California Health News

El Camino Hospital dropped from Anthem Blue Cross health plans

Kevin Knauss

Anthem Blue Cross of California

Anthem Blue Cross announced that as of February 29, 2016, El Camino Hospitals in Mountain View and Los Gatos will no longer be a network provider for their individual and family health plans. Anthem Blue Cross spelled out how they will no longer authorize or approve scheduled elective admissions to El Camino Hospital.

Letter from Anthem Blue Cross

February 29

Re: El Camino Hospital

Anthem Blue Cross has been engaged in discussions to renegotiate the terms of its Commercial Hospital Agreement with El Camino Hospital, which includes hospital campuses in Mountain View and Los Gatos. Regrettably, Anthem Blue Cross and El Camino Hospital were unable to reach agreement and the contract terminated effective February 29, 2016. From that date forward, Anthem Blue Cross will generally no longer authorize or approve scheduled or elective admissions to El Camino Hospital for Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company members.

Anthem Blue Cross notified physicians who admit to El Camino Hospital of this development so that they can arrange for admission of all Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company members to alternate facilities. The following is a partial list of alternate contracted facilities in the El Camino Hospital service area:

Please be aware that there are limited benefits for Anthem Small Group and Individual PPO members who receive care at El Camino Hospital on or after the above listed termination date, except for medical emergencies. Members who are pregnant, currently undergoing a course of treatment, have a current authorization for health care services or are otherwise concerned about disruption of treatment, should be directed to call an Anthem Blue Cross Customer Service Representative using the toll-free telephone number located on their identification card.

Frequently Asked Questions about El Camino Hospital termination

Overview

1. Why did El Camino Hospital terminate its contract with Anthem Blue Cross?

Anthem Blue Cross and El Camino Hospital, with hospital campuses in Mountain View and Los Gatos, have been engaged in negotiations for several months to reach reasonable contractual language and reimbursement rates that are beneficial to both organizations. Unfortunately, Anthem Blue Cross and El Camino Hospital were unable to reach agreement and the contract terminated effective 12:00AM, February 29, 2016. El Camino Hospital provides services to members in the South San Francisco Bay area.

How Members are Affected

2. What Anthem Blue Cross products are affected by this hospital termination?

This termination affects the out-of-pocket obligations for most Anthem Blue Cross members who are enrolled in Commercial PPO, EPO, HMO, and POS benefit plans and receive care at El Camino Hospital. Members, who have a Medicare supplemental policy for Part A and Part B (Medigap), are not affected by this contract termination.

3. Will members be notified about the contract termination?

Within five days of the hospital’s termination from the network, Anthem Blue Cross notified subscribers who personally accessed or had a covered family member access El Camino Hospital within the last 12 months. In addition, members authorized or scheduled for a service or procedure at El Camino Hospital were notified. The letters instruct members to call the Customer Service number on their ID card if they are in a current course of treatment at El Camino Hospital or have questions or concerns about the contract termination. The letters states the following legally-required message regarding completion-of-covered-services/continuity-of-care:

If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Please contact the Anthem Blue Cross customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO/PPO consumers, by telephone at its toll-free number, 1-888-HMO-2219, or at a TDD number for the hearing impaired at 1-877-688-9891, or online at www.hmohelp.ca.gov .

Note: Anthem Blue Cross does not mail notices to members enrolled in ASO, JAA, MCS, or other self-funded plans (however, this does not preclude member eligibility for continuation of covered services). A template notice is available that can be forwarded to clients for their use in notifying their associates about the contract termination.

4. How are Anthem Blue Cross HMO members affected by El Camino Hospital’s contract termination?

All non-emergency hospital services must be approved by the HMO member’s participating medical group/IPA. If approved, Anthem Blue Cross will cover the claim at the member’s in-network benefit levels. If not approved by the member’s participating medical group/IPA, the claim will be denied, as stated in the members Evidence of Coverage (EOC).

5. How do members know if their doctor will be affected by this hospital termination?

Many doctors have admitting privileges at more than one hospital. Just because a member’s doctor may have admitting privileges at El Camino Hospital does not necessarily mean that a doctor cannot treat his or her patients at another participating hospital.

Physicians, Medical Groups, and Alternate Hospitals

6. What other participating hospitals are located near El Camino Hospital?

Anthem Blue Cross has a statewide hospital network of over 300 acute care facilities. The Find a Doctor function at www.anthem.com/ca can be used to locate a participating hospital in a specific area. The following is a partial list of alternate participating general acute care hospitals within the vicinity of both El Camino Hospital campuses:

For a complete list of contracting hospitals, as well as ambulatory surgical centers and other ancillary facilities, please see Anthem Blue Cross’s website at www.anthem.com/ca. Customer Service representatives can check the provider database for a physician’s admitting privileges at another nearby in-network facility. Members should confirm the information they receive with their treating physician. Every effort will be made to assist members in determining their choices and understanding the potential financial consequences of seeking care with a provider that is not in

Anthem Blue Cross’s provider network

7. Will Anthem Blue Cross notify PPO physicians and admitting HMO medical groups about the contract termination?

PPO physicians and HMO medical groups agreed in their contracts to admit members to Anthem Blue Cross’s participating hospitals to ensure that each member receives the maximum benefit level under his or her benefit agreement. Anthem Blue Cross mailed letters to the PPO physicians who maintain privileges/affiliations at El Camino Hospital and to the admitting medical groups, informing them about the contract termination.

These letters instruct physicians to obtain alternate admitting privileges if necessary and arrange for the redirection of members to alternate participating hospitals.

