ACA... Some questions.

[tvguy]

An important point about “keeping your doctors”: Medical groups negotiate contracts with insurance companies periodically. A group can decide to not participate in any particular insurance plan if agreements can’t be reached when contracts are renegotiated. Just as insurance companies can negotiate with different hospital networks to make them in network or not. The government can’t mandate that doctors must accept specific insurance companies. Or that insurance companies must make every hospital, physician or lab in network.

In the last 2 years in my area, the largest physician group could not come to an agreement with BCBS Medicare Advantage plans. So they stopped participating in that insurance. Patients were notified well before the contract expired in July, so they were able to make decisions before open enrollment. The majority of patients chose to move to other insurance companies & stay with the physician group.

We have a highly regarded cancer center here. Last fall 2 different insurance companies announced the cancer center would no longer be in network because the 2 sides were unable to agree on covered treatments & reimbursements. Again, many patients had to decide if they wanted to find another insurance company or choose other cancer treatment options if the need should arise.

So my point is…. Keeping your doctors, your preferred hospital network, laboratory or rehabilitation therapists is very fluid. Your doctor may start out as in network, but that could change the next time contracts are negotiated. Its another thing in life that’s not guaranteed.

My friend switched insurance policies a couple of years back because not a single primary care Doctor accepted the plan she had. And in California, you have to see a Doctor within 30 miles of your home.

 

[disneychrista]

My friend switched insurance policies a couple of years back because not a single primary care Doctor accepted the plan she had. And in California, you have to see a Doctor within 30 miles of your home.

Where do you come up with some of these ridiculous so called "rules'? I have never heard of plan, outside of Kaiser, that required you to see a doctor within X miles of your home. There are people who don't even live within 30 miles of a doctor.

 

[tvguy]

Where do you come up with some of these ridiculous so called "rules'? I have never heard of plan, outside of Kaiser, that required you to see a doctor within X miles of your home. There are people who don't even live within 30 miles of a doctor.

EDIT: MY MISTAKE. LAW IS 30 MINUTES AND 10 MILES, NOT 30 MILES.


FROM AI
Covered California plans typically require that primary care services be located within 30 minutes or 10 miles of your residence, adhering to state travel time and distance standards. While in-network routine care must be within these limits, emergency services are covered anywhere, and you may request exceptions for specialist care.


Not me. California law. And yes, you are correct but it is the law.
https://www.disabilityrightsca.org/...are-time-and-distance-standards-for-providers

 

[barkley]

My friend switched insurance policies a couple of years back because not a single primary care Doctor accepted the plan she had. And in California, you have to see a Doctor within 30 miles of your home.

this is why it's vital in retirement planning if you are planning on utilizing (if you are able) retiree health insurance to see WHAT plans you are eligible to as a retiree/if there are any providers where you live/plan to move to. my former government employer in California offers VERY different plans to retirees vs. active employees. people retired and found out the plan they had as an active employee wasn't offered to retirees and they were left w/plans that didn't cover the providers they had for years. in our situation we moved out of state and the only plan offered is an obscenely expensive PPO w/ no 'preferred providers' anywhere in the region.

 

[focusondisney]

EDIT: MY MISTAKE. LAW IS 30 MINUTES AND 10 MILES, NOT 30 MILES.


FROM AI
Covered California plans typically require that primary care services be located within 30 minutes or 10 miles of your residence, adhering to state travel time and distance standards. While in-network routine care must be within these limits, emergency services are covered anywhere, and you may request exceptions for specialist care.


Not me. California law. And yes, you are correct but it is the law.
https://www.disabilityrightsca.org/...are-time-and-distance-standards-for-providers

The link you provided covers Medi Cal (Medicaid). It also says insurance companies can apply for exemptions if they cannot get providers within those limitations. The linked article doesn’t say anything about Medicare or other insurance plans. No one can force a provider to participate in/ accept a particular insurance company. So again, the provider in your current plan can choose to no longer accept that insurance in the future,

 

[tvguy]

The link you provided covers Medi Cal (Medicaid). It also says insurance companies can apply for exemptions if they cannot get providers within those limitations. The linked article doesn’t say anything about Medicare or other insurance plans. No one can force a provider to participate in/ accept a particular insurance company. So again, the provider in your current plan can choose to no longer accept that insurance in the future,

Not talking about Medicare. Just Covered California and Medi-Cal, which operate under the same rules in California.

