California Health News

Blue Shield to drop Stanford Health Care from IFP network

Kevin Knauss

Health Plan News for California

Blue Shield withdrawing Stanford Health Care for IFP network

To support our affordability mission, Blue Shield is withdrawing Stanford Health Care from our Individual and Family Plan (IFP) Exclusive PPO Network and has added the University of California Health System

As part of our continuing efforts to help make access to health care more affordable for our members, Blue Shield of California is removing Stanford Health Care from our Individual and Family Plan (IFP) Exclusive PPO Network, effective January 1, 2016. Stanford Health Care remains a provider for all of our other plans outside of the IFP Exclusive PPO Network.

Stanford Health Care includes Stanford Hospital, Lucile Packard Children’s Hospital, Stanford Medical Group, Lucile Packard Medical Group, and University Healthcare Alliance.

Our commitment to affordably priced health coverage
This decision supports our ongoing mission to ensure all Californians have access to quality health care at an affordable price. Stanford Health Care’s rates are among the most expensive in California and its high costs are not consistent with our mission.

We are excited to have the University of California Health System, which includes UC San Francisco Medical Center (UCSF), in our IFP Exclusive PPO Network of hospitals, physicians, and specialists ensuring that IFP members will continue to have access to an extensive network of specialists through their plan.

Blue Shield has taken steps to ensure members will continue to have uninterrupted access to comprehensive medical care in their area.
Blue Shield is committed to providing a comprehensive network of hospitals and physicians for our members, including members purchasing our plans through Covered California. As a reminder, our IFP members now have network access to UC San Francisco Medical Center and the rest of the UC medical facilities through our Exclusive PPO Network. UCSF is also conveniently located in the Bay Area and offers care and specialist services.

Continuity of care
IFP plan members and/or their dependents currently receiving an active course of treatment with Stanford Health Care that extends beyond the end of the Exclusive PPO network transition period on January 1, 2016, may contact Blue Shield Customer Service regarding continuity of care and, if qualified, request to complete treatment of their condition with their current provider. This continuity of care also applies to EPO plan members, as our EPO plans will be withdrawn effective January 1, 2016 and members will be assigned to an equivalent PPO plan that utilizes our Exclusive PPO network.

For members who have a qualifying condition, Stanford Health Care will be considered in network and their benefits will be paid accordingly. If members are in the hospital prior to the transition day of January 1, 2016 and discharged after, Stanford will be considered in network.

Emergency services covered
Blue Shield members who need emergency services should call 911 or seek care at the nearest emergency room, including the Stanford Health Care facilities. Blue Shield will provide the full level of benefits for emergency services.

Stanford withdrawal communications timeline
Blue Shield of California will alert IFP members according to the timing below. Affected members include any IFP members that have recently received service at a Stanford facility and all IFP members that live within a 30 mile radius of Stanford.

Additional IFP Exclusive PPO network updates
Vaca Valley Hospital (Solano County), Washington Hospital (Alameda County) and North Bay Medical Center (Solano County) are also being withdrawn from the IFP Exclusive PPO network, effective January 1, 2016. The reason for these withdrawals is the same as the Stanford withdrawal decision. Their rates are among the most expensive in California, which is not consistent with our affordability mission.

In 2016, Blue Shield will change its EPO network to a PPO network in regions 1, 2, 6, and 9 (Rural North, Wine Country, Alameda, and Monterey counties).

Links to more information about the Stanford withdrawal and other network hospitals:

Questions & Answers for Blue Shield of California Members

Blue Shield has updated the FAQs for the Stanford exclusion on December 9, 2015

On October 1, 2015, we sent you a broker alert to make you aware of the Stanford Health Care Individual & Family Plan (IFP) Withdrawal from Blue Shield’s IFP networks. That alert contained communications to members and FAQs specifying that this was not a contract termination but an exclusion of this provider from our IFP networks.

Since then, there have been some minor changes made to the linked FAQs. First, DMHC approval is no longer pending. Finally, there was a correction made to the FAQs at the top of page four: Continuity of Care (COC) rates have been adjusted to adequately reflect this contract exclusion.

