New rule to help self-insured dental, hurt voluntary EAPs
By Allison Bell
The Obama administration has posted a 32-page batch of Patient Protection and Affordable Care Act regulations that could reshape some non-medical health benefits.
The rule was finalized Wednesday.
The package, Amendments to Excepted Benefits, affects one category of benefits that are free from most of the requirements that apply to major medical coverage: “limited excepted benefits.” The category includes dental benefits, vision benefits, long-term care benefits and some other types of benefits, such as employee assistance plans.
The Internal Revenue Service, the Employee Benefits Security Administration and the U.S. Department of Health and Human Services have decided to let employers with self-insured dental and vision plans treat the plans as excepted benefits without necessarily having to charge workers separate premiums for the benefits.
The excepted-benefits regulation changes that affect vision and dental benefits will also apply to employer-sponsored LTC benefits, such as long-term care insurance benefits or home care benefits, officials say in a preamble to the final rule.
The IRS, EBSA and HHS have decided that the provider of an EAP program with excepted benefits status cannot include wellness benefits, such as coverage for checkups and immunizations, in the benefits packages, and that the employer and EAP cannot charge the employees to participate in the EAP.
The rules do not apply to individual health coverage
The regulations are set to appear in the Federal Register Oct. 1, take effect 60 days later, and apply to group plans and group plan insurance issuers for plan years beginning on or after Jan. 1, 2015.
The federal government developed the “excepted benefits” system for the sake of administering the laws that came along before PPACA, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In the past few years, Obama administration officials have been working to update the system to reflect the changes made by PPACA.
Letting PPACA apply to a benefit would have a much bigger effect than applying HIPAA requirements. HIPAA, for example, might require an employer and an insurer to give a worker a chance to keep a benefit after the worker leaves the employer. PPACA might require the provider of any affected benefit, even dental insurance, to cover at least 60 percent of the actuarial value of the major medical essential health benefits package.
Up until now, employers have not been able to treat their self-insured dental and vision plans as excepted benefits unless they charged extra premiums for the benefits, and they have been treating voluntary, employee-paid EAPs as HIPAA-excepted benefits.
The agencies that came out with the final rule released today noted that they promised when they released a proposed version of the regulations in December 2013 that they would continue to treat any dental, vision or EAP programs that qualified as PPACA-excepted benefits in the proposed regulations as excepted benefits through at least 2014.
Officials acknowledged in the preamble that the EAP rule changes could disrupt existing EAP arrangements.
In the proposed rule, the agencies talked about setting rules for a new type of “limited wraparound coverage,” aimed at workers who are getting individual major medical coverage from a PPACA exchange. The agencies said they will issue wraparound product regulations later.

Open enrollment for buying or changing plans in the Health Insurance Marketplace begins November 15, 2014, and runs through February 15, 2015. During this time, the health plans offered on the Marketplace are “open” and accepting new people. Uninsured people and others who did not use the Marketplace last year can get coverage that can start as early as the beginning of 2015.
Are you one of the nearly 320,000 Pennsylvanians who currently get their health coverage through the Marketplace? If you do nothing, your insurance plan will automatically reenroll you. For many people, this will work just fine. But having the right health insurance is very important for your health. You should make sure that automatic reenrollment is the best choice for you.
Here are five things you should consider as we head into the open enrollment period:
1. Watch for important mail (or email) from the federal government and your insurance plan. The government will send you a notice about reenrollment. Your insurance company will send you a notice about how much your plan will cost in 2015 and how much you will save on your monthly bill, if you are eligible for Affordable Care Act financial assistance (through a tax credit).
So far, it looks like premiums won’t change much next year on average. But that’s on average. The plan you are enrolling in could have a significant increase or decrease.
2. Is your health or your family’s health changing? Is a baby on the way? Do you need surgery? Make sure your current health plan still meets your needs. Maybe a plan with a more expensive monthly premium, but a lower deductible and lower copays, would be better for next year.
3. Have your finances changed? Did your household income go up or down? Make sure you update your financial information with the Marketplace. If your income went up and you don’t report it, you may wind up receiving more financial assistance (tax credits) than you should. You would then end up having to reimburse the government. If your income went down, you may be missing out on some financial help, just when you need it the most.
4. Has your health plan changed? Health plans change from year to year. For example, premiums and copays may change. Your doctor may no longer be covered by the plan. Look over your plan carefully to make sure it’s still right for you.
In addition, some new health plans are being added to the Marketplace, and some plans are leaving. One of the new plans may give you better value at lower cost. If the plan you have now is discontinued, your insurance company will automatically offer you a plan that is most similar to the discontinued one.