8. Will Anthem Blue Cross assist physicians in acquiring admitting privileges at an alternate hospital if necessary?

Anthem Blue Cross is ready and willing to assist our physician and medical group partners in acquiring admitting privileges at a participating hospital if necessary. In the event that a member’s physician cannot admit to an alternate hospital after a hospital contract termination, then Anthem Blue Cross will work with the physician or other healthcare professional to admit members to an in-network facility.

Post-Termination Care

9. What if a member was in-patient at El Camino Hospital on the day the contract terminated?

If a member is in-patient at 11:59 PM the day before the contract terminated, then the member will continue to receive uninterrupted care at El Camino Hospital until he or she is discharged. In addition, the member’s in-network benefit levels will apply for the entire in-patient stay.

10. What about members who need to complete a course of treatment, have a scheduled procedure, or need an out-of-network referral for medically necessary services at El Camino Hospital following the termination?

California law provides for completion of covered services/continuity of care for certain medical conditions following a provider’s termination if, among other things, the provider and the plan agree on a rate of payment. The current contract between Anthem Blue Cross and El Camino Hospital has provisions that cover members for continuity of care/completion of covered services after the contract terminates. It is always Anthem Blue Cross’s intent to be prepared by having a Continuity-of-Care Agreement in place sufficient to meet the requirements of Health & Safety Code Section 1373.96. Anthem Blue Cross will comply with applicable requirements for completion of covered services/continuity of care in accordance with the law. If a member began a course of treatment at El Camino Hospital before the contract termination date for one of the following conditions, the member or his/her physician can request continuity of care by calling Anthem Blue Cross’s Customer Service Department:

Eligibility for continuity of care depends on factors outlined in the member’s EOC. Continuity of care/completion of covered-services will be considered by Anthem Blue Cross’s Transition Assistance Department on a case by case basis. When a case is approved, the claim(s) is/are processed at in-network benefit levels.

Note: HMO members and physicians wishing to request continuity of care/completion of covered services would not contact Anthem because all medical management is delegated to the provider group. HMO members and physicians should contact their participating medical group.

11. What if the member does not qualify for completion of covered services / continuity of care? Can the member receive care from El Camino Hospital anyway?

PPO and Traditional (Indemnity) Members:

Large Group: Members electing to receive care at a non-contracting facility may be responsible for higher out of pocket expenses depending on benefit plan design for authorized and non-authorized services as stated in the member’s EOC. Note: There may be different arrangements for ASO groups or other self-insured clients.

Individual and Small Group: Members electing to receive care at a non-contracting facility will in most cases be responsible for higher out of pocket expenses depending on benefit plan design as stated in the member’s EOC.

HMO Members:

All services must be approved by the member’s participating medical group/IPA. If approved, the claim will be covered at the member’s in-network coverage schedule of benefits. If not approved by the member’s participating medical group/IPA, and services are received at El Camino Hospital, the claim will be denied as stated in the member’s EOC.

PPO physicians and HMO participating medical groups and IPAs that admit patients to El Camino Hospital have been informed about the contract termination so that Anthem Blue Cross members will be admitted to participating network facilities following the contract’s termination date.

12. If a member does not have access to an alternate participating provider or a particular service is not available elsewhere, can he or she receive that service from El Camino Hospital?

Anthem Blue Cross assures its members that they will have timely access to care. If a service is not available at an alternate participating provider, PPO members may request an out-of-network referral by contacting Customer Service. Requests will be reviewed on a case by case basis pursuant to Anthem Blue Cross’s out-of-network referral policy. When an out-of-network referral is approved by Anthem Blue Cross, the member’s in-network benefit levels will apply. However, because El Camino Hospital will no longer be in Anthem Blue Cross’s provider network, members may be responsible for higher out of pocket expenses, depending on their benefit plan. Every effort will be made to assist members in understanding the potential financial consequences of the decision to seek services from a non-participating provider.

13. What about members who need emergency medical care at El Camino Hospital following the contract’s termination date?

A hospital’s emergency medical services do not require pre-authorization, regardless of where they are delivered. El Camino Hospital must provide services for members requiring emergency care. Coverage will be provided according to the member’s policy benefits.

Anthem Blue Cross encourages members to make informed decisions about when to use urgent care as opposed to emergency room care. Urgent care is appropriate when a member needs a physician’s attention for a condition that is non-life threatening. Any member needing urgent care, but whose physician or network provider is unavailable, should go to the nearest immediate or urgent care facility.

Contract Negotiations

14. What is the status of the negotiations between Anthem Blue Cross and El Camino Hospital?

Anthem Blue Cross does not share details of its confidential contract negotiations with the public. Our primary goal during contract negotiations is to ensure we are compensating hospitals fairly, while assuring the best access to health care at an affordable price for our members. We take protecting our members from exceedingly high medical costs very seriously and cannot agree to a contract that puts further pressure on the rising cost of health care paid by our customers.

15. Don’t hospital negotiations usually work themselves out after the contract termination date?

Negotiations often do work themselves out after the contract termination date, but that is not always the case. Anthem is working collaboratively with El Camino Hospital as well as the PPO physicians and medical groups that maintain admitting privileges to the hospital, to ensure a smooth transition for our members.

**Cost of Care in California** Our customers frequently tell us that they cannot support continued increases in their health benefit costs. It is important for everyone to understand why costs for health care are going up so steadily. You can learn about the causes behind rising costs and the work Anthem Blue Cross is doing to protect our members from even higher costs at www.anthem.com/ca/costofcare.