A system issue caused electronic remittance advices (ERA) to go missing at Anthem Blue Cross.
Covered California reports that 289,021 Bay Area individuals have enrolled in exchange plans, which significantly surpasses original targets.
How can I identify mirror products that are sold outside of Covered California but utilize the narrowed exchange provider networks? Practices must review patient ID cards and eligibility information closely to identify whether the practice is in or out of network for that particular plan. A detailed list of exchange and mirror product names for the San Francisco region can be found by clicking here.
As previously reported, Anthem Blue Cross notified physicians in August of upcoming changes to the insurer’s reimbursement policies and claims editing software, ClaimsXten.
Along with the August notice, Anthem provided a comprehensive grid outlining all new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies. Once these changes are implemented, physicians may notice a difference in how certain codes and code pairs are adjudicated.
Questions about any of the claims editing rules or payment policies can be directed to Blue Cross Provider Care Department at (800) 677-6669. The nation's second-largest health insurer is shaking up its approach to paying doctors, putting a major investment behind the idea that spending more for better primary care can save money down the road. Starting this summer, WellPoint Inc., which insures some 34 million Americans, will offer primary-care doctors a fee increase, typically of around 10%, with the possibility of additional payments that could boost what they get for treating the patients it covers by as much as 50%. Wellpoint said Friday it will increase the fees it pays to doctor practices, and it will start paying for services like preparing care plans for patients with complex medical problems. WellPoint said it wants to give doctors a chance to do more for patients outside of episodic care, or just treating people when they become sick. Topics of interest to both consumers and agents related to Covered California and the ACA biased in favor of the successful implementation of the Exchange and deliberately apolitical. The numbers for the ACA in California are cold: 900,000 Californians will lose their individual health care plans Dec. Individual policyholders represent only 7 percent of the health insurance market, but they are an attractive demographic and the wrong people to anger. Obama played the hero for some allowing insurance companies to keep their customers on existing plans through 2014. People who did everything right know now that they cannot keep the plans they had - and they’re the first in line to be handed the real bill for the Affordable Care Act. Covered California is open for business, more or less, but many Californians won’t go there if they need health insurance for themselves or their families.
For the roughly two million Californians who currently buy health insurance on their own, only about a third will qualify for government tax subsidies - and to get the subsidy, people must buy through Covered California. Without a subsidy to offset rates, there’s no compelling reason for the majority of individual health insurance customers to shop on the exchange. Off-exchange plans will still be required to meet 10 benefits standards outlined in the health care law. Most people with existing individual policies in California will get new plans by the end of the year.
All new plans will have to cover a minimum set of medical costs and include standardized benefits. Guest Author, A.Marshall, is a retired attorney whose blog, An Ad Hoc Guide to the Affordable Care Act, seeks to make sense of buying health care under Obamacare. Many individuals and families with complicated income situations are confused about how to calculate their MAGI (modified adjusted gross income) for purposes of determining eligibility for premium support under the Affordable Care Act (ACA). Other than the items specified by the statute, there are no other add-backs to the calculation.
Contributions to a qualified retirement account, such as a Simplified Employee Pension (SEP) plan. Keep in mind that these rules are subject to change - in fact, the definition of MAGI in the Affordable Care Act has already been changed by Congress twice since the law was first written. From October on, these and other broadcast advertisements will run statewide along with print and radio ads connecting with specific ethnic communities, as well as languages beyond English and Spanish. Covered California has budgeted $45 million for the initial push of paid media through March 2014 and plans to spend another $35 million from April to December 2014. Covered California previously said they would implement a new quality rating system for health insurers this fall, two years earlier than required by the ACA.
Covered California opted to exclude all GAs from the individual exchange, a market that has not been penetrated to any great degree by GAs in California. Covered California announced participants for the new Small Group Health Options Program (SHOP) marketplace.
The plans, a mix of HMOs and PPOs, will be sold through licensed agents who are trained and certified by Covered California. Michael Lujan, Director of Sales and Marketing for Covered California’s SHOP, resigned today.