5. Remember: If you do nothing, you will be automatically enrolled in the plan offered in the notice from your insurance company. To keep that plan, you don’t have to do anything. But, if you want to change that plan, you must take action. The notice will explain what to do.
If you have questions, or would like more information about open enrollment, you can:
• Contact your health insurance plan.
• Go to LocalHelp.HealthCare.gov on the web to get a list of nearby organizations that can give you personal help.
• Call the Marketplace’s 800 number: 1-800-318-2596.

Brown Vetoes Bill To Create Marketplace for Vision Insurance
Monday, September 29, 2014

Gov. Jerry Brown (D) has vetoed a bill (AB 1877) that would have established a statewide marketplace for vision insurance that would be separate from but linked to Covered California, the Sacramento Business Journal reports.
Covered California is the state’s health insurance exchange under the Affordable Care Act (Robertson, Sacramento Business Journal, 9/26).
Details of Bill
AB 1877, by Assembly member Ken Cooley (D-Rancho Cordova), called for the state to create a vision care access council that would have contracted with insurers to provide stand-alone coverage for vision care. The council and its processes would have been modeled after the state’s health insurance exchange and would have sought to establish links to Covered California.
The bill called for funding for the new exchange to come from vision insurers, not the state (California Healthline, 8/4).
Details of Veto
In a veto message, Brown said the bill would have created a “new state bureaucracy” and questioned whether creating a separate marketplace for vision coverage would have been allowed under federal law.
Brown added that it is not “advisable to divert Covered California’s focus with a new scheme,” noting that the bill would “require Covered California’s board to run the [vision] council’s operations and use the board’s staff and resources to conduct the activities of the council” (Brown veto message, 9/25).
Reaction From Vision Insurer
Rob Lynch — president and CEO of VSP Global, a provider of stand-alone vision coverage — said that VSP Global was “surprised and shocked” by Brown’s veto of AB 1877 (Kasler, Sacramento Bee, 9/28). VSP and other insurers had agreed to pay $250,000 to launch the marketplace for vision insurance, as well as millions of dollars in start-up costs (Sacramento Business Journal, 9/26).
Lynch noted that the state Senate and Assembly had passed the bill unanimously (Sacramento Bee, 9/28).

How Insurers Are Finding Ways to Shift Costs to the Sick
Source: New York Times
Health insurance companies are no longer allowed to turn away patients because of their pre-existing conditions or charge them more because of those conditions. But some health policy experts say insurers may be doing so in a more subtle way: by forcing people with a variety of illnesses — including Parkinson’s disease, diabetes and epilepsy — to pay more for their drugs.
Insurers have long tried to steer their members away from more expensive brand name drugs, labeling them as”non-preferred” and charging higher co-payments. But according to an editorial published Wednesday in the American Journal of Managed Care, several prominent health plans have taken it a step further, applying that same concept even to generic drugs.
The Affordable Care Act bans insurance companies from discriminating against patients with health problems, but that hasn’t stopped them from seeking new and creative ways to shift costs to consumers. In the process, the plans effectively may be rendering a variety of ailments “non-preferred,” according to the editorial.
“It is sometimes argued that patients should have ‘skin in the game’ to motivate them to become more prudent consumers,” the editorial said. “One must ask, however, what sort of consumer behavior is encouraged when all generic medicines for particular diseases are ‘non-preferred’ and subject to higher co-pays.”
I recently wrote about the confusion I faced with my infant son’s generic asthma and allergy medication, which switched tiers from one month to the next. Until then, I hadn’t known that my plan charged two different prices for generic drugs. If your health insurer does not use such a structure, odds are that it will before long.
The editorial comes several months after two advocacy groups filed a complaint with the Office of Civil Rights of the United States Department of Health and Human Services claiming that several Florida health plans sold in the Affordable Care Act marketplace discriminated against H.I.V. patients by charging them more for drugs.
Specifically, the complaint contended that the plans placed all of their H.I.V. medications, including generics, in their highest of five cost tiers, meaning that patients had to pay 40 percent of the cost after paying a deductible. The complaint is pending.
“It seems that the plans are trying to find this wiggle room to design their benefits to prevent people who have high health needs from enrolling,” said Wayne Turner, a staff lawyer at the National Health Law Program, which filed the complaint alongside the AIDS Institute of Tampa, Fla.
Mr. Turner said he feared a “race to the bottom,” in which plans don’t want to be seen as the most attractive for sick patients. “Plans do not want that reputation.”
In July, more than 300 patient groups, covering a range of diseases, wrote to Sylvia Mathews Burwell, the secretary of health and human services, saying they were worried that health plans were trying to skirt the spirit of the law, including how they handled co-pays for drugs.
Generics, which come to the market after a name-brand drug loses its patent protection, used to have one low price in many insurance plans, typically $5 or $10. But as their prices have increased, sometimes sharply, many insurers have split the drugs into two cost groupings as they have long done with name-brand drugs. “Non-preferred” generic drugs have higher co-pays, though they are still cheaper than brand-name drugs.
With brand names, there’s usually at least one preferred option in each disease category. Not so for generics, the authors of the editorial found.
One of the authors, Gerry Oster, a vice president at the consulting firm Policy Analysis, said he stumbled upon the issue much as I did. He went to his pharmacy to pick up a medication he had been taking for a couple of years. The prior month it cost him $5, but this time it was $20.
As he looked into it, he came to the conclusion that this phenomenon was unknown even to health policy experts. “It’s completely stealth,” he said.
In some cases, the difference in price between a preferred and non-preferred generic drug is a few dollars per prescription. In others, the difference in co-pay is $10, $15 or more.

