Anthem Blue Cross AND Stanford Health Care Contract Will Terminate
1. Why did Stanford Health Care terminate its contract with Anthem Blue Cross?
Anthem Blue Cross (“Anthem”) and Stanford Health Care (“Stanford,” formerly known as Stanford University Medical Center) have been engaged in active commercial contract negotiations for several months following Stanford’s decision to issue a termination notice for its hospital, clinics and PPO physician practices, effective September 8, 2014. Unfortunately, despite Anthem’s requests to rescind its termination and/or extend the termination date so as to avoid disruption in care for our members, Stanford terminated its agreement, effective 12:01am, September 8, 2014. Had Stanford not taken this action, the contract would still be in effect today.
Note: Anthem Blue Cross and Stanford’s affiliate, Lucile Packard Children’s Hospital, recently agreed to a multi-year contract. Lucile Packard Children’s Hospital is not affected by Stanford Health Care’s decision to terminate from Anthem’s provider network.
2. What Anthem Blue Cross products are affected by this hospital termination?
This termination could affect the out-of-pocket obligations for most Anthem Blue Cross members who are enrolled in Commercial PPO, EPO, HMO, and POS benefit plans and receive care at the terminating hospital. Members, who have a Medicare supplemental policy for Part A and Part B (Medigap), are not affected by this contract termination.
3. Will members be notified about the contract termination?
Within five days of a hospital’s termination from the network, Anthem Blue Cross notified subscribers that personally accessed, or had a covered family member access, Stanford Health Care within the last 12 months. In addition, members authorized or scheduled for a service or procedure at Stanford Health Care within 180 days after the termination date were notified.
The letters instruct members to call the Customer Service number on their ID card if they are in a current course of treatment at Stanford Health Care or have questions or concerns about the contract termination. The letters state the following legally-required message regarding completion-of-covered-services/continuity-of-care: If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Please contact the Anthem Blue Cross customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO/PPO consumers, by telephone at its toll-free number, 1-888-HMO-2219, or at a TDD number for the hearing impaired at 1-877-688-9891, or online at www.hmohelp.ca.gov.
Note: Anthem Blue Cross does not mail notices to members enrolled in ASO, JAA, MCS, or others self-funded plans (however, this does not preclude member eligibility for continuation of covered services). A template notice is available that can be forwarded to clients for their use in notifying their associates about the contract termination.
4. How are Anthem Blue Cross HMO members affected by Stanford Health Care’s contract termination?
All non-emergency hospital services must be approved by the HMO member’s participating medical group/IPA. If approved, Anthem Blue Cross will cover the claim at the member’s in-network benefit levels. If not approved by the member’s participating medical group/IPA, the claim will be denied, as stated in the members Evidence of Coverage.
Physicians, Medical Groups, and Alternate Hospitals
5. How do members know if their doctor will be affected by this hospital termination?
Many doctors have admitting privileges at more than one hospital. Just because a member’s doctor may have admitting privileges at Stanford Health Care does not necessarily mean that a doctor cannot still treat his or her patients at another Anthem Blue Cross participating hospital.
6. Did Anthem notify PPO physicians and admitting HMO medical groups about the contract termination?
PPO physicians and HMO medical groups agreed in their contracts to admit members to Anthem Blue Cross’s participating hospitals to ensure that each member receives the maximum benefit level under his or her benefit agreement. Anthem Blue Cross mailed letters on August 14, 2014 that explained the pending contract termination to admitting HMO medical groups and PPO physicians who maintain privileges/affiliations at Stanford Health Care. These letters also encouraged the physicians to obtain alternate admitting privileges and/or arrange for the redirection of members to alternate participating hospitals. Additional letters to admitting PPO physicians and HMO medical groups were mailed immediately following the Hospital termination date of September 8, 2014 to inform them that the contract did, in fact, terminate, while again asking that they gain alternate admitting privileges if they have not already done so.
7. Will Anthem Blue Cross assist physicians in acquiring admitting privileges at an alternate hospital?
Anthem Blue Cross is ready and willing to assist our physicians in acquiring admitting privileges or making alternate admitting arrangements at a participating hospital if necessary. In the event that a member’s physician cannot admit to an alternate hospital after a hospital contract termination, then Anthem Blue Cross will work with the physician or other healthcare professional to admit members to an in-network facility.
