Members who live in rating regions 1, 7, and 10 and who transition into a new Anthem EPO plan for 2018 can apply for Continuity of Care coverage if their current provider is no longer in network. They can call member services and ask for assistance with their ongoing treatment with their current providers.
This enforcement action is the result of deficiencies identified in DMHC surveys and 245 specific grievance system violations identified by the DMHC Help Center during the investigation of consumer complaints from 2013 through 2016. Including this fine, the DMHC has fined Anthem Blue Cross $11.66 million for grievance system violations since 2002.
All the plans offered will EPO (Exclusive Provider Organization) with no out-of-network coverage. Anthem will retain the BlueCard for travel coverage for its Blue Cross members. The 2018 plans will continue to use the Pathway network of providers.
$15 million of the fund will be allocated to pay actual out-of-pocket costs, up to a set amount, that settlement class members claim they incurred due to the cyber attack.
In order to give members impacted by this change plenty of time to plan for their coverage needs in 2018, we are notifying affected members over the next few days that their current plan will be discontinued on December 31, 2017. This includes all on and off exchange members outside of rating regions 1, 7 and 10, and HMO members in rating region 7. It’s important to note that until 2018, their coverage stays the same. All they need to do is keep paying their premiums.
Next year, we will offer plans in three regions of Northern California only, which will include Redding, Santa Clara County, and Stockton/Modesto. The coverage options will include EPO plans available both on-exchange and off-exchange, and at all metal levels. Staying in these three key areas will help ensure Californians in those regions have access to health plans.
As part of our ongoing efforts to manage these drug costs, we are expanding our precertification program to include medical specialty edits. The expansion of our precertification program will allow clients who currently have our precertification program to benefit from these enhancements. There are two components to this expansion:
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.
Members can make an appointment with a licensed doctor to come to their home or office in two hours or on their schedule. Hours of availability are from 8 a.m. to 8 p.m., seven days a week, including holidays.
To make it easier than ever to find local level 1 pharmacies for your clients, refer to this Rx Choice Tiered Pharmacy list for California. A circle with either a 1 or a 2 next to each pharmacy indicates whether it’s a level 1 or a level 2.