 

[focusondisney]

Not talking about Medicare. Just Covered California and Medi-Cal, which operate under the same rules in California.

This post didn’t reference Medi Cal at all, but made a general “In California” statement, as if it applied to every medical situation & all insurance.

My friend switched insurance policies a couple of years back because not a single primary care Doctor accepted the plan she had. And in California, you have to see a Doctor within 30 miles of your home.

 

[tvguy]

This post didn’t reference Medi Cal at all, but made a general “In California” statement, as if it applied to every medical situation & all insurance.

Read the link

 

[barkley]

No one can force a provider to participate in/ accept a particular insurance company

along the same lines-a provider can cap the number of patients they take from an individual plan (including Medicare plans). it's vital when looking at any insurance plan to see if a particular provider/specialist you want to use/retain, even if they are listed as covered/a participating provider-WILL RETAIN you as a patient. our Medicare plan was discontinued at the end of 2025 so we had to look to others. our pcp has had a years long wait list to become a patient so we contacted their office to ensure we could be retained if we switched to another plan that listed him as covered-good thing we did b/c they noted that an exception would be communicated to allow for us to select him as our 'new' pcp b/c otherwise he was coded as not accepting 'new' patients for any of the plans he is listed under.

 

[Mackenzie Click-Mickelson]

So my point is…. Keeping your doctors, your preferred hospital network, laboratory or rehabilitation therapists is very fluid. Your doctor may start out as in network, but that could change the next time contracts are negotiated. Its another thing in life that’s not guaranteed.

Agreed and another scenario that can happen is a buyout or a merger.

A few years ago KU Med bought out Olathe Med, recent stories have covered that due to that buy out quite a bit of patients now have much higher bills due to either different coding, different billing amounts charged or doctor or visit is now considered an outpatient.

https://www.kansascity.com/news/local/community/johnson-county/olathe/article314578029.html

 

[focusondisney]

Read the link

Maybe you should. It says Medi Cal. It applies to insurance companies in that program. It does not mandate physicians to accept any particular insurance. Your post I quoted incorrectly implied the rule applied to every insurance in every program.

 

[disneychrista]

EDIT: MY MISTAKE. LAW IS 30 MINUTES AND 10 MILES, NOT 30 MILES.


FROM AI
Covered California plans typically require that primary care services be located within 30 minutes or 10 miles of your residence, adhering to state travel time and distance standards. While in-network routine care must be within these limits, emergency services are covered anywhere, and you may request exceptions for specialist care.


Not me. California law. And yes, you are correct but it is the law.
https://www.disabilityrightsca.org/...are-time-and-distance-standards-for-providers

Does not apply to anyone not on Medi-cal

 

[tvguy]

Does not apply to anyone not on Medi-cal

Ok

 

[tvguy]

Maybe you should. It says Medi Cal. It applies to insurance companies in that program. It does not mandate physicians to accept any particular insurance. Your post I quoted incorrectly implied the rule applied to every insurance in every program.

I did not intend to imply anything but Covered California and Medi-cal as that is what this thread is about.

 

[focusondisney]

I did not intend to imply anything but Covered California and Medi-cal as that is what this thread is about.

The thread is about LeeBee’s sister, who lives in Louisiana. Only you made it about California.

 

[tvguy]

The thread is about LeeBee’s sister, who lives in Louisiana. Only you made it about California.

Just discussing on a discussion board.

 

[robinb]

this is why it's vital in retirement planning if you are planning on utilizing (if you are able) retiree health insurance to see WHAT plans you are eligible to as a retiree/if there are any providers where you live/plan to move to. my former government employer in California offers VERY different plans to retirees vs. active employees. people retired and found out the plan they had as an active employee wasn't offered to retirees and they were left w/plans that didn't cover the providers they had for years. in our situation we moved out of state and the only plan offered is an obscenely expensive PPO w/ no 'preferred providers' anywhere in the region.

Retiree plans are not required to follow ACA rules, so you are on the hook for many things that are required to be covered under your employee plan. For instance, my DD24 was kicked off my DH’s plan and we suddenly had to pay for lab work and colonoscopies. It was annoying that even a Blue Chip company that self insured cut costs on their retirees because they could.