CalCPA ProtectPlus

 

News from Anthem Blue Cross:

Who needs one more thing to sort, file and recycle?  No one we know.

Give your mailbox and your recycle bin a well-deserved break – get your medical claim summaries online at anthem.com/ca. 

Right now, you’re getting your medical claim summaries (also called Claim Recaps or Explanation of Benefits [EOBs]) in the mail. The claim summary tells you how your benefits were paid and if you owe any part of the bill.

Sign up for paperless claim summaries today!

• Log in to anthem.com/ca
• Click on “Profile”
• Scroll down and select “Go Paperless”

Note: Going paperless applies only to your medical claims. You’ll still get paper claims for other types or services, like dental or vision care.

Join us in thinking outside the mail box!

Once you go paperless, you’ll get an email each time you have a new claim summary that’s ready to view. We’re happy to offer one more way to help keep your life and our planet a little less cluttered.

You’ll need to be registered to go paperless

If you’re already registered but haven’t been to the site in awhile you may need to register again. If you’ve never registered, now’s the time!

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Maintaining a successful health plan demands constant attention to changing conditions and regularly updating plan designs. It means responding to an evolving market, adapting to public policy initiatives, and taking advantage of new medical developments. That’s why there are always changes for the Group Insurance Trust to announce during the annual open enrollment period. This year, with the passage of the Patient Protection and Affordable Care Act (“health care reform”) the number of changes are greater than usual and carry a more serious financial impact.

Following is an outline of the most important plan modifications subscribers will see this year. Some are in response to health care reform but not all.

Health Care Reform Mandates

Beginning January 1, every health plan must comply with the following provisions:

• All dependents up to age 26 are eligible for coverage
• No cost-sharing for in-network preventive services
• No pre-existing limitations for children under 19
• Prior authorization or higher cost-sharing disallowed for out-of-network emergency services
• New rules for appeals process
• Removal of lifetime maximum limits (copay and HSA plans)
• Removal of lifetime limits for hospice care (copay and HSA plans)
• Removal of annual limits on durable medical equipment (HMO plans)

Premium Rates

Naturally, all these mandated changes come at a price. Over the past seven years, the Group Insurance Trust has delivered single digit increases that were well below national and regional trends. However, a thorough analysis of the costs associated with these mandated benefits, plus unusually high claims experience in 2009, resulted in an increase to CalCPA ProtectPlus medical plan rates that is significantly higher than that of previous years.

Because each firm’s rates are based on a combination of factors, each firm’s increase is unique. Renewal packets, including rate information specific to each firm, were mailed to participating firms on November 1. If you did not receive your renewal package please contact Banyan Administrators, LLC at (877) 480-7923 immediately. (continue reading…)

Anthem Blue Cross has announced the launch of a new California website designed to provide reliable information to women about health issues specific to them. It will save women time searching for health related answers since everything is in one place and is accessible at any time of the day or night, which is the convenience that women need with their busy schedules. 

“We recognize that the lives of today’s women are filled with work, friends and family. At Anthem, we wanted to develop a place that’s just for them,” said Pam Kehaly, president of Anthem Blue Cross. “This dynamic new site is all about women’s health, and it can help women in California feel, and become their healthy best.”

According to Anthem’s press release last week, they selected SmartNow to develop the content for the site. SmartNow works with the top two hundred women’s health experts across the country, so the content is relevant, reliable and current. In addition, the information is designed to meet women’s personal, professional and business needs.

Anthem’s press release states that the site will help women:

• Stay on track with a dining out and fast food guide;
• Get more nutrition for their money with a down-loadable grocery guide iPhone app for Anthem members;
• Learn about health conditions and diseases;
• See how improved health can help lower costs;
• Learn how to compare quality and costs for hospitals in their area.

“At home, the woman is most often the one who makes the health care decisions that will impact the health of their family,” Anthem leaders said. “At work too, women are often the ones to make the choices about health care coverage and wellness offerings for their employees. This new site is intended to help guide women in California toward the right choices both at work and at home.”  

This great site provides the tools and programs needed to help women make healthier decisions and help those around them to do so as well. To check out this new site from Anthem click here.