Questions & Answers for Blue Shield of California Members

Transitioning away from Stanford Health Care providers

January 2016

Overview

Blue Shield of California has decided to remove Stanford Health Care from the IFP Exclusive PPO (EPPO) network effective January 1, 2016. The network filing (as of September 11, 2015) is currently pending approval by the Department of Managed Health Care (DMHC). This decision supports our ongoing affordability mission, which is critical in achieving our larger goal of ensuring all Californians have access to healthcare at an affordable price.

Stanford Health Care includes Stanford Hospital, Lucile Packard Children’s Hospital, Stanford Medical Group, Lucile Packard Medical Group and University Healthcare Alliance.

Blue Shield continues to provide a robust provider network for our members, including those purchasing our plans through Covered California. Earlier this year, Blue Shield and the University of California (UC) signed a new network agreement that now provides our IFP members on- and off-Exchange with in-network access to UC San Francisco Medical Center and the rest of the UC medical facilities through our EPPO network.

Member FAQs

What is happening?

Blue Shield is removing (with DMHC approval) Stanford Health Care from its IFP Exclusive PPO (EPPO) network effective 1/1/2016.

What does with DMHC approval mean?

Every year we file our provider network with the DMHC for review. We must wait for approval from the DMHC for our Exclusive PPO network, which excludes Stanford Health Care effective January 1, 2016. This approval has been obtained.

Why is Blue Shield doing this?

Stanford Health Care – which includes Stanford Hospital, Lucile Packard Children’s Hospital and three affiliated medical groups – is among the most expensive providers in California, making it increasingly difficult to provide access to affordable care to our members. To ensure continued access to quality healthcare for our members, Blue Shield has also added new providers to its IFP EPPO network including UCSF in the San Francisco Bay Area and the rest of the UC healthcare system.

Which Blue Shield plans are affected by this change?

Blue Shield Individual and Family Plan PPO members that are accessing Stanford Health Care.

Which Stanford Health providers are included in this change?

Stanford Health Care includes Stanford Hospital, Lucile Packard Children’s Hospital, Stanford Medical Group, Lucile Packard Medical Group and University Healthcare Alliance.

Isn’t Blue Shield raising its IFP rates for 2016 in Santa Clara and San Mateo counties?

The 2016 rates recently published by Covered California reflect premiums with Stanford Health Care no longer part of our IFP EPPO network. The rates would have been higher if Stanford Health Care had remained in-network.

Didn’t Blue Shield just sign a new network contract with Stanford Health Care?

Yes, Blue Shield and Stanford Health Care renewed their network relationship earlier this year. Blue Shield has had discussions with Stanford regarding their on-going participation in the IFP EPPO network only and the parties have not been able to come to terms for their continued participation in this specific network.

Does this affect all Blue Shield members including those enrolled in group plans?

No, Blue Shield members enrolled in our group plans can continue to use Stanford Health Care as an in-network provider. This latest decision only affects members using our IFP EPPO network.

Does this leave a hole in BSC’s IFP EPPO network in the South Bay area?

Since Stanford is a tertiary facility for non-Stanford Medical Center affiliated medical groups, it is not the primary admitting facility for most providers in Santa Clara County, therefore minimizing member disruption. There are more than 3,300 physicians (PCP as well as specialty) who will continue to be in our IFP EPPO network in Santa Clara County. In addition, BSC will continue to meet state regulator’s network adequacy requirements (15-mile/30-minute access).

BSC also recently signed a new network agreement with the University of California, giving BSC IFP members access to all UC hospitals, including UCSF.

How will you let your IFP members know about this change?

We will notify our IFP members within a 30-mile radius of Stanford Health Care and members who have recently utilized Stanford facilities via email or mail of the network change.

Will you alert your in-network primary care physicians who refer to Stanford Medical Center or LPCH?

Yes, once we receive approval from the DMHC. We will reach out to area providers who refer to Stanford Medical Center or LPCH.

Which providers are available to members?

Blue Shield continues to make available a robust provider network for our members including those purchasing our plans through Covered California. Earlier this year, Blue Shield and University of California (UC) signed a new network agreement that now provides our members using our IFP EPPO network in-network access to UC San Francisco Medical Center and the rest of the UC medical facilities.

 

What if members need emergency care during this transition?

Blue Shield of California members who need emergency services should call 911 or seek care at the nearest emergency room, including the Stanford facilities. Blue Shield will provide the full emergency care level of benefits for these services.

If a member has already received authorization for services, can they keep their appointment?

