CA AB72- Small Group and Individual Benefit updates to meet new guidelines
Anthem has made changes to health benefit plans to meet the requirements of recent legislation passed in the state of California. Assembly Bill (AB) 72 requires the following changes.
AB72- If you receive services from an In-Network Facility at which, or as a result of which, you receive non-Emergency Covered Services provided by an Out-of-Network Provider, you will pay no more than the same cost sharing that you would pay for those same non-Emergency Covered Services received from an In-Network Provider, and you will not owe the Out-of- Network Provider more than the In-Network cost sharing for such non-Emergency Covered Services.
Communications about AB72 will also go out to your Individual Grandfathered and ACA clients by the end of July. These changes became effective on July 1, 2017 and are reflected in the revised Evidence of Coverage (EOC).
Member and Employer Letter
Dear Plan Administrator,
Thank you for choosing Anthem Blue Cross (Anthem) as your health care partner. Anthem has made changes to your employees’ small group health benefit plans, effective July 1, 2017, to meet the requirements of recent legislation passed in the state of California, Assembly Bill 72 (2017). The updated Evidence of Coverage (EOC) includes the following language:
If you receive services from an In-Network Facility at which, or as a result of which, you receive non –Emergency Covered Services provided by an Out-of-Network Provider, you will pay no more than the same cost sharing that you would pay for those same non-Emergency Covered Services received from an In-Network Provider, and you will not owe the Out-of-Network Provider more than the In-Network cost sharing for such non-Emergency Covered Services.
PPO EOCs include the following additional text:
If you consent in writing to receive non-Emergency Covered Services from an Out-of-Network Provider while you are receiving services from an In-Network Facility, the Plan will pay such Out-of-Network services based on the applicable Out-of-Network cost sharing stated in your “Evidence of Coverage”. The written consent to receive non-Emergency Covered Services from Out-of-Network Providers while you are receiving services from an In-Network Facility must demonstrate satisfaction of all the following criteria:
1. At least 24 hours in advance of care, you consent in writing to receive services from the identified Out-of-Network Provider;
2. The consent was obtained by the Out -of-Network Provider in a document that is separate from the document used to obtain the consent for any other part of the care or procedure. The consent was not obtained by the Facility or any representative of the Facility at the time of admission or at any time when you were being prepared for surgery or any other procedure;
3. At the time of consent, the Out-of-Network Provider gave you a written estimate of your total Out-of-Pocket cost of care, based on the Provider’s billed charges for the services to be provided. The Out-of-Network Provider shall not attempt to collect more than the estimated amount without receiving a separate written consent from you or your authorized representative, unless the Provider was required to make changes to the estimate due to circumstances during the delivery of services that were unforeseeable at the time the estimate was given;
4. The consent advises that you may elect to seek care from an In-Network Provider or that you may make arrangements with your Plan to receive services from an In-Network Provider for lower Out-of-Pocket costs;
5. The consent and estimate was provided to you in the language you speak, if the language is a Medi-Cal threshold language, as defined in subdivision (d) of Section 128552; and
6. The consent advises you that any costs incurred as a result of your use of the Out-of-Network benefits are in addition to the In-Network cost-sharing amounts and may not count toward the annual In-Network Out-of-Pocket Limit or In-Network Deductible.
The EOC is a written guide to the services the health plan covers and what employees pay for services. To obtain a copy of their updated EOC, members may call the toll-free phone number on the back of their ID card or log in as a member at anthem.com/ca.
Changes apply to California Small Group and Individual (Under 65).