Health insurance hassle in Nevada County
April 15, 2014
For help with Covered California
Local insurance brokers: Steve Sauer (530-274-2211) or Scott Scirpo (530-470-1250).
To sign up: http://www.coveredca.com
With its many modern amenities, Nevada City's 95959 ZIP code doesn't seem like it would be challenging for health insurance.
But under Covered California, it feels like that for Nevada City dweller Randy Harris.
"I want to tell the world what's happening in Nevada County," said Harris, 58, owner of BluBilt water systems and a 30-year county resident. "It's frustrating."
Harris, who previously had private insurance with Blue Shield, said he had been excited about the Affordable Care Act — "Obamacare" — implemented in the state under the moniker Covered California.
"Healthcare has been my single issue," he said. "When I heard Obama was for healthcare, that's all I needed to hear (to support him)."
He signed up early, more than three months ago.
In doing so, Harris joined what is now more than 1.2 million Californians enrolled in the state's Covered California system, according to the latest tabulations as of the March 31 deadline for open enrollment.
(Note: Covered California extended the deadline for open enrollment to 11:59 p.m. on April 15 because there was a surge of last-minute attempts to get signed up.
After today, sign-ups are still available if you experience a major life event, such as having a baby, getting married, change in income or moving to a new area. See http://www.coveredca.com).
Under the new plan, Harris was pleased to see his health insurance premiums drop to $200 per month with a $2,500 deductible. That was down from the $380 per month, with a $5,000 deductible, that he had been paying under his former Blue Shield insurance plan.
But the lower premiums came with a price: He had to switch health insurance providers to Blue Cross and he had to let go of his physician of 15 years, whom he trusted and counted on. His prior physician was not part of the Blue Cross network under the plan offered by Covered California.
Harris said his choice of new doctors under the Blue Cross network offered through Covered California was narrower and mostly limited to physicians who specialize in low-income patients enrolled in Medicaid, the health program for the poor known as Medi-Cal in California.
"I went from being a health care consumer to being a Medicaid patient," he said. "It's not that I'm knocking the Medicaid doctors — they do the good work."
Debbie Wagner, director of community outreach for Dignity Health Sierra Nevada Memorial Hospital, recommends that people signing up for Covered California contact a local insurance broker to help them navigate the system.
"They help people get on the right plans, they know the rules," said Wagner, adding there are many knowledgeable brokers locally who will advise at no cost.
"It's all going to work out eventually," Wagner said of Covered California. "But it's just the beginning, so there are growing pains."
Darrel Ng, Sacramento-based spokesman for Anthem Blue Cross in California, said his records showed there were 51 primary care physicians available to Harris within 20 miles. As to the choices, Ng said they were the same as for any consumer who purchased the basic Blue Cross plan for individuals and families.
Patient detailed problem obtaining treatment
Harris said he has had difficulties getting the treatment he needs for a precancerous lesion on his nose that his former doctor had diagnosed and was planning to treat in-house.
"It's literally costing me my nose," he said.
The first problem with Covered California — having to switch health insurance providers — came during the enrollment process, he said.
Harris said he was shocked to find out that Anthem Blue Cross was the only selection for him as a resident of the 95959 ZIP code.
If he lived in Grass Valley, he would have had at least three choices, including Blue Cross and Blue Shield.
Other consumers elsewhere in the state appear to be having the same problem as Harris. According to an article last Sunday in the Santa Cruz Sentinel, some plans may not be available in certain ZIP codes because of a state rule requiring that all of one ZIP code had to be within 15 miles of a hospital that was in the network.
Wagner, of Dignity Health, said she was familiar with the 15-mile rule, but that "it was an insurance contract issue" that has not yet been resolved.
"I know Dignity Health tried to work on it, but it was an insurance plan decision and we didn't get anywhere," she said.
She recommended consumers contact a knowledgeable insurance broker who is familiar with the regulations.
Rodger Butler, of the California Department of Managed Healthcare, said the state did have a rule requiring that all insurance plans provide adequate geographic access to physicians and hospitals.
For most plans, he said, that means the physicians and hospitals must be within 15 miles or 30 minutes of the consumer's home.
An exception is made for rural areas, Butler said.
He said he had no word if Nevada County was considered a rural area or whether the 15-mile/30-minute rule applied in Nevada City.
"Anyone with questions should call our help desk at 1-888-466-2219," Butler said.
According to Ng, Blue Cross is the major provider for Covered California throughout the state.
"We're the only one committed to building a network, to doing the work in this area," he said.
Dr. Garrett Eckerling of Grass Valley, Harris' former physician under Blue Shield, said he had never heard of this state rule.
"That doesn't make sense," said Eckerling.
Harris, meanwhile, signed up for Blue Cross under Covered California. But as it turned out, Eckerling was not part of the Blue Cross network that was available to Harris under Covered California.
Eckerling said that he was invited by Covered California to join the basic Blue Cross network, but he declined because of the reimbursement rate paid to physicians.
"The rates (paid to doctors) were so low that it would have been difficult to maintain a practice," he said.
Ng said over 500 doctors statewide have added their names to the Blue Cross plan network under Covered California.
"Should this doctor want to join the Anthem Blue Cross network, I would encourage him to contact provider relations," Ng said.
In the meantime, Harris said he found a new doctor who was in the Blue Cross network available under Covered California — Dr. Jane Ragan of Grass Valley.
But Ragan does not perform the same skin procedure that Eckerling had planned to do in-house to remove the lesion.
Ragan referred Harris to a Nevada County dermatologist.
The dermatologist's staff told Harris that he will have to pay the $200-$300 cost for the procedure out of pocket, or he could "do better by going down the hill," meaning to a dermatologist in Auburn, Roseville or Sacramento, he said.
Eckerling said the procedure would have cost less than that in his office.
In addition, the Nevada County dermatologist was not available for an appointment until two months later. Harris opted to make an appointment with the dermatologist's physician assistant, who was available in one month. He will end up waiting more than four months after a pre-cancer diagnosis to get treated, when he could have already had the procedure and be on his way to recovery by now, he said.
"Should (Harris) not want to wait, there are six more dermatologists in Auburn that are in the (Blue Cross) network," Ng said.
He added that Blue Cross was the only health insurance provider making the effort to extend Covered California statewide.
"Anthem Blue Cross is committed to selling a plan in 58 counties," he said.
As for Harris, he's not as bullish anymore on the whole Covered California idea.
"We're a wealthy county," Harris said. "This should not be happening."
To contact Staff Writer Keri Brenner, email firstname.lastname@example.org or call 530-477-4239.