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Covered CA - Frequently Asked Questions

Covered California & Other Insurance Exchange Networks

Sansum Clinic has established a hotline with information and answers to your questions about the Affordable Care Act (ACA) and Covered California.

Call Our ACA HOTLINE: (805) 898-3301

Resources:

Obamacare Explained | A Guide for Californians. Produced by KQED News and The California Report (March 2014)

Learn all about the Affordable Care Act health insurance plans and premiums available in California. Are you eligible for a subsidy (in the form of tax credits) to help you buy insurance? Whether you have insurance at work, through Medicare or Medi-Cal or don't have insurance at all, this guide summarizes what you need to know.

Covered California website is CoveredCA.com.

  • The website offers a list of Frequently Asked Questions, which addresses many questions patients may have about Individual or Small Group plans being offered in Region 12 of California.
  • There is also a link to the insurance brokers licensed to enroll under Covered California on the website Covered CA.com.
  • Patients can shop and compare multiple plans at one time for benefits/cost.
  • To speak with a Covered California representative call:
    English (800) 300-1506
    TTY (888) 889-4500
    Español (Spanish)  (800) 300-0213

 
Anthem Blue Cross website is Anthem.com/ca.

Health Resource Center

Sansum Clinic’s Health Resource Center can assist you with the websites listed above if you do not have access to a computer. It is located on the first floor of Sansum Clinic’s multi-specialty site at 215 Pesetas Lane, or you can call the center at (805) 681-7672.  Hours are Monday thru Thursday from 9:00 am to 4:00 pm and Friday 9:30 am to 12 noon; or by appointment.

Frequently Asked Questions:

1. Question: Is Sansum Clinic part of the Covered California Exchange?

Answer: We are part of the Covered California Exchange through Anthem Blue Cross for Individual plans in Region 12 (for patients living in Santa Barbara, San Luis Obispo, Ventura Counties). For patients living in other Regions of California/States, please check with Anthem Blue Cross directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.

2. Question: Is Sansum part of all of the Blue Cross Exchange plans? 

Answer: We do not know at this time. Sansum Clinic does know we are In Network providers for Anthem Blue Cross Individual plans in Region 12 (patients living in Santa Barbara, San Luis Obispo, and Ventura counties) on Covered California (Exchange) or off-Exchange (purchased at health plan directly). For patients living in other Regions of California/States, please check with Anthem Blue Cross directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.

3. Question: I have been told by Sansum Clinic staff and read on the Sansum Clinic website that Sansum Clinic is part of Anthem Blue Cross Individual Plan Exchange and off-Exchange network; however, Sansum Clinic providers are not showing up on the Covered California website. What does this mean?

Answer: Sansum Clinic has an agreement with Anthem Blue Cross Individual plans  in Region 12 (patients living in Santa Barbara, San Luis Obispo, and Ventura counties). For patients living in other Regions of California/States, please check with Anthem Blue Cross directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network. We have been told by Anthem Blue Cross that Covered California committed to having Sansum Clinic appear on their website by December 16, 2013.

4. Question: Are Sansum Clinic providers considered In Network or Out of Network for Anthem Blue Cross and/or Blue Shield Covered California (Exchange) or off-Exchange? 

Answer: Sansum Clinic providers are In Network providers for Anthem Blue Cross Individual plans sold on Covered California (Exchange) or off-Exchange in Region 12 (people who live in Santa Barbara, San Luis Obispo, Ventura counties).  Sansum Clinic is considered Out of Network for Blue Shield Individual Plans and Small Group Plans through Covered California (Exchange) and off-Exchange (plans sold directly by the health plan for Individual and Small Group plans). For patients living in other Regions of California/States, please check with your broker, Covered CA, or the health plan directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network. 

5. Question: What does Out of Network mean? 

Answer: Sansum Clinic providers may not be in your particular plans’ network of participating providers, which will likely necessitate you to pay higher Out of Network  Coinsurance, Out of Network Deductibles, and Out of Network benefits at a higher out of pocket cost than In Network providers.  Generally, there are different accumulators for In Network versus Out of Network benefits as well. It is best you discuss this with your broker, Covered California, or health plan directly to discuss what the Out of Network benefits are for your chosen plan.