Anthem withdrew its application to be on the Small Business Health Options Program (SHOP) last week. The Anthem announcement included the not so subtle reminder that they are a participant in California Choice, a privately owned small group exchange that has operated successfully in state for a decade or more. Originally, Covered California required insurers to participate in SHOP as a condition of being on the individual exchange, but they had to remove that requirement to attract new insurers.
Anthem had been under fire from DOI Commissioner Dave Jones for a series of recent small group rate increases that he considers excessive.
The Obama administration delayed for one year a provision, commonly known as the employer mandate for one year, that calls for businesses with 50 or more workers to provide affordable health insurance to workers or pay a $2,000 fine per employee. This delay is not expected to have much of an impact on the majority of large employers as most provide health benefits now. If fewer employers offer coverage, and more workers go through Covered California in the first year, and employers see their workers the employees are more or less happy with the arrangement, more businesses might simply decide to pay the penalty in 2015 rather than the substantially higher cost of covering their workers. For the first time in three years, Blue Shield of California leads enrollment in the state’s insurance exchange while Oscar, a closely watched newcomer, experienced a slow start. The Covered California exchange said it won’t release enrollment figures by company until later this month, and insurers declined to share specifics until then. A spokesman for Anthem declined to discuss the company’s California results ahead of the exchange’s announcement. Last week, Covered California said about 425,000 new enrollees had picked out coverage but more last-minute applicants were being counted. The California exchange added two new insurers for this year — Oscar and UnitedHealth Group Inc.
Both Oscar and UnitedHealth are only selling policies in a limited number of regions and each insurer had less than 1,000 enrollees by early January. Covered California had denied UnitedHealth’s bid to sell statewide during 2016 and instead limited the insurer to five of the state’s 19 rating regions, primarily rural counties in Northern California. Oscar, on the other hand, blanketed Southern California with ads touting its high-tech, customer friendly approach to healthcare.
The New York company was a relative unknown in California and going up against established insurers with strong name recognition and existing networks of doctors and hospitals. HMO giant Kaiser Permanente appears on track to remain in third place in Covered California, behind Blue Shield and Anthem.
Peter Lee, executive director of Covered California, said the exchange plans to release detailed data on enrollment by health plans and ethnicity later this month. Support for community health reporting, including Vital Signs, is provided by The California Endowment. While practices were reimbursed for the affected claims through electronic funds transfer (EFT), they have not yet received the detailed claims information in order to post to individual accounts. Rather, it was due to a recent change in CalPERS claims processing that resulted in a several week delay in processing of ERAs. For the San Francisco region, a wide array of new Exchange-based insurance products have been offered by 5 participating health insurance companies.
Every plan offered in the exchange must also be offered outside of the exchange, using the same provider network.
While the notice advised physicians that most changes would go into effect on December 8, 2012, Blue Cross announced in November that implementation of these changes has been delayed until early 2013. Physicians are encouraged to review the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.
It also will offer doctors an opportunity to share in some savings when better patient care leads to a reduction in costs.
That means, for example, working with overweight people who have diabetes to develop an exercise plan and then making sure they stay on it. They are proactive enough to have bought their own coverage, successful enough to afford it and vocal when they realize that their premiums are likely to rise - even double for some. Instead they’ll turn to health insurance agents and buy coverage directly from insurance companies. People who earn too much to expect government help will be shopping for off-exchange plans, where they’ll have more options and the process is much faster.
If it is not grandfathered and you do nothing, you health insurance carrier will transition you to a ACA compliant plan that is closest in coverage and rate to your current plan.
That means that the more than one million California residents who now have individual plans, and are not eligible for subsidies, will very likely be paying a higher monthly premium. That means that the various types of tax deductions listed in the Adjusted Gross Income sections of the IRS 1040 or 1040A forms are also income reductions for purposes of the ACA. The ads will expand awareness of the health benefit exchange, of how the process for shopping and signing up for insurance coverage works, and of how people can find out whether they qualify for financial assistance. Kaiser Permanente, Sharp Health Plan and Western Health Advantage jointly wrote that the exchange should prominently display quality ratings. The public SHOP and private CaliforniaChoice exchanges will feature the following carriers in common: Health Net, Kaiser, Sharp and Western Health.