Before ending their biannual convention, California Republicans voted to oppose two state ballot measures related to health insurance rate regulation and random drug testing for doctors, the Sacramento Bee/Fresno Bee reports.
State Republicans voted to oppose Proposition 45, which would give the state insurance commissioner the authority to reject health insurance rate increases.
Assembly Minority Leader Connie Conway (Tulare) said, “The last thing we need is yet another flawed ballot initiative that further embeds government into private health care decisions,” adding, “Prop. 45 will give one politician … who is a Democrat … vast new powers over health care.”
Conway said, “Treatment decisions should be made by doctors and patients, not by a politician.”
The party also has voted to oppose Proposition 46, which would:
• Increase the state’s $250,000 limit on pain-and-suffering awards in malpractice lawsuits;
• Require doctors to undergo random drug-testing (Cadelago, Sacramento Bee/Fresno Bee, 9/21).

“Grandmother” Bill for Small Employer
Governor Brown signed Senate Bill 1446 into law, which will provide transition relief to small employers who have not yet brought their group health plan into full compliance with the ACA. The law goes into effect immediately.
Small group, non-grandfathered health plans which were in effect on December 31, 2013 and are still in effect as of the bill’s signing, may be renewed and continue to be in force through December 2015, although carriers maintain the option of providing these non-ACA compliant policies to their customers or not. The group of eligible small plans includes those that used the early renewal option offered last year to change to a December renewal.
The elements of the ACA for which there will be relief include:
• Coverage for the 10 “essential health benefits”, including pediatric dental.
• Pre-existing condition limitations for participants over the age of 18.
• The restriction that rates be solely based on age, geographic area and family tier.
Of course, groups are not prevented from moving to a fully ACA compliant plan should they elect to do so. This change does not affect plans that are already in full ACA compliance or individual policies.

Ask any insurance professional what business they are in, and the answer will likely include the word “planning” – helping customers plan ahead so they are prepared and protected. Putting product and coverage solutions in place for customers helps them be prepared. Chances are, your clients can and should do more, particularly around planning for natural catastrophes. Take the opportunity today to share with your customers five compelling reasons for making a disaster plan and the steps to take to create one.
Natural disasters on the scale of Hurricane Katrina or the recent Moore, Oklahoma tornado rivet our attention and evoke sympathy for the victims and survivors. Although such large-scale events are relatively rare, seventy-five percent of all American households are at risk for experiencing some type of natural disaster including earthquakes, floods, storms and wildfires. Equally startling is that relatively few have done much to prepare.
The Hartford Center for Mature Market Excellence partnered with the MIT AgeLab to conduct research to better understand peoples’ experiences with natural disasters. Eight focus groups were held with people age 50 or older in different locations around the country. We also conducted a series of interviews with Hartford claims adjusters to ask them about their experiences working with individuals and families in the wake of natural disasters.
Our research showed that it’s just human nature not to plan for a disaster – mainly because we think it won’t happen to us. But living through a disaster is a memory that is never forgotten. One research participant describes it this way: “I was five years old when I experienced my first tornado. To this day, I can hear my dad yelling ‘Go to cellar. Go to cellar.’ We weren’t there very long before we heard this roar. We came out of the cellar and the house was gone. … so I’ve been sensitive to tornadoes ever since.”
Take a look at what some of our research participants and The Hartford claims adjusters said as they reflected on the importance of being prepared.
1. It could save your life: Having a plan could mean the difference between life and death.
“[The earthquake] made me wake up, like ‘Hello! Reality check!’ [I realized] this really could cost me my life, my home and everything I own.”
2. Disasters are traumatic: Having a plan can help to reduce stress and anxiety.
“The customers cry a lot. Not when you get there, but when you walk around the house and they are flooded with memories, or are just overwhelmed. It affects your heart.”
3. A support network will be in place: Knowing whom you can count on brings peace of mind.
“We don’t know who is supposed to help us. Would it be the fire department? How do we know who’s going to be there for us? Most people don’t know.”
4. You will have more control: You may not have control over a disaster, but being prepared for one can give you some control in the aftermath.
“We had a severe hailstorm and it [broke] the windows … They said there was a big rainstorm on its way, too. So I immediately started covering those windows with plastic. I made sure that all of my neighbors got some plastic, and we went around and fixed their windows, too. We all got ready for the rain.”
5. Your expectations will be more realistic: It is easier to put your life back together when you know what to expect.
“If you’ve lost your home and your car is floating away, and then all of a sudden you have an [insurance] company representative saying, ‘We need an inventory of your contents,’ it puts a strain on people at a tough time.”
The Hartford created It Could Happen to Me: Family Conversations about Disaster Planning a consumer guidebook to help people better prepare for natural disasters and catastrophes by talking to – and planning with – family, friends and neighbors. The guidebook outlines the ABC’s of a comprehensive plan and includes checklists, worksheets and resources to make the planning process as easy as possible
Contact our Insurance Specialist for a copy of the Guidebook…Planning is key to surviving!!!