6. Question: Are all Sansum Clinic providers contracted with Blue Shield Covered California?

Answer: No, Sansum Clinic providers are not contracted with Blue Shield Individual or Small Group plans on Covered California (Exchange) or off-Exchange (those sold directly by the health plans) for people who live in Region 12 (Santa Barbara, San Luis Obispo, Ventura Counties) and do not qualify for Medi-Cal or Medicare.  We are contracted with Blue Shield for Group plans as we have always been in past. 

7. Question: Is PDL (Pacific Diagnostic Laboratories) contracted with Anthem Blue Cross and/or Blue Shield Covered California (Exchange) or off-Exchange products? 

Answer: You will need to ask your broker, specific health plan or Covered California for laboratory providers covered by your Individual or Small Group plan.

8. Question: Is Prescription Pharmacy located at 215 Pesetas Lane/51 Hitchcock Way and/or Sansum Pharmacy taking Anthem Blue Cross Individual plan and/or Blue Shield Covered California (Exchange) or off-Exchange pharmacy plans?

Answer: You will need to ask your broker, specific health plan or Covered California for pharmacy providers covered by your Individual or Small Group plan.

9. Question: What other providers in Santa Barbara County are contracted with Anthem Blue Cross and/or Blue Shield Covered California (Exchange) or off-Exchange Individual or Small Group plans? 

Answer: You will need to ask your broker, specific health plan or Covered California for information regarding whether the provider in question is considered In Network or Out of Network for any Individual or Small Group plan.

10. Question: Will Sansum Clinic be able to tell me my out of pocket cost before proceeding with recommended procedures/treatment.

Answer: If we have confirmed your eligibility with your chosen health plan, and you have a plan that includes Sansum Clinic as an In Network provider, we should be able to if services/procedures are known when your out of pocket costs are estimated.

11. Question: Will Sansum Clinic accept health plans from out of state Exchange programs?

Answer: Yes. However, you will have to verify if care at Sansum Clinic or with Sansum Clinic providers will be considered In Network or Out of Network.   Out of Network means that the provider is not participating in your particular plan even though we may have an agreement/contract with the plan for other plan types (Group plans, for example).

12. Question: Will mental health or eye benefits be carved out through other plans affiliated with Anthem Blue Cross or Blue Shield of California? 

Answer: It is unknown at this time if Covered California (Exchange) or off-Exchange Metal plans (Platinum, Gold, Silver, Bronze, and Catastrophic) will use other plans to supply this benefits/network of providers or if Sansum Clinic mental health providers and eyewear/vision providers would bill your health plans under your medical benefits.

13. Question: What Covered California insurances are contracted with Sansum Clinic?

Answer: The only plan Sansum Clinic has an agreement with for Individual Plans is Anthem Blue Cross on Covered California (Exchange) and off-Exchange for Region 12 (if you live within Santa Barbara, San Luis Obispo, Ventura counties). We are also a Health Net Small Group Plan participating provider on Covered California (Exchange) and off-Exchange.

14. Question: Will I be able to keep my Sansum Clinic doctors if I get insurance under Covered California?

Answer: Yes, if you live in Region 12 (Santa Barbara, San Luis Obispo, Ventura counties) and sign up with Anthem Blue Cross Individual plan on Covered California (Exchange) or off-Exchange (sign up directly with Anthem Blue Cross).  For patients living in other Regions of California/States, please check with your broker, Covered California or health plan directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.

15. Question: Where do I go to get insurance under Covered California?

Answer: Go to CoveredCa.com or consult a local broker (coveredCA.com lists licensed brokers who are able to sell Individual and Small Group Exchange/off-Exchange Metal plans). Covered California marketplace must be used if you qualify for a subsidy.

16. Question: Are there any insurance brokers that can sign me up?

Answer: You can visit CoveredCa.com for a list of licensed brokers authorized to sell Individual and Small Group Exchange Metal plans, check with Anthem Blue Cross directly; or visit Anthem.com/ca.

17. Question: How does the Exchange insurance affect my coverage?

Answer: We do not know at this time. If you received a letter from your current individual insurance carrier, you should follow the advice in the letter to obtain new coverage for 2014.

