Resources


 

Health Care Reform Resources for you

This Resource page will be updated regularly when new information is available.

This is a page you will want to bookmark, as you will use these links and information many times during your search for the right health insurance plan. We have organized the resources into the following sections:

If you need information on specific health care reform topics, refer to the detailed pages we’ve created. At the bottom of each page we’ve listed specific health care reform resources that relate to that topic.


Provider Networks

If you have a physician you want to keep seeing, then it is important to verify which networks the doctor is in by using the provider network links below.

I do not recommend calling the doctor’s office and asking. The doctor’s office personnel will not be able to tell you which networks are for individual plans versus the networks for company-sponsored group health insurance.

Once you’ve narrowed the choice down to 1 or 2 plans and networks, the doctor’s office can give you a Yes or No answer to accepting the plans you want to apply for.

Follow the instructions provided for each of the doctor search tools below and you can determine which health insurance plans your doctor accepts.

Once you have decided which plan to apply for, call the doctor’s office to verify they accept the plan and network before you begin the application.

See examples of how to use the Anthem Blue Cross and the Blue Shield of California doctor search tools in the Video below:

California Provider Search Tool Examples & Instructions: WATCH FIRST

Learn how to correctly use the Provider Search Tools for every health insurance company in California. This video shows doctor search examples using the Anthem Blue Cross and the Blue Shield of California web search tools. The instructions on how to use every search tool are shown the on the SPF Insurance website. Because of the recent 2017 Rate Increase announcements it will be vital that you know which networks your doctors participate in before deciding what to do during the Open Enrollment period this fall. At SPF Insurance we specialize in helping our clients get the right plans, and that includes ensuring that your doctor accepts the plan. Checking to see what provider networks your doctor accepts is the second step in our proven 5-Step process.

Provider Network Links:

  • Anthem Blue Cross Provider Network Search Click Here

    Doctor Search Tool for Anthem Blue Cross

    On the first page you will use the right side under “Search as a Guest.” Under the light blue button, click the link “Search by Selecting a Plan or Network.”

    On the next page use the left side and select “Medical” from the drop-down menu under “What type of care are you searching for?” Next you will select the state. Then under “Select a plan/network” you will select the type of network.

    Anthem lists a bunch of different networks, but the only one’s you need to select are the one’s at the top of the list under the “Medical Networks on-Exchange” called “Pathway X.” The on-Exchange or Covered California provider networks are identical to the off-Exchange networks, so we can choose from these four networks:

    • Pathway X – PPO Tiered Network
    • Pathway X – HMO Network
    • Pathway X – PPO Network

    Once you’ve selected the network, click the blue “Continue” button.

    On the next page you can enter you doctor’s last name and then in the drop-down menu under “Who Specializes in” you will want to select the “All Specialties” option at the top of the list. You can select your doctor’s specialization if you are certain of it, otherwise use All Specialties.

    The last step is to enter the City where your doctor’s office is located. Then click the blue “Search” button below.

  • Blue Shield of California Provider Network Search Click Here

    Doctor Search tool for Blue Shield of California

    The Blue Shield 2017 network search tool looks very different than last year.

    The initial page shows a large white box with 10 options shown inside. The ones we’ll focus on are the two at the top: Doctors, and Primary Care Physicians. You’ll use the “Doctors” option whenever you are searching to see if your doctor is in the network.

    The “Primary Care Physician” box is only used to select your primary doctor from an HMO plan.

    Click on the “Doctors” block and you will get a drop-down box with the question “Are you a Blue Shield member?” You’ll select the “No” answer.

    On the next page it will ask “Where are you located?” You’ll want to put in the city or zip-code where your doctors are located unless they work near your home. Then click the blue “Continue” button.

    On the next page it will ask you “Do you already have a plan in mind?” Answer this question with a “Yes.” This will allow you to select the network and plan you want.

    On the page where it says “Find Your Plan,” you’ll want to click the text “Choose Plan Type.” This will show a drop-down menu with all the network names. For 2017 you’ll want to select either the “2017 Individual and Family PPO Plan (including Covered California)” or the “2017 Individual and Family HMO Plan (including Covered California).” Then click on the “Select Sub Plan” text and choose any plan name from the drop down menu that shows up (I always select the Silver 70 PPO). It does not matter which one you use because they all have the same network of doctors. Then click the blue “Continue with this plan” button.

    You will finally reach the “Search Doctors” page. Here you can search for your Physician’s name by clicking the “Doctor Name” bullet, entering your physician’s last name in the entry field, and clicking the light-blue “Search” button.

  • Cigna Provider Network Search Click Here

    Doctor search tool for Cigna

    Cigna provides a fairly easy to use provider search tool. Just enter your zip-code, then select the year 2016 on the next screen, and then select the “LocalPlus” network on the next screen. These steps have taken you to the Cigna network provider search tool resource. Here you need to select “Person by Name” in the Find a… box. Then insert your doctor’s name in the next box and click the blue search button on the right side.

  • Health Net Provider Network Search Click Here

    Doctor search tool for Health Net

    Health Net’s provider search tool is a little bit awkward until you get used to it. First, select the year you want, then select the “location type.” I’ve found the easiest way to search is to select the “county” option. Then type in the name of the county, and click continue.

