Column 79 Anthem QA

Since Anthem Blue Cross has enrolled the majority of people in the individual market for far northern California, I think the following Q & A might be a valuable way to start the year.  These were provided to brokers in the last few weeks.

1. What if a provider that is showing under a particular network online is saying they don't participate in that network or with Anthem?

You can send that doctor's information to your agent who can forward it to their Regional Sales Manager. The Provider Solutions team is directed to outreach to the doctor.  Please provide the doctor's name, address, phone number and a brief synopsis of what was said.


2. What if a provider is saying they take Off-Exchange Individual business but not On-Exchange business? 

Again.  Education is needed in this case.  See above



3. How long does it take to remove a provider from the network?  How long does it take to add a provider to a network?

Changes to networks usually take about three weeks to be updated on the Provider Finder tool once we receive the appropriate notification form the provider.

4. Is the Select PPO network for Small Group plans and Pathway network for Individual the same?

No.  The Select PPO Network for Small Group and the Pathway PPO Network are separate and distinct networks. 


5. What are the total number of doctors in each network?

Keeping in mind that networks are fluid and constantly change, here are the approximate counts for our networks: Individual: Pathway PPO/EPO - 39,000; Small Group: Statewide PPO (Prudent Buyer) - 59,000, Select PPO - 40,000, 


6. Is the Pathway network the same for both On and Off Exchange? 

Yes. There is No difference whatsoever. 


7. Are the Pathway Network reimbursement rates to the provider the same for both On and Off Exchange Individual business?


8. What is Anthem doing to educate providers on networks and plans?

Anthem has made extensive efforts to outreach to all 39,000 Pathway physicians to help educate and inform, including numerous email and letter campaigns and a comprehensive phone campaign reaching out to every one of the 39,000 physicians.


9. What is the difference between Pathway and Pathway X?  Will the X ever be dropped?

The "X" is an identifier for Exchange.  However, in California, the Pathway and Pathway X networks are identical.  The networks are the same both on and off exchange.  

10.  What Rx lists are associated with your Individual plans?

Individual ACA plans use the Select Formulary Drug List.


10. What Rx lists are associated with your Small Group plans?  

Small Group has plan options that include both the Select and the National Formulary lists.


11. Is the Individual Rx list a Closed formulary?  

No, there is no formulary under ACA plans; there are requirements to meet select number of medications in all therapeutic categories and classes. 


12. What if a member is prescribed or needs a medication not on the list? 

Members who need prescriptions outside the list should consult with their doctors, who may request exceptions on their behalf. 

13. Please define the current premium grace period for Individual Anthem members?  

Under current law in California, SB2X sets the grace periods as follows.  For ACA on exchange members who get a government premium subsidy, the grace period is 3 months, for ACA members who do not get a government premium subsidy, the grace period is 31 days.


14. What does MSP (Multi State Plan) mean and why must it be there on some Individual plans?

The Multi-State Plan (MSP) Program, established under the Affordable Care Act, directs Office of Personnel Management (OPM) to contract with private health insurers in each State to offer high-quality, affordable health insurance options called Multi-State Plans. One carrier is selected to represent each metallic tier for both on and off the exchange (mirrored)... These plans are offered by the carriers but are managed by OPM. These plans do not have coverage in "Multiple States" like the designation might suggest.  "Multi-State" is simply a designation and does not mean the plans provide coverage in other states. Coverage out of the state of California is for emergency and urgent care only.



15. Will BlueCard come back to Anthem Individual ACA plans? 

We are currently reviewing our stance on BlueCard and the pricing impact on current rates. Blue Card is the feature of the plan that allows reciprocity between "Blue" providers in other states. As stated above: Coverage out of the state of California is for emergency and urgent care only.



16. Are there any Off-Off Exchange Individual plans with no Rx deductible? 

Yes, Anthem Bronze Pathway PPO 6250/20% and Anthem Bronze Pathway EPO 6250/20% have no deductible for RX tiers 1 and 2.