Centene and Obamacare


Lack of providers

Class action lawsuit!


Factual Allegations of Centene’s Business Model

Harvey v. Centene Corp., 18-cv-00012, U.S. District Court, Eastern District of Washington (Spokane)

A multi-state class action lawsuit against Centene, filed in federal court, will try to make Centene serve up the medical coverage they offer on the menu. Good luck to the class action plaintiffs — the national group of Centene-insured patients.

I hope it doesn’t take a long and drawn out lawsuit to rectify the situation of getting cheated out of healthcare.

Unfortunately none of our gatekeepers have cared to do their jobs.

But that’s life, these days, in the United States of America — this is capitalism, and there’s a lot of money in healthcare! And money talks!

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Provider Network Survey
Letter to Centene about the Ambetter faulty provider networks.
Letter to Centene about the Ambetter faulty provider networks.

In August of 2016, when I made my provider network survey of all the health insurance plans available to me, Centene’s Buckeye Ambetter was the worst offender (along with Caresource.) Ambetter had 90% inaccuracies — only 10% of the doctors they listed as accepting new patients were actually accepting new patients — I know because I called them all. And I reported it to officials — my survey even got the attention of The New York Times in an article called, Insurers’ Flaws Lists Send Patients Scrambling — an article that starts out with my name!

Too bad that the Ohio Department of Insurance, along with our state and federal government representatives and other agencies such as the State Attorney General’s Office and The Centers for Medicare & Medicaid Services, and healthcare advocacy groups like SPAN Ohio and UHCAN, were not motivated to demand accurate and adequate provider networks, by using their positions of influence and authority to fix it. I laid it out for them on a silver platter.

You just have to wonder why our leaders were not moved to make corrections when I gave them the results of my survey. It is so blatantly wrong to let insurers continue to sell Obamacare health insurance when you know they lie about access to medical coverage.

The government even foots the bill for most of the plans that Centene sells. Wasting our health, squandering our national healthcare dollars.

The New York Times, January 11, 2018 – Health Insurer Centene is Sued Over Lack of Medical Coverage

But we still have the legal system to give us hope. We must wait. And see.
Good luck with your healthcare! Photo © 2018 healthcarephotostock.com

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Michelangelo's David

a turkey with spread wings

R.I.P.

R.I.P. American Dream.  If you are an artist, writer, musician, inventor, entrepreneur, shop owner, lawyer, plumber, carpenter, waitress, or any number of hard working workers with jobs that don’t provide large group employer-based health insurance, quit right now and run for cover! It’s survival time! This year, thanks to the uncertainties, the calculated congressional and presidential threats, and the other garbage that politicians have thrown at us all year long, health insurance premiums are 42% higher for adults, and 60% to 85% higher for the kids. Even newborn babies are being welcomed to the world by a big, double-digit rate hike. Surprise!

Furthermore, while prices have risen 500% in the past five years for individuals, national network PPOs have been eliminated for individuals. Individuals are left with Medicaid-like health maintenance organizations, which are considerably less health insurance than the PPO plans that Ohio got rid of last year. I’m sorry for the artists, writers, musicians, inventors, entrepreneurs, shop owners, etc. Did you ever think that having health insurance would be such a huge obstacle in your quest for success?

R.I.P. PPOs., the last bastion of equal healthcare along side the big corporation counterparts. It isn’t fair.

How big is the price of healthcare? SO BIG!

©2017 Penny Gentieu

2018 Rate Review for the individual non-group health insurance market

New for 2018, Marketplace rates for children will rise 20% to 53%, on top of the additional average 42% rate increase insurers in Ohio demand in 2018.

Child rates in the past they have always been 63.5% of the adult base rate until the age of 21. Next year, 0-14 will be 76.5% of the adult base rate, with ages 15 to 20 being 83.3% to 97% of the adult base rate.