18. Question: Does the new Insurance Exchange affect my Medicare benefits?

Answer: No, it does not.  Medicare is a Federal Insurance Program  for disabled patients and/or people over 65 years of age.

19. Question: Will I be able to get insurance even though I have a pre-existing condition?

Answer: Yes, the Accountable Care Act (ACA) has included this provision in all Individual and Small Group Plans in California and most, if not all, of the United States (depending on the State).

20. Question: What do the plans cover?

Answer: There are five types of plans – Platinum, Gold, Silver, Bronze, and Catastrophic – and all plans under the Metal plan being offered on Covered California (Exchange) or off-Exchange (direct through the health plan) must offer actuarially similar benefits.  However, the cost of the plan may vary and Out of Network costs/benefits may vary by Metal plan type and health plan (carrier).

21. Question: What plan is better for me as a Sansum Clinic patient?

Answer: Sansum can only tell you that if you want to keep your Sansum Clinic doctor, you need to buy an Individual Plan for you and your family that we are currently contracted with to serve you for In Network benefits. The only plan at this time that Sansum Clinic is contracted for/in Provider Network for Individual plans is Anthem Blue Cross Individual plan through Covered California (Exchange) and Off-Exchange (directly through Anthem) for patients who live in Region 12 (Santa Barbara, San Luis Obispo, and Ventura counties). For patients living in other Regions of California/States, please check with your broker, Covered California or health plan directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.  We are also known In Network providers for patients who live in Region 12 (Santa Barbara, San Luis Obispo, Ventura counties) with Health Net PPO for their Small Group Plan on Covered California (Exchange) and off-Exchange.

22. Question: Which plans have more coverage? 
Answer: Patients can use the Shop and Compare tool of the Metal plans on the CoveredCA.com website. In general, Platinum plans offer the highest level of benefits, but are more expensive. In addition, Bronze plans offer the lowest level of benefits and are the least expensive. Gold and Silver Metal plans are somewhere in between Platinum and Bronze plans.  

23. Question: Can I still have a secondary insurance with Covered California?
Answer: We do not know at this time. Please verify this with CoveredCa.com, your broker, or your health plan directly. 

24. Question: Where can I get information about whether or not my Sansum Clinic provider is participating in the Individual or Small Group Covered California (Exchange) or off-Exchange (directly through the health plan)? 

Answer: Sansum Clinic and all our providers are only participating with Anthem Blue Cross Individual plans on/off-Exchange and Health Net PPO Small Group plans on/off-Exchange. We may be considered Out of Network for any other Individual/Small Group plans sold in Region 12 of California (Santa Barbara, Ventura and San Luis Obispo counties); other regions of California; other states/federal on/off-Exchange products sold in other States.

25. Question: How do I find out if Sansum Clinic providers are participating in my Individual plan purchased through a non-Anthem Blue Cross Individual PPO plan? 

Answer: Sansum Clinic and our providers will not always know if we are In Network or Out of Network for many of these EPO, PPO, EPPO plans and it is best if you call the specific health plan or Covered California to get this confirmation. Sansum Clinic and our providers will require you to sign a Notice regarding In Network or Out of Network status, which will also indicate that you may be responsible for your plan’s Out of Network copay, coinsurance and maximum out of pocket costs, which are different than In Network benefits on many plans being sold on and off the Exchange. This waiver is designed to inform you about the possibility that higher out of pocket costs may be levied by your plan if you see Sansum Clinic providers on an Out of Network basis. 

26. Question: Are Anthem Blue Cross Individual plans (on or off-Exchange and sold in Region 12 - Santa Barbara, Ventura, San Luis Obispo counties), either on Covered California or through a broker or at health plan directly, accepted at Sansum Clinic by all of Sansum Clinic providers? 

Answer: Yes. However, there are a few exceptions, including PDL (as PDL labs are not billed by Sansum Clinic to any insurance company); as well as Dr. Richard Chung (neurosurgeon), Sansum Radiologists, and Retina Ophthalmologists, all of whom Sansum Clinic bills for only when patients are seen within Sansum Clinic facilities.

DISCLAIMER: This document was created to assist Sansum Clinic patients and as of December 28, 2013 this information is accurate to the best of our knowledge. We are getting new information all the time and will update this as material information changes.
 

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