    In the lower section, click on the “Filter by provider name” option, and enter your doctor’s name. Then click the green Continue button. This will take you to another page where it will display all the doctors with that name. If you doctor does not show up in that list, he/she is not in any of the Health Net networks. If you see your doctor’s name, then click the green “view details” button, and this will bring up a panel showing specific information about your doctor.

    Inside that panel there is a “Select a Plan” menu which shows all the Health Net networks the doctor participates in. For individual plans on Covered California there is a section in bold which shows these networks. Outside of Covered CA you are looking for the PPO Individual & Family network, the HSP Individual & family network, the EPO individual & family networks, and the HMO Community Care network. If you don’t see any of these, then your doctor does not accept Health Net’s individual plans.

  • Sharp Health Plan Provider Network Click Here

    doctor search tool for Sharp Health Plan in San Diego

    The Sharp Health Plan network is primarily composed of 2 Sharp physician groups and 4 north county medical groups. The following medical groups are in the Sharp network:

    1. Sharp Community Medical Group (SCMG) – Premier & Performance (network 1 & 2)
    2. Sharp Rees-Stealy (SRS) – Premier & Performance (network 1 & 2)
    3. Rady Children’s Health Network/Children’s Physicians Medical Group (CPMG) – Performance (network 2)
    4. Primary Care Associates Medical Group (PCAMG) – Performance (network 2)
    5. Greater Tri-Cities IPA (GTC) – Performance (network 2)
    6. Arch Health Partners – Performance (network 2)

    Sharp Health Plan offers two networks to choose from. The Premier network includes only Sharp providers. The Performance network is larger and includes medical groups outside Sharp’s control. Therefore, Sharp Health plans using the Performance network 2 have higher premiums than the Premier network 1 plans.

    Use the “I’m a Guest” area and select the “Search All Networks” option. Then click the Orange Search Providers button at the bottom right. Resist the urge to tweak any of the other settings on this initial page.

    You’ll now see all the doctors like your’s in San Diego. Just above the list there is a search entry box. Put your doctor’s name there and click the “Search” button. If your doctor is in the network you will see his/her name show up below. On the right side of the screen is a gray “Advanced Search” area. Inside here there is a “Network” drop-down menu that will show you which networks this doctor accepts. You can also click on the doctor’s name and on the next page it will show the networks the doctor participates in.

  • Kaiser Permanente Provider Network Click Here

    The Kaiser Permanente provider network search resource is very simple to use. Just select the region you live in from the drop-down menu and hit go. Then enter your city name or zip-code, and the name of your Kaiser Physician and hit the “Search” button.

    All Kaiser physicians will accept health care reform plans.

  • Western Health Advantage Provider Network Click Here

  • Molina Healthcare Provider Network Click Here

    To get to the Molina Healthcare provider search tool, you must visit the company homepage and then click the “Find a Doctor or Pharmacy” button in the website navigation bar under the logo.

    On the next page you will select the “Search by City or Zip” option, then select your “State.” Wait just a second while the page reloads, then select the name of your city from the drop-down menu, or enter your doctor’s zip code.

    In the “Select a Coverage and Provider Type area you will select the “Molina Marketplace” in the Coverage drop-down menu and select either “Primary Care Physician” or “Specialist” from the Provider Type drop-down menu. Then scroll down slightly and click the dark teal “Search” button.

    This will give you a list of ALL the Molina doctors within within 5 miles from the center of the city or zip code you provided. You will now have to scan through the list to see if your doctor’s name shows up.

  • Oscar Health Insurance Provider Network Search Click Here

    Click the down arrow next to the “Doctors Type” entry and select “Doctor name.” Then type in your doctor’s name in the neighboring field.

    As you type the doctor’s name Oscar will show you a list of doctors with the same (or similar) name. If you see your doctor’s name in the list then click on it to verify that it is your doctor. If not, then click the green search button (magnifying glass). This will bring up the list of doctors that match the name you entered.

    If you don’t see your doctor’s name, then he/she is not currently in the Oscar network.

  • Medi-Cal Provider Directory Search Click Here

  • United Healthcare of California Provider Network Search Click Here


Pharmacy Benefits & Formulary Lists

Each health insurance company has their own list of drugs that they will cover for a co-payment. These lists are called their Formulary. To make sure your specific drugs are covered you will need to search for them using the links provided below.

You can also use the following link to get retail prices for your medications at a pharmacy near where you live. Click here.

Use these prices to determine if it makes sense to be on a Bronze plan without prescription benefits versus a Silver plan with drug co-payments.

If you have questions, please call us.


Patient Protection and Affordable Care Act Documents And Analysis

This section is for the curious and the people that want to know the details of Obamacare. These are the rules and regulations of the ACA. The creation of this website is based on reading a lot of this material.

We’ve also included websites that write great analyses of the ACA and how it works. These are all sources we feel are the best and most authoritative.

http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm Entitled The Patient Protection and Affordable Care Act. {NOTE: Mar. 23, 2010 – [H.R. 3590]}. From the U.S. Government Printing Office

http://www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013-04084.pdf Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation; Final Rule. From the Federal Register dated February 25, 2013

http://www.ecfr.gov/cgi-bin/text-idx?SID=4428aa6823445709fbaa0c9b703b8742&mc=true&tpl=/ecfrbrowse/Title45/45CsubchapB.tpl The most updated set of Federal Regulations regarding the Affordable Care Act. The text that effects most people is in part “155”.


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