Procedures, treatments, or services from Stanford Health Care providers that have already been authorized will be covered at in-network rates.

Does this mean that members will no longer be able to see their Stanford personal physician?

Affected IFP members may continue to seek services from Stanford Health Care providers after the contract termination date, but reimbursement for any such services, other than emergency services, will be reimbursed at the lower “Non-Preferred Provider” benefit level. Members will be responsible for all additional charges, up to the usual billed charges. PPO members who wish to have their provider visits covered at the higher, preferred benefit level, must receive care from a Blue Shield preferred in-network provider. If you need assistance identifying a preferred provider in the Blue Shield network, please contact customer service at the number of your ID card.

If you began a course of treatment (or received an authorization) prior to January 1, 2016 for certain conditions [see below for more details], your care might be eligible for continuity of care.

What qualifies for “continuity of care?”

Some examples of conditions that may qualify for continued care with the terminated provider include, but are not limited to:

 Pregnancy, including immediate postpartum period.

 A surgery or other treatment that was previously recommended and documented by the provider to take place within 180 days of the effective date of termination and which is authorized by Blue Shield.

 An acute condition requiring prompt medical attention and that has a limited duration (not to exceed the acute phase of the condition when care can be safely transferred to a contracted provider).

 A serious chronic condition, for the period of time necessary to complete a course of treatment and to arrange for safe transfer of care to a contracted provider (but not to exceed 12 months from the date of termination).

 Care for a child who is newborn to 36 months (not to exceed 12 months from the date of termination).

 Terminal illness, defined as “an incurable or irreversible condition that has a high probability of causing death within one year or less.” The member can continue care with the terminated provider for the duration of the terminal illness.

 Continuity of care is also available if the member is receiving services for a serious mental health condition.

What if a member is a patient at Stanford hospital when the contract terminates?

Members will automatically qualify for continuity of care. Stanford will honor network rates in place at time of your admittance.

If a member has already received approval for a transplant. Will the member have in-network benefits?

Yes. In-network benefits will apply for members who are eligible for transplants (see transplant section).

What if a member has already received authorization for a hospital procedure or service? Will Blue Shield contact them?

 IFP members with open authorizations for the hospital at the time of the termination will receive a letter instructing them to contact Member Service to initiate COC eligibility.

Examples:

−Scenario A: A member admitted to the hospital prior to 12:01 am, January

1, 2016 will receive the higher, preferred benefit level (contracted rates).

−Scenario B: Providers of services authorized prior to termination but for

services scheduled for after the termination (12:01 am on January 1, 2016) will be adjudicated at contracted rates. The member’s out-of- pocket expenses will remain at the preferred level of benefits.

What copays or deductible will members be responsible for if they qualify for continuity of care?

Members eligible for COC such as in the case of transplants, are only responsible for their copay or deductible at their preferred (in-network) level.

What other changes are there in Blue Shield’s IFP EPPO network for plans sold through Covered California?

As we look toward 2016, we continue to make adjustments to our products, pricing and network based on much more comprehensive data. We are also responding to the evolving needs of consumers and Covered California.

 In 2016, Blue Shield will be one of two statewide PPO plans in California

o Our IFP Exclusive PPO (EPPO) network will be available at all metal tiers, and it will be sold in all counties and zip codes throughout the state.

 Blue Shield has added the following providers in 2015 to the EPPO network and they will remain in the EPPO network for 2016:

o University of California hospitals and medical centers (UC Davis, UC Irvine, UC San Francisco, UC San Diego and UCLA)

o Cedars Sinai Medical Center

o Eisenhower Memorial Medical Center

In addition to Stanford Health Care, Blue Shield has also removed the following hospitals from its IFP EPPO network for 2016.

o Washington Hospital (Alameda County)

o North Bay Medical Center (Solano County)

o Vaca Valley Hospital (Solano County)

 In 2016, Blue Shield will change its EPO network to a PPO network in regions 1, 2, 6 and 9 (Rural North, Wine Country, Alameda, Monterey)

o All PPO plans offer out-of-network benefits. Members who access these will pay out-of-network rates.

o All PPO plans include BlueCard, a feature that provides members with access to covered services – including urgent and emergency care – outside California. BlueCard services will now allow those in rural areas to access providers across the state border. This was an especially important issue for members living in the Lake Tahoe area.

o Members in these regions will now have access to the following providers:

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