2018.  Individuals, those who don’t get health insurance from an employer or from the government, are supposed to feel lucky to at least still be able to buy health insurance. We were warned that rates would go through the roof this year. That’s due to the uncertainty of the government reimbursing insurers for CSRs, the uncertainty over the insurance requirement mandate, the uncertainty of a repeal, as well as the totally understandable (not), predictable, ever-rising, unsustainable, runaway medical and non-negotiable pharmaceutical cost factors, that alone amount to a 7% rate increase in 2018, along with the resumption of the ACA tax on premiums that was halted last year, and some increases in administration costs. We braced for rates going up 40% or more. 

On top of the outrageous, unbelievable rate hikes for adults that are 40 times the rate of inflation going to our little sector of the healthcare business, CMS snuck in that equally as outrageous and unbelievable rate hike for children.

How big are the rate hikes? SO BIG!!!!!!!!!!
A typical family may see a rate hike of 29% for themselves, and 71% for their children.

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Typical family, photographed here in 2000, has been through it all.

A Little Story About A Typical Family

Take your typical Ohio family – say, John and Pam, who are 55. They have two kids who are 17 and 20. John is an independent contractor and earns $78,000. Pam is an adjunct university professor and earns $21,000. Together they make $99,000 before taxes, just over the 400% Federal Poverty Level that would qualify them for a health insurance subsidy. Their net income after taxes is $78,000.

Having to buy individual insurance, they chose Molina, because that was the only plan in which they could find doctors who would accept them as patients.

Toledo, Ohio is a closed town when it comes to doctors accepting new patients. When it became too costly in 2016, John and Pam had to give up their Medical Mutual PPO insurance and hence their ProMedica doctors that they had been going to for 20 years. Molina was one of the cheapest insurance plans they could buy. But they had to find new doctors, because their long-time doctors didn’t accept Molina insurance.

MercyHealth doctors are in the Molina network, and they are not as closed as ProMedica doctors.  That’s why our typical family chose Molina over CareSource, another cheap plan, but one with a 90% inaccurate provider network, a network that supposedly included ProMedica doctors, but not really. (ProMedica, when last checked, had only one primary care family practice doctor accepting new patients, but you’d have to call back in a month to schedule an appointment, which supposedly would be scheduled for three months after that.*)

If John and Pam had made just two thousand dollars less (see Kaiser subsidy calculator here),  this typical family would have qualified for a $3,334 subsidy this year (undoubtably it would be more than $6,000 in 2018 because the SLCSP which is tied to the subsidy may be 20-30% more, in tandem with the rest of the plans; see rate increases below.) The subsidy would have reduced their health insurance premiums to 10% of their gross income for a silver plan, but alas, they make too much money to qualify.

John and Pam chose a gold plan with a lower deductible because they couldn’t afford the risk, just in case, of having to come up with $7,500+ to meet the deductible before the insurance would kick in.

With an increase of over $6,000 in 2018 for health insurance, their tightest budget, cutting down on food, recreation, transportation and clothing, exceeds their net income. Forget about helping with their kids’ education or even saving for their own retirement, which is coming in 10 short years – in 2018, they will be going into credit card debt on their necessary expenses just to be able pay for health insurance.

As it was, in 2016 John and Pam paid 22% of their net income on health insurance, $17,448, at $1,454/month (John and Pam’s rates were $554.50 each per month, and the kids’ rates were $172.62 each). It was considerably more than they were paying just a few years before. An affordable and reasonable percentage as written in  the ACA would be 13% of their take-home, or 10% of their gross. 22% of their take-home pay on health insurance made their budget very tight.

Next year, John and Pam’s health insurance will go up 39%. Health insurance will surpass housing as biggest chunk of their budget, becoming a whopping 31% of their take-home income, $24,240 for the year; $2,040/month. The astronomical but necessary expense for health insurance squeezes out any money that could ever have been saved for retirement, which they need to fund, and eliminates any possible budget they may have hoped for to help their kids with higher education expenses.