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—A Note from Susan Young, Executive Director of the Group Insurance Trust of the California Society of CPAs

In addition to the quality medical care and competitive prices members have come to expect, when you subscribe to a CalCPA-endorsed ProtectPlus health plan, you get the added benefit of an administrative support team whose sole purpose is to make your insurance dealings clear, easy, and responsive. This is never more critical than when you find yourself facing a denied claim. If this should happen, here are the steps you can take to get an explanation and, at least sometimes, a decision reversed.

Begin by calling the Anthem member service phone number on the back of your medical ID card. You should have your EOB (explanation of benefits) in hand so that you can ask why a particular treatment was either denied or only partially paid. If the answer isn’t clear, or you feel the claim wasn’t handled properly, your next step should be to call the ProtectPlus service representatives at Banyan Administrators at (877) 480-7923. Every member of the Banyan team is a licensed agent and is there to serve you. Moreover, they are your advocates. Their job is to make sure you get the care you need as smoothly as possible, so you shouldn’t feel shy about asking. This is what your insurance plan is all about.

If the Banyan agent doesn’t solve the problem to your satisfaction, Banyan can walk you through the Anthem appeals process. Appeals are handled slightly differently depending on whether they concern completed care, treatments in progress, or future procedures. Anthem will provide a written response within 30 business days with the results of its decision.

At this point most disputes are resolved, but if you are still not satisfied you have the final option of filing for an Independent Medical Review (IMR). The IMR is provided by the California Department of Insurance (DOI). There is no charge to you for this service and the DOI’s decision is binding. Simply complete and submit the one-page application to request a review. Anthem will provide the applicable medical records and claims documentation required by the DOI and you can add any pertinent information in support of your claim. The Department will inform you of its determination in approximately 30 business days following submission of the IMR request.           

Because the ProtectPlus program is a Multiple Employer Welfare Arrangement (MEWA), ProtectPlus plan participants must submit their IMR application to the Department of Insurance which oversees MEWAs. IMR requests for many other healthcare plans in California are reviewed by the Department of Managed Care.  You can download the IMR application at http://www.insurance.ca.gov/0100-consumers/0020-health-related.

A powerful new tool recently added to the Anthem Online Services website now allows ProtectPlus subscribers to locate treatment facilities, compare prices and get other indicators about the expertise of the facility in a specific area of medicine. Though simple in use and appearance, this new function actually makes real a longstanding but elusive promise of modern healthcare—comparison shopping for medical services. With this information in hand, you can now decide whether one treatment facility is worth a lot more money than another and whether you are willing to go farther to save a little or a lot.

You can access these new tools by logging onto the Anthem Blue Cross website directly (www.anthem.com) or you can click through from the ProtectPlus site (www.cpaprotectplus.com). If you take the latter route, choose “Plan Members” then go to “My Plans” and click on “ProtectPlus (Anthem Blue Cross).” Please note that Anthem recently completed a major re-design of its website and you will be instructed to register, or re-register if you had an account on the earlier website, before accessing your account information. Once on your Anthem personal Account Summary page you will find several icons that you can click and drag onto your personal menu to customize your page.

Click on the “Facility Cost and Quality” icon to open the Anthem Care Comparison page. Once there click on “find a facility for a procedure or condition.” A drop-down list provides categories of treatment (e.g. cancer, lungs, orthopedic, or pediatric conditions). When you have chosen a category you can then choose from another list of procedures and diagnoses. You then put in your city or zip and the distance you are willing to travel. (continue reading…)

The following information is provided by Anthem.com:

Specialty Pharmacy Update: Upcoming Brand Change and Enhancements

We’re committed to helping make health care more affordable for our clients through the integration of medical and pharmacy benefits. In support of this, our parent company completed a deal in late 2009 to sell its NextRx pharmacy benefit management subsidiaries-including PrecisionRx Specialty Solutions (PRxSS), the specialty pharmacy- to Express Scripts, and subsequently entered into a contract with Express Scripts to provide certain operational and administrative support for our prescription drug plans. As a result, customers will gain the advantage of best-in-class programs from both organizations  and integration of their medical and pharmacy benefits from leaders in their respective fields.

