PAMF doctors in Covered California’s Blue Shield network for 2014

Dec. 10--SANTA CRUZ -- Santa Cruz County residents who have insurance coverage with Anthem Blue Cross for doctors with the Palo Alto Medical Foundation are playing a waiting game because Anthem's contract with PAMF and Sutter Health expires Dec. 31.

"This is one of those December impasses," said Dr. Larry deGhetaldi, who heads the Palo Alto Medical Foundation Santa Cruz and Sutter Santa Cruz, noting all of Sutter Health is affected. "We really expect these contracts to be resolved by Dec. 31."

DeGhetaldi said the state requires letters be sent to clients when an agreement is not reached 60 days before the old one expires.

"It freaks patients out," he said. "We've had a little over 500 calls."

DeGhetaldi said the negotiations relate to Anthem plans being sold outside of Covered California, the state's health exchange.

"They are not related to the Anthem Covered CA product at all," he said. "We are not participating in either the Covered CA Anthem or the Health Net products. We are participating in the Blue Shield EPO (exclusive provider organization) Covered CA product in this county."

The Covered California website (www.coveredca.com) includes an online physician directory that includes PAMF doctors in the Blue Shield plans, which include bronze, silver, gold and platinum plus a catastrophic plan and the Small Business Health Options Program.

Anthem spokesman Darrel Ng confirmed the negotiations and provided a different perspective.

Sutter is "one of a very few providers with clauses that don't allow us to reveal line-item pricing data to Covered California," he said.

Sutter hospital prices were highlighted Dec. 3$2,200 at Sutter's California Pacific Medical Center.

PAMF doctors are in the Blue Shield plan, which is the least expensive, but DeGhetaldi was surprised that that plan omits three ZIP codes, including Boulder Creek, Davenport and the Los Gatos Summit.

Blue Shield spokeswoman Lindy Wagner said this is due to a state Department of Managed Healthcare requirement.

"If a ZIP code is only partially within the 15-mile radius area from a network hospital, then the DMHC requirement cannot be met for that ZIP code and the entire ZIP code must be excluded," she said.

Covered California spokesman Roy Kennedy recommended people who do not find their physicians in the directory to call the doctors to ask if they are in a network and which one.

Follow Sentinel reporter Jondi Gumz at Twitter.com/jondigumz

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