8. What other participating Anthem Blue Cross network hospitals are available in the area of Stanford Health Care? Anthem Blue Cross has a statewide hospital network of over 300 acute care facilities. The Find a Doctor function at www.anthem.com/ca can be used to locate a participating hospital in a specific area.
The following is a partial list of alternate participating general acute care hospitals within the vicinity of Stanford Health Care:
• El Camino Hospital, 2500 Grant Road, Mountain View, CA 94040
• Good Samaritan Hospital, 2425 Samaritan Dr., San Jose, CA 95124
• Menlo Park Surgical Hospital, 570 Willow Rd. Menlo Park, CA 94025
• Mills Hospital, 100 S. San Mateo Dr., San Mateo, CA 94401
• O’Connor Hospital, 2105 Forest Ave., San Jose, CA 95128
• Peninsula Hospital & Medical Center, 1501 Trousdale Dr., Burlingame, CA 94010
• Santa Clara Valley Medical Center, 751 S. Bascom Ave., San Jose, CA 95128
• Sequoia Health Services, 170 Alameda De Las Pulgas, Redwood City, CA 94062
• UCSF Medical Center, 505 Parnassus Ave., San Francisco, CA 94143
• Washington Hospital, 2000 Mowry Ave,, Fremont, CA 94538
For a complete list of contracting hospitals, as well as ambulatory surgical centers and other ancillary facilities, please see Anthem Blue Cross’s website at www.anthem.com/ca.
Customer Service can check the provider database for a physician’s admitting privileges at another nearby in-network participating facility. Members should confirm database information with their treating physician.
Every effort should be made to assist members in determining their choices and understanding the potential financial consequences of seeking care at a hospital that is not in Anthem Blue Cross’s provider network.
What if a member was in-patient at Stanford Health Care on the day the contract terminated?
If a member was in-patient at 11:59pm on the day before the contract terminated, the member will continue to receive uninterrupted care at the terminated hospital until he or she is discharged. In addition, the member’s in network benefit levels will apply for the entire in-patient stay.
What about members who need to complete a course of treatment, have a scheduled procedure, or in need an out-of-network referral for medically necessary services at Stanford Health Care following the termination?
California law provides for completion of covered services/continuity of care for certain medical conditions following a provider’s contract termination if, among other things, the provider and the health plan agree on a rate of payment. Anthem presented Stanford Health Care with a Continuity-of-Care Agreement (rate of payment) sufficient to meet the requirements of Health & Safety Code Section 1373.96, but unfortunately, Stanford Health Care rejected it.
Therefore, with the exception of authorized care as described below, completion of covered services/continuity of care at Stanford Health Care will not be available.
PPO members
Authorized Care at Stanford Health Care from September 8 – October 8, 2014.To help ensure members receive the care they need in a timely manner, Anthem Blue Cross will be honoring all PPO member authorizations for services at Stanford Health Care issued before the contract termination for care rendered between September 8 and October 8, 2014 pursuant to Anthem’s Out of Network Referral Policy. For these authorized covered services, Anthem Blue Cross will apply the member’s in-network benefit levels. The hospital will be reimbursed using an applicable non-participating provider fee schedule during the 30-day transition period. The hospital will be paid directly, not the member. However, this may result in higher out of pocket expense for members. Anthem Blue Cross’s UM department will be conducting outreach to the PPO members with authorizations issued before the contract termination for care at Stanford Health Care to discuss treatment options. Members will be advised that Anthem Blue Cross will honor authorizations from September 8 to October 8, 2014 pursuant to Anthem Blue Cross’s Out of Network Referral Policy and that there may be cost implications of choosing to go to Stanford Health Care rather than a participating hospital.
Requests for Out of Network Referrals/Authorizations for Services after October 8, 2014
Anthem Blue Cross’s Out of Network Referral Policy allows members to request care from a non-participating provider under certain circumstances (i.e., medical necessity, geography, etc.). When a member or physician calls Customer Service to make such a request, approvals will be handled according to the policy. When approved, members’ in-network benefit levels will apply. The hospital will be reimbursed using an applicable non-participating provider fee schedule.