In light of the changes brought on by the ACA, Word and Brown has expanded its Individual Department as well, offering various services to support agents.
Relatively small plans like Alameda Alliance for Health, Chinese Community Health Plan, Contra Costa Health Services, and L.A. Without the legal power to stop the rate increases, jones has been scorching Anthem in the media and lobbying the Exchange Board to exclude Anthem from the SHOP.
It will give those with a large number of part-time and low-wage employees more time to get their ducks in a row.
According to a recent IRS ruling, only those people not offered affordable coverage at work will qualify for subsidies through the Exchange, but since employers won’t be required to offer it, or report who they are covering, it is unclear how Covered California or the IRS will know who is eligible. This web site is owned and maintained by California Health Benefit Advisers, LLC, which is solely responsible for its content. To ensure a better experience on our site, we recommend using a recent version of Internet Explorer, Google Chrome or Mozilla Firefox. But interviews with industry officials indicate some insurers, such as Blue Shield and Molina Healthcare Inc., picked up more business while others lost ground during the Affordable Care Act’s third open enrollment.
But last month, the company said its Obamacare enrollment in California and 13 other states was 30 percent lower than expected and rivals’ lower rates were one reason. Then in November, the company announced heavy losses on individual policies across the country, and it cut back on marketing of exchange coverage companywide.
But its initial sales in Los Angeles and Orange counties were modest, according to sources who saw preliminary enrollment totals. The company hasn’t commented on its California enrollment, but overall it covers more than 125,000 people in New York, New Jersey, Texas and California. Molina, based in Long Beach, also made substantial gains during open enrollment after a smaller presence the first two years, according to people familiar with the market. The state spent $29 million on marketing during the recent open enrollment to attract the uninsured and persuade existing enrollees to renew.
Physicians who are still missing CalPERS remittances can call (800) 677-6699 to request them. About 300,000 will be eligible subsidized coverage in the exchange and most will get better coverage at lower cost. In the end, some 600,000 Californians who don’t qualify for subsidies should expect to pay more a lot more an many case.
Many of the off-exchange plans are not yet available because government regulators still need to approve them. Marshall has been a frequent commenter on our Q&A Advice blog under the name, Freelancer. The phased approach will allow Covered California to test the ads and fine-tune its customer service process. According to Peter Lee, currently available insurer data are out of date and only cover plans that differ significantly from those that will be offered through the Exchange.
While definitely not part of Gen-x or Gen-y, I generally look for some objective comparative data to make purchasing decisions. Without Anthem Blue Cross, the SHOP will be decidedly less attractive to employers and agents. Care Health Plan lack the resources to field small group plans in the SHOP, but their participation in the individual exchange is desirable. Whether the board would have done that remains a moot point since Anthem has taken that chip off the table. But the final tally will likely drop because some people don’t pay their initial premium or they find coverage elsewhere.
The issue is specific to just Anthem Blue Cross and Blue Shield of California, because they are the only two plans offering narrowed networks. The losers are professionals, entrepreneurs, and mom and pop business owners who did the right thing by buying private health insurance. Covered California instead is determining strategies for quickly collecting performance data during the first year of the exchange and creating its own ratings. That would certainly be to their advantage, so insurers who sell PPOs should be looking for ways to help Covered California quickly gather performance data so that they can compete on a level playing field in the ratings game.
Lujan is expected to release a statement later today and we will continue to provide updates as they become available.
Some web sites or blogs have posted worksheets based on IRS forms developed for very different purposes. The are losing their coverage and facing higher rates to buy replacement coverage that is ACA-compliant.
In fact, MAGI is defined in different ways in well over a dozen different sections of the tax code.



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