Column 47

Column 47 May 17 2014

 

During this current transition with Covered California there is a great deal of concern about network adequacy.  There is legislation pending to address this issue, but in the meantime, it's a real challenge for anyone insured under the new individual health insurance products.  It does not matter if your plan was written under Covered California or direct with the insurance company, the individual product provider networks are the same. 

 

 

There is a program under Anthem that could be of value to some.

 The Transition Assistance Program provides a process that allows continued care for members when one of the following conditions is met. :

o Their Primary Medical Group (PMG), Independent Physician Association (IPA), Preferred Provider Organization Provider (PPO Provider), Hospital, or other provider is terminated from the Anthem Blue Cross participating provider network.

o They are a new enrollee in an Anthem Blue Cross plan (except members with an Individual contract) and their treating provider is not part of the Anthem Blue Cross participating provider network.

o Continuity of care is at risk for reasons over which the member has no control. (Members who have elected to make changes in their coverage which cause them to be out-of-network are not eligible for this program).

 

Their form provides further clarification as follows:

 

If you are in an active course of treatment for an acute medical condition or a serious chronic condition.

An acute medical condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem that requires prompt medical attention and that has a limited duration.

A serious chronic condition is a medical condition due to a disease, illness, or other medical problem that is serious in nature and that persists without full cure or worsens over time or one that requires ongoing treatment to maintain remission or prevent deterioration.

 

Completion of covered services may be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider;

o If you are in an active course of treatment for any behavioral health condition;

o If you are pregnant, regardless of trimester;

o If you have a terminal illness;

o If you have a newborn child between the ages of birth and 36 months. Completion of covered services may be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider;

o If you have a surgery or other procedure that has been authorized by the previous plan or its delegated provider and is scheduled to occur within 180 days of the effective date of coverage for a newly covered enrollee.

 

However, it is important to note that if you require ongoing care for any chronic condition and you are not in an acute phase of your illness, one requiring a special course of treatment, you should select an in-network provider to meet your ongoing health care needs and you do not need to complete this form.

 

Clearly there is limited application for this program and one must actually apply to be approved, but at least there is some access available.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: All information in this column is provided" to the best of my knowledge" subject to final regulation by the respective agencies at press deadline.  Please submit questions to This e-mail address is being protected from spam bots, you need JavaScript enabled to view it