California Health Care

by John Hansen

If Kaiser Permanente has a surplus of income, then why not just give the money back to the members? Why not just lower prices for everyone?

Blue Shield of California has their 2% commitment, where they give refunds back to their members if they make over 2%. Why doesn’t Kaiser Permanente just follow suite?

Kaiser Permanente is the most efficiently run health plan in California. It consistently outranks its competitors due to its integrated system and streamlined processes. Efficiency lowers costs that can be passed on to consumers.

Kaiser Permanente couldn’t handle the amount of new enrollments that lower prices would bring in. Its network just isn’t big enough.

Already, Kaiser Permanente is struggling to deal with the huge amounts of increases in enrollment since the implementation of Health Care Reform in California. Due to Kaiser’s integrated system, they are unable to expand as fast as their chief competitors, Anthem Blue Cross and Blue Shield of California.

KP is...

by John Hansen

The reinsurance stipulation of the Affordable Care Act comes to an end in 2016. This could prove advantageous for Kaiser Permanente, who tends to only be hurt by reinsurance.

Reinsurance was designed to decrease the risk of carriers getting too many high cost enrollees. In reality, it decreases the risk not only of adverse selection, but also the risk of poor management of a health plan.

Reinsurance required health insurance carriers with lower risk enrollees to give funds to other carriers who had higher risk enrollees. The assumption was that this stipulation would decrease the carrier’s fears of Health Care Reform causing them to get an adverse selection of new members, which would increase their risk and their costs.

Kaiser Permanente argued the obvious from the beginning: Higher risk pool is not only created by adverse selection, but it is also created by poor health plan management. The better you service your clients and get them to do their checkups and maintain t...

by John Hansen

Due to the efficiency of the Kaiser model, the end of reinsurance, top ratings in the state and growing popularity, Kaiser Permanente also has to deal with the problem of what to do with surplus income. They have three main options.

This option sounds the most appealing to consumers as well as to the Obama Administration and Covered California. However, it is likely the least appealing to Kaiser Permanente at this point in time.

Kaiser Permanente, who prides itself in offering affordable health care (including their Covered California Kaiser plans) just can’t afford to lower prices too much more than they already have. Why? Lower prices could bring too many new members. California’s monster HMO is limited in how many new members it can take on.

Anthem Blue Cross and Blue Shield of California can grow their reach quickly simply by contracting with more doctors, hospitals and physician networks. But for Kaiser to add many more members, they would need to take on a more dif...

by John Hansen

During the 2016 Open Enrollment for Covered California, Blue Shield of California enrolled the largest amount of new clients into the exchange of any of the carriers in the Health Insurance Marketplace. Blue Shield took 28% of market share followed by Anthem Blue Cross at 25%, Kaiser Permanente at 24% and Health Net at 13%. Of the enrollments with the other eight carriers offered by Covered California, they only added up to 9% of the marketplace.

Top leaders in Blue Shield addressed this question and commented that it came down to three areas:

“Where we were competitive on network, choice and price, we tended to do well in those markets,” said Jeff Smith, Vice President of Individual and Family Plans for Blue Shield of California.

In a room full of leading California brokers in May of 2016, the room seemed to be in agreement that usually Blue Shield of California was the leader when it came to Network. Blue Shield has maintained a large network and continued to build it....

by John Hansen

For many die-hard PPO lovers, this sounds like the sky is falling. Oh, no you’re not! I chose a PPO because I didn’t want someone else to pick my Primary Care Physician (PCP).

I didn’t want to get babysat by an HMO. That’s the whole reason I chose a PPO in the first place. I’ll make the choice regarding who my doctor is thank you very much.

A lot of fears have surfaced since Covered California made this decision:

Yes, you’ll get assigned a doctor, but you don’t ever have to see that doctor, and you can go see a specialist or another doctor without a referral from your assigned doctor. You don’t have to ever see your assigned doctor, and you can change doctors any time you want.

Also, carriers are going to try to assign you to the doctor that you’ve already been seeing if they can. This will help avoid unnecessary confusion on the part of the consumers and the doctors. But getting the systems in place to harvest this information could be difficult for carrie...

by John Hansen

In 2015, one of the top carriers with Covered California, Blue Shield, pulled their fifteen Regional Sales Managers (RSM’s) out of the field and brought them back to the main office to service their agents remotely. This allowed their RSM’s to service more agents and to serve them more effectively.

Typically, health insurance carriers have Regional Sales Managers driving all over the state of California visiting brokers. They visit about five brokers a day, make that personal connection and offer to help their agents in any way they can.

Each RSM has his or her own region. Depending on how well that region does for the carrier, they reward the RSM accordingly. The #1 goal is to get the agents to sell more Blue Shield. Mobile Regional Sales Managers do that in several ways:

Stuck behind a desk and a phone, the smiles, handshakes and personal conversation are minimized, but the ability to help agents trouble shoot problems with enrollments, billing, claims, etc. has bee...

by Stephen Saucier

Even though open enrollment for 2016 coverage is just about to start, the team at Covered California is already working hard to ensure that customers will have even better plan designs for the 2017 Covered California open enrollment period. A key part of their approach to improve the 2017 open enrollment period is to gather as much information as they can through surveys, from the carriers, and from customers to identify areas that need more clarity and transparency. This helps pin point where things are going well and the areas that could use improvement.

There are at least three potential changes to plan designs coming in the 2017 Covered California open enrollment period that are pretty exciting:

While it’s not a guarantee that all of these changes will take place, it does seem likely. If they do, it will mean a significant improvement in the overall value of many Covered California Health Plans.

Another way the Covered California Plan Management team is working har...

Moving can be a stressful time. Some may find moving to a new area and learning to navigate challenging. Others stress about getting used to a new job, school or community space. Moving undoubtedly brings difficult transitions, whether moving closer or further away from family. Despite the whirlwind of emotions, it also comes with health insurance challenges.

Moving to a new state often means you will have to switch or transfer your plan, resulting in more steps to complete before you’ve fully settled into your space. By learning how to change or transfer insurance easily, you’ll reduce the stress of moving and cross one thing off your moving checklist.

Changing health insurance when moving states comes with many requirements and specific enrollment periods. You can usually only switch health insurance if moving to California during an open enrollment period. This means you can only apply for new coverage on January 1st of the following year at the very earliest. However, your move...