Note: There may be different arrangements for certain ASO/self-funded/self-insured Anthem Blue Cross accounts/clients.
HMO members: HMO members and physicians wishing to request continuity of care/completion of covered services would not contact Anthem because all medical management is delegated to the provider group. HMO members and physicians should contact their participating medical group.
If a participating HMO medical group determines that a service is not available elsewhere in the network or otherwise determines care is appropriate and necessary at Stanford Health Care, then they can authorize the HMO member’s care at Stanford Health Care and associated claims will be treated as in-network.
What if the member does not qualify for the one-month transition period or out-of-network referral? Can the member choose to go to Stanford Health Care anyway?
PPO and Traditional (Indemnity) Members:
Large Group: Members electing to receive care at a non-contracting hospital may be responsible for higher out of pocket expenses depending on benefit plan design for authorized and non-authorized services at the hospital as stated in the member’s EOC. Note: There may be different arrangements for ASO groups or other self-insured clients.
Individual and Small Group: Members electing to receive care at a non-contracting hospital will in most cases be responsible for higher out of pocket expenses depending on benefit plan design as stated in the member’s EOC.
HMO Members: All hospital services must be approved by the member’s current participating medical group/IPA. If approved, Anthem Blue Cross will cover the claim at the member’s in-network coverage schedule of benefits. If not approved by the member’s participating medical group/IPA, and services are received at the terminated hospital, the claim will be denied as stated in the member’s EOC. Admitting HMO participating medical groups/IPAs were informed of the termination so they can admit patients to participating network hospitals following the contract termination.
If a member does not have access to an alternate participating facility or a particular service is not available elsewhere, can he/she go to Stanford Health Care? Anthem Blue Cross assures its members that they will have timely access to care. If a service is not available at an alternate participating hospital, PPO members may request an out-of-network referral by contacting Customer Service. Requests will be reviewed on a case by case basis pursuant to Anthem Blue Cross’s out-of-network referral policy. When an out-of-network referral is approved by Anthem Blue Cross, the member’s in-network benefit levels will apply. However, because Stanford Health Care will no longer be in Anthem Blue Cross’s provider network, members may be responsible for higher out of pocket expenses, depending on their benefit plan. Every effort will be made to assist the member in understanding the potential financial consequences of their choice to go to Stanford Health Care.
13. What about members who need emergency medical care from Stanford Health Care following the termination? Emergency medical services do not require pre-authorization, regardless of where they are delivered. Stanford Health Care must provide services for members requiring emergency care. Coverage will be provided according to the member’s policy benefits. Anthem Blue Cross encourages members to make informed decisions about when to use urgent care as opposed to emergency room care. Urgent care is appropriate when a member needs a physician’s attention for a condition that is non-life threatening. A member needing urgent care, but whose physician or network provider is unavailable, should go to the nearest immediate or urgent care facility.
Contract Negotiations
14. What is the status of the negotiations between Anthem Blue Cross and Stanford Health Care? Anthem Blue Cross does not share details of its confidential contract negotiations with the public. Our primary goal during contract negotiations is to ensure we are compensating hospitals fairly, while assuring the best access to health care at an affordable price for our members. We take protecting our members from exceedingly high medical costs very seriously and cannot agree to a contract that puts further pressure on the rising cost of health care paid by our customers.
15. Don’t hospital negotiations usually work themselves out after the contract termination date?
Negotiations often do work themselves out after the contract termination date, but that is not always the case. Anthem is doing everything it can to work collaboratively with Stanford Health Care, as well as affected PPO physicians and HMO medical groups, in order to ensure a continued smooth transition for our members.
**Cost of Care in California** our customers frequently tell us that they cannot support continued increases in their health benefit costs. It is important for everyone to understand why costs for health care are going up so steadily. You can learn about the causes behind rising costs and the work Anthem Blue Cross is doing to protect our members from even higher costs at www.anthem.com/ca/costofcare.
