Everything You Wanted To Know About Your Health Plan (But Were Afraid To Ask)

It can be well worth the effort to go up against your health plan if it denies you treatment you think you need.

That’s just one of the many lessons consumers can glean by using a new online tool unveiled last week by the Department of Managed Health Care.

It shows that last year, nearly two-thirds of Anthem Blue Cross enrollees who filed an appeal with the department to challenge a denial of care ended up getting the medical services they requested. The same was true in well over half of the appeals filed by people with Blue Shield of California coverage and 45 percent of cases involving members of Kaiser Permanente, the state’s largest insurer. In some of those cases, the insurer itself decided to reverse its decision.

The department’s “health plan dashboard,” which can be found on its website, contains information pertaining only to the plans it regulates. But those plans cover 25 million Californians — nearly three-quarters of the state’s insured population.

There are many other sources consumers can use to educate themselves about insurance plans, but the Department of Managed Health Care has a wealth of data that probably exceeds any other organization’s, said Betsy Imholz, director of special projects at Consumers Union, an advocacy group.

Imholz noted that many consumers are unaware of all the information available, and it is often difficult to understand. Reporting on quality and other aspects of health care is still in a developmental stage, she said. “But our hope is that data will become better and more accessible. “This [dashboard] is a good step.”

The interactive dashboard allows consumers and researchers to filter through multiple data sets that include: enrollment numbers, premium rate histories, consumer complaints, quality surveys and the financial status of health plans. And it generates easy-to-understand charts and graphs.

The site covers full-service medical plans, as well as specialty care such as dental, vision and mental health.

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The department created the dashboard with a “consumer assistance” grant of about $400,000, awarded in 2014 under the Affordable Care Act. Grants of similar amounts were awarded to 11 other states, including Connecticut, Massachusetts, North Carolina and New York. The funding allow states to develop programs that address consumers’ health insurance questions and concerns, according to the Centers for Medicare & Medicaid Services site.

No other grantee used the funds to create a similar dashboard tool. But the Mississippi Insurance Department, for example, created a “Health Insurance Consumers Guide,” which provides newly insured people with information about their health plans, including how to file a complaint.

Marta Green, chief deputy at California’s Department of Managed Health Care, said that while the data have been publicly available for quite some time, a lot of it was hard to read. It was also scattered across disparate databases. The dashboard is intended to consolidate and simplify it so consumers, researchers and the department itself can better understand how well the health plans are doing.

One of the more useful features of the dashboard, department officials said, is that it allows for side-to-side comparison of different health plans.

For example, it shows that so far this year, Anthem Blue Cross has been fined nearly $2 million for violations, while Kaiser has been fined just over half a million. Users can also see how health plan rates have changed over time, and which rate changes the department has deemed “unreasonable.”

Another state agency, the Office of the Patient Advocate also releases report cards, rating the quality of health plans with data from the National Committee for Quality Assurance, a nonprofit that publishes its own national evaluations. On the NCQA website, the public can find ratings on a scale from 1 to 5 for health plans in each state.

California’s Patient Advocate report card assigns star ratings in different domains of care, including prevention services, treatment, screenings and mental health, said Jennifer Lenz, an assistant vice president at the National Committee for Quality Assurance. It puts out separate report cards for HMOs and PPOs.

The Office of the Patient Advocate is scheduled to release its 2016 report at the end of this month.

Covered California, the state’s health insurance exchange, also rates the health plans it sells, based on member surveys that include responses about medical appointments, customer service and the quality of medical care.

Imholz said that most consumers are interested in comparing premiums, but there are other things they should also pay attention to when shopping for a plan: the total cost of care, the quality of care and the overall consumer experience. It’s less obvious to look up enforcement actions, she said. “But if past is prologue, it’s important for people to know about violations.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Source: Kaiser Health