The Hartford’s Tenant Insurance protects your personal property, covers your liability, protects you from having to cover unintentional damage to the home you are renting, and provides assistance with living expenses if you are displaced from your home due to fire or other losses.

• A tenant’s personal property is not covered by the landlord’s insurance. If there is a fire where you live, your landlord is only responsible for the damage to the building. Replacing your clothes, electronics, kitchen items, jewelry, furniture, and other personal belongings is your responsibility. The same applies to theft, lightning, windstorm, hail, explosion, smoke, vandalism, and other hazards. Without a tenant insurance policy, there is no coverage to help you replace everything you worked so hard to have.
• Where would you go if you had fire or smoke damage in your home? A tenant policy can provide money to find alternate housing until you can return to your home or find a new place to live.
• Your landlord can hold you liable for damage you unintentionally cause to their property.
• Tenant insurance can also provide financial protection by offering liability coverage if someone is injured on your rented property. Do you own a dog? Personal liability protects you if your dog bites someone and you are sued. It can pay legal defense fees in these circumstances.

How much coverage do I need?

With tenant insurance, you need to determine the amount of coverage that is right for you. When selecting the amount of insurance, you will want to think about everything you own. How much would it cost to replace your clothes, television, furniture, dishes, and small appliances? The amount of personal property coverage can be as low as $10,000 or can be over $100,000. You should select the coverage amount that would provide you will enough money to replace everything.

The lowest liability limit available on a tenant policy is $100,000. If you own a dog or have other personal assets you want to protect, you should consider selecting a higher liability limit.

How much will it cost?

The average tenant insurance policies are less than $200 a year. Your premium is determined by the amount of coverage you need. You can protect your personal belongings and financial liability for less than $5 a week. You can also receive a discount on your auto insurance policy for carrying tenant coverage from The Hartford.

Contact your Personal Lines Sales Representative at Probity Insurance Services to learn more.

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.

Open Enrollment for 2014 coverage is over. But you may still have options to get health coverage. You may qualify for a Special Enrollment Period:

A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby). that allows you to buy a private health plan through the Marketplace.
You may qualify for Medicaid and the Children’s Health Insurance Program (CHIP):  You can do this any time, all year. If you qualify you can enroll immediately.

If none of the options for getting covered outside Open Enrollment works for you, your next chance to enroll in health coverage through the Marketplace is the next Open Enrollment period for 2015 coverage is November 15, 2014 to February 15, 2015.

Businesses can begin offering coverage to their employees any time. There’s no limited enrollment period for businesses to offer coverage to their employees.
• If your business has 50 or fewer full-time equivalent (FTE) employees, you can use the Small Business Health Options Program (SHOP) Marketplace to offer coverage to your workers.
• If you offer SHOP coverage and have fewer than 25 employees, you may be able to get a Small Business Health Care Tax Credit. Learn more about the SHOP Marketplace and other topics of interest to business owners.

https://www.healthcare.gov/what-is-the-shop-marketplace/