equals $24.5 million that will be returned to 29,232 Small Business policyholders who were enrolled in the Blue Shield plans that did not meet the MLR threshold. The average rebate amount per Small Business policyholder is about $827.

Will Obamacare Kill Healthy San Francisco?

Chris Rauber is asking those questions at the San Francisco Business Times, and apparently, so is much of the San Francisco business community.  Well summed up by Jim Lazarus of the San Francisco Chamber of Commerce:

Among the problem area, according to Lazarus:

  • The federal individual mandate is not met by Healthy San Francisco.
  • The health reimbursement accounts now used by some San Francisco businesses to comply with the local mandate won’t be available next year.
  • Healthy San Francisco, after Jan. 1, will be primarily an “avenue of last resort” for individuals, including undocumented residents, who don’t qualify for other programs. “Some may be willing to stay in the program and pay the penalty” for not having individual insurance, Lazarus speculated.
I agree that these are the major sticking points, but it is the Employer Spending Requirement that the business community (especially the Golden Gate Restaurant Association) would really like to get out from under.  Businesses of 20-49 employees are particularly hard-hit here, as the Federal law exempts them, but San Francisco’s Health Care Security Ordinance does not.

Not to worry, says Mayor Lee.

Like many other parts of the Affordable Care Act and upcoming health care reform changes, we will put this in the “Likely to change between now and 2014” file.
UPDATE 8/1/14 – The Usual Suspects has a good collection of related articles on Healthy San Francisco going.

New Yorkers to Pay 50% Less for Health Insurance – NY Times

In yesterday’s NY Times, it was reported that individual health insurance premiums are expected to drop by 50% in 2014, when the full effect of the Affordable Care Act (a.k.a., “Obamacare”) kick in.  Here is the most shocking line in the article:

Because the cost of individual coverage has soared, only 17,000 New Yorkers currently buy insurance on their own.

New York state is home to almost 20,000,000 (that’s TWENTY MILLION) people.  And 17,000 of them buy their own health insurance.  According to the article, 2.6 million go uninsured.  Let’s let those numbers sink in for a moment.

New York is one of a handful of states that already has guarantee-issue coverage for individuals.  That is, medical underwriting does not exist; any individual can purchase individual coverage, even those with expensive, chronic diseases.  How many of the 17,000 do you think are completely healthy individuals, who do not receive coverage from an employer?  Right.  Well, no wonder the average cost to an individual is $1,500/month for these individual policies.  OK, here are a couple of takeaways:

  • The individual mandate — the requirement that all individuals purchase qualified health insurance in 2014 or pay a penalty — is crucial to the success of the Affordable Care Act.  We must force healthy people into the system, in order to sustain a competitive marketplace that benefits all individuals.
  • Can that 17,000 number possibly be correct?  Is it really true that 13% of New Yorkers go uninsured, 87% get their health insurance from an employer, and less than one-tenth of one percent purchase their coverage on the individual market?  California has twice as many residents as New York, and somewhere between 500,000 and one million purchase their own individual health insurance.

I will do a little more fact-checking and report back…

Rebates coming to small business from Anthem and Blue Shield of California

Chad Terhune of the LA Times reports that Anthem Blue Cross and Blue Shield of California will be required to issue rebates to small businesses this August, for failing to meet the minimum 80% medical loss ratio threshold in 2012, as required under the Affordable Care Act.

Blue Shield of California insures 29,000 small businesses in California, while Anthem Blue Cross is the largest small business insurer in the state, covering 45,000 small businesses.  Your Allpointe broker will be contacting you once specific dollar amounts are released.