While John and Pam’s health insurance is going up 29%, health insurance for their kids goes up 71%. The family’s health insurance premiums next year will cost $6,792 more than last year!

Time to stop the killing.

Too bad for the 30% of the individual market, like John and Pam, who don’t get a subsidy; their health insurance expense is simply unsustainable. They may have to keep working into their seventies, because there’s no way they can save money for retirement when the insurer gets every red cent. And their kids can forget about college.

Kaiser Family Foundation: How Premiums Are Changing In 2018

See also, June 11, 2017 Rate Review Observations

2016 Provider Network Survey

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This survey was made in July and August 2016 of all the internal medicine and family practice primary care doctors listed on the networks of healthcare.gov plans offered by Anthem, Paramount, Med Mutual-Promedica, CareSource, Molina, and Buckeye Ambetter within 15 miles of 43615, Toledo, Lucas County, Ohio. On each provider network directory connected to the plans on healthcare.gov, I searched for internal medicine and family practice primary care doctors who are accepting new patients. I compiled a list of all the doctors listed as accepting new patients, totaling 308.* I called their offices and asked if they were accepting new patients.

Ohio Citizen Rate Review Provider Network Survey

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To Recap:

  • Anthem Blue Cross Blue Shield has 13, not 39 PCP family practice and internal medicine doctors accepting new patients. 67% inaccurate.
  • Paramount has 31, not 89 PCP family practice and internal medicine doctors accepting new patients. 65% inaccurate.
  • Med-Mutual-ProMedica has 20, not 136 PCP family practice and internal medicine doctors accepting new patients. 85% inaccurate.
  • CareSource has 17, not 166 PCP family practice and internal medicine doctors accepting new patients. 90% inaccurate.
  • Molina has 36, not 159 PCP family practice and internal medicine doctors accepting new patients.  77% inaccurate.
  • Buckeye Ambetter has 10, not 98 PCP family practice and internal medicine doctors accepting new patients. 90% inaccurate.

The average of the  six percentages representing the inaccuracies, misrepresentations, falsely advertised lies, untruthfulness and phoniness in our Toledo provider network databases is EIGHTY PERCENT !!

 Here are some things I was told by the doctors offices:

Seven said they keep calling to have the list changed but they don’t update, one moved to Arizona, one moved to California, one moved to Oak Harbor, one moved to Bowling Green three years ago, two are retired, one isn’t practicing anymore, six you must pay an additional annual membership fee of $1,650 and they still take your insurance,  five are geriatrics only, two more only see patients in the nursing home, one more only sees patients in Hospice, two only see mental health patients, five said they have no control over the lists, one only sees Owens Corning employees and asked twice to be taken off the list, eight screen for age, address, state of health and doctors you’ve seen and then decide if they are accepting new patients or not, 15 do not accept new patients but their residents do, 26 do not accept new patients but their nurse practitioners do, one is not practicing medicine anymore, two are not PCPs, one only sees addiction program patients, eight are hospitalists, one is a hematologist, one is a sleep doctor, five are kidney doctors, not PCPs, one sees only adolescents, one is a pediatrician, three are sports doctors, six were not locatable, more than one said they put doctors on the list without asking and they never update them, one said they haven’t accepted new patients for 30 years, etc., etc., etc….

Ironically, Lucas County has one of the highest resident to PCP ratios in the entire state of Ohio, so why is it that the overwhelming majority of PCP doctors are not taking new patients? Are they being extinguished by insurance companies by not being paid enough money, useful in name only for the time being, to populate provider network directories that lead to nowhere in an Orwellian scheme that controls utilization and increases corporate wealth, or what?

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*I called all 78 internal medicine doctors and all 204 family practice doctors. I also called 26 doctors on the lists who were actually not PCP’s, but doctors of other specialties who came up in my search for internal medicine and family practice PCP’s, who were wrongly listed, such as hospitalists, cardiologists, nephrologists, psychiatrists, pediatricians, pulmonologists, sports doctors, critical care doctors, gerontologists, and an occupational medicine doctor.

