Be prepared for Covered California changes in 2017

December 07, 2017
Area(s) of Interest: Advocacy Health Care Reform Practice Management 

In 2016, Covered California, California's health benefit exchange, enrolled approximately 1.4 million individuals in qualified health plans. It is critical that physician practices understand their participation status, which products are being offered and what changes to expect in 2017. 

Some of the most significant changes for Covered California in 2017 are:

  • All Covered California enrollees, including those with a PPO or EPO, will be assigned to a primary care physician. The assignment will either happen by January 1, 2017, or within 60 days of the enrollee’s effective date with the plan.

  • United Healthcare will exit California’s exchange marketplace at the end of 2016, impacting approximately 1,200 enrollees. All other plans that offered coverage in 2016 will continue to do so in 2017.

  • Three plans will be expanding into new regions this year:

    • Molina is expanding its HMO coverage into Orange County (region 18).

    • Oscar is expanding its EPO coverage into San Francisco (region 4); Santa Clara (region 7); and San Benito, Santa Cruz, and Monterey (region 8).

    • Kaiser is expanding into Santa Cruz and Monterey (region 8).

  • Anthem Blue Cross, which offered a PPO product in all geographic regions in 2016, will return to offering only its EPO product for individual/exchange enrollees in the following counties:

    • Region 1: Northern counties

    • Region 2: North Bay Area

    • Region 3: Greater Sacramento

    • Region 4: San Francisco County

    • Region 5: Contra Costa County

    • Region 6: Alameda County

    • Region 7: Santa Clara County

    • Region 8: San Mateo County

    • Region 9: Santa Cruz, San Benito, Monterey

    • Regions 15 and 16: Los Angeles counties

    • Region 17: Inland Empire

    • Region 18: Orange County

    • Region 19: San Diego County

Physicians are reminded that the Anthem Blue Cross EPO product does not offer member coverage for services provided by an out-of-network provider except in urgent/emergent situations. The change in product type from PPO to EPO may also result in changes to the provider network network and access to participating hospitals in each region. Click here to see which hospitals will NOT be participating in the Pathway PPO/EPO plans effective January 1, 2017. Physicians in affected counties who are currently contracted with Anthem for the exchange/mirror PPO product are encouraged to check the directory to confirm whether they will be part of the plan’s EPO network in 2017.

  • Anthem Blue Cross will now only offer its PPO product in the five following regions for 2017.

    • Region 10: Central Valley

    • Region 11: Fresno, Kings, Madera counties

    • Region 12: Central Coast

    • Region 13: Eastern counties

    • Region 14: Kern County

There are some other minor benefit design changes for 2017, such as some increases and decreases to copays for different plan tiers and visit types. For more information, see the 2016 and 2017 standard benefit design grids.

To help physicians understand the changes taking place and how they will affect their practice, the California Medical Association has published a new tip sheet, “Surviving Covered California: Preparing for changes in 2017.”

The tip sheet is available free to membershere.


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