 All members who obtain specialty medications from PRxSS will obtain them from CuraScript, the Express Scripts specialty pharmacy, after September 20, 2010. We will continue managing specialty pharmacy drug programs and will continue to provide a dedicated account service team. Members will keep their existing ID cards and numbers, Customer Service phone numbers, drug lists and benefit designs. However, specialty pharmacy members and website users will experience some changes upon migration.

 What Isn’t Changing:

• CuraScript order processing times are very similar to the member experience with PRxSS. Rather than targeting a turnaround time, CuraScript targets a required patient delivery date.

• PRxSS will transfer to CuraScript any prescriptions that have remaining refills on active prescriptions less than one year old. The member will be able to place the refill orders online or by phone.

• Members taking specialty medications should continue to use the same phone number (800-870-6419) and e-mail address (specialtycustomerservice@express-scripts.com) they use today.

• All customer service hours remain the same.

• Health plan-specific specialty drug lists remain the same.

What Is Changing:

• Existing specialty pharmacy customers may notice changes to the automated phone system.

• The color and layout of paperwork in order packages from CuraScript will differ from what PRxSS used.

• Customers may notice that their prescriptions are being filled at any of the three main CuraScript facilities (Indianapolis, Ind; Orlando, Fla; New Castle, Del), but prescriptions could also be filled by other, smaller CuraScript facilities.

• CuraScript will be the brand on all specialty pharmacy packages, label names and practice of pharmacy communication.

• CuraScript will offer its CareLogic clinical programs to transitioning PRxSS patients; these programs include those that PRxSS offers today.

 Web Experience

Members may access their health plan’s website for specialty pharmacy information and online tools. If they currently access their health plan information online, they can now review their specialty pharmacy information as well. After September 20, when they view their pharmacy information online, they will be re-directed to the Express Scripts website and may be asked to provide registration information. This information will be used to manage their pharmacy benefits and preferences for communication and privacy.

 Members will be able to use many of the web enhancements listed below to help them better manage their specialty medications:

• Review up to 18 months of prescription history

• Schedule refills for certain specialty medications (some medications require the patient to call)

• See when orders have shipped or are processing

• Choose from a variety of payment methods

• Set required delivery date for specialty medications

• Order supply kits, if needed

• View specialty and home delivery medications, if applicable, filled by Express Scripts on the same web page

The PRxSS website, precisionrxspecialtysolutions.com, will be retired after September 20, 2010. Those who visit the site after that date will be re-directed to curascript.com. 

 Member Communications

Current PRxSS customers will be sent mailings, which include a Frequently Asked Questions document, beginning September 3.

 If you have any questions, please contact your account representative.

[Information Source]

CaliforniaHealthline.org  -  Friday, April 30, 2010

On Thursday, WellPoint officials announced that the company’s subsidiary, Anthem Blue Cross of California, has withdrawn its request to raise premium rates for individual policyholders by as much as 39%, the Los Angeles Times reports.

The increase would have taken effect on Saturday and affected as many as 800,000 of Anthem’s customers. California Insurance Commissioner Steve Poizner (R) confirmed the company’s decision (Helfand, Los Angeles Times, 4/30).

Background

In February, Poizner WellPoint to delay the rate hike, which originally would have taken effect on March 1.

Anthem officials later said they would delay the rate hike until May 1, pending the findings of an investigation by external actuaries hired by Poizner, the Sacramento Bee reports.

Report Pending

Although the complete report is expected to be released as soon as Tuesday, Poizner released a summary of the findings on Thursday (Caina Calvan, Sacramento Bee, 4/30).

Poizner said the actuarial firm had found “multiple, significant errors” with Anthem’s proposal, including its calculations of medical claims trends (Wilde Mathews, Wall Street Journal, 4/30).

The report — conducted by the actuarial consulting firm Axene Health Partners — found that among other errors, Anthem overstated medical costs by raising the effect of aging. The actuaries found that modifying those numbers could lower the average rate hike by 10.2% (Los Angeles Times, 4/30).

Those errors “would have led to massive and unjustified rate increases,” Poizner said, adding that Anthem was notified about the errors “and they admitted to the mistakes” (Sacramento Bee, 4/30). (continue reading…)