The Skinny on Narrow Networks in Health Insurance Marketplace Plans is a study made by the Robert Wood Foundation. It quantifies what makes a small or extra small network. Toledo has maybe 450 primary care physicians. An extra-small network has 11% or less of the total number of physicians practicing in an area. That would be about 50 PCPs in Toledo. A small network has 30% or less, which for Toledo would be about 135 PCPs. The insurers are lying about the doctors’ availability to make their networks seem larger. Doctors that don’t accept new patients and haven’t for years can hardly be considered in-network for new patients. From my survey, which shows 13 to 36 PCPs available in the network to new patients, not even one of those is of a sufficient sized network to be allowed to sell on the Marketplace.

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HOW OHIO HANDLES PROVIDER NETWORK COMPLAINTS

For example, my CareSource complaint to the Ohio Department of Insurance:Screen Shot 2016-08-16 at 2.47.41 PM

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Excerpt from CMS’s 2017 letter to Issuers:

What will the CMS do about Toledo’s grossly inaccurate provider databases?

v. Network Transparency 
This section discusses how CMS intends to label each QHP network’s breadth as compared to other QHP networks on HealthCare.gov. This information will be available to consumers when they are considering which plan to enroll in, and would include a designation that indicates the network’s relative breadth. We intend to further consider how we will display this breadth information as we continue consumer testing. The purpose of the labeling is to provide increased transparency to enrollees about the type of provider network in the coverage they are selecting.


Each network’s breadth will be compared to the network breadth of other QHPs available in the same geographic area. CMS will identify network breadth based on analysis of QHP provider and facility data submitted as part of the 2017 certification process. This analysis will compare an issuer’s contracted providers to the number of specific providers and facilities included across all QHP networks available in a county. The rating will focus on hospitals, adult primary care, and pediatric primary care with either a separate classification for each of the three categories or a composite overall classification that reflects the overall network for all three of the indicated specialties. CMS will make a final determination to use a separate or composite rating based on the results of consumer testing, and intends to provide this information as part of the 2017 QHP certification instructions. These specialty areas were chosen based on consumer feedback that access to specific hospitals and preferred primary care physicians is important to potential enrollees when comparing plans.


We plan to provide the classifications of network breadth for each plan at the county level. These classifications will be determined by calculating the percentage of providers in a plan’s network, compared to the total number of providers in QHP networks available in a county. We will divide the number of each QHP’s servicing providers at the issuer, network, county, and specialty combination level by the total number of all available QHP servicing providers for that county, including Essential Community Providers (ECPs). This number is the Provider Participation Rate (PPR). As a baseline standard, networks that are within one standard deviation of the mean PPR will be classified as Standard. Those with a PPR that is more than one standard deviation above the mean PPR will be classified as Broad. Those with a PPR that is more than one standard deviation below the mean PPR will be classified as Basic. Applying this methodology to 2016 QHP issuer provider data, we found that approximately 68 percent of the plans would have been categorized as Standard, about 16 percent would have been classified as Basic, and about 16 percent would have been classified as Broad. We will conduct an analysis of QHP 2017 provider data using the same methodology to determine each plan’s classification. These calculations will be based on the network provider data that each QHP issuer submits as part of QHP certification and would be updated annually.



A form on Network Adequacy new this year that is filled out with the insurer’s rate filings (are these public records available on SERFF?):

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The lack of transparency in Ohio is appalling. Instead of having effective rate review, we are kept in the dark, the perfect breeding ground for corruption. See this blog post regarding the final outcome of my Medical Mutual provider network and pricing complaint, including the part at the end where Ohio issues an August 24 report on rate hikes from 2013 to 2017: http://ohiocitizenratereview.info/letter-complaint-examiner/

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Related: Letters to Insurers

Related: Provider Network Complaints Get Buried

Related: Medical Mutual SuperMed PPO Provider Network