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Showing posts from January, 2012

Blue Shield CA Agrees to Settlement over Autism Coverage

California Insurance Commissioner Dave Jones announced today that he as reached a settlement agreement with Blue Shield of California Life & Health regarding the carrier's non-compliance with California's Mental Health Parity law.

Blue Shield of California agreed to end the dispute with the California Dept of Insurance and to cover ABA therapy (Applied Behavioral Analysis) as a life-saving medical benefit for autistic children in California.

Blue Shield of California Life & Health has agreed to cease the following practices:

*Denying ABA therapy as an uncovered service
*Challenging the medical necessity of ABA therapy
*Forcing parents into an unnecessary Independent Medical Review to secure treatment

Blue Shield has agreed to establish a dedicated customer service unit to respond to inquiries from families seeking approval for necessary ABA therapy and to pay for services at higher in-network benefit levels.

Read the CA DOI Press Release

This is very good news for Blue Shiel…

Wellpoint Partnering With Primary Care Physicians

WellPoint (parent company of Anthem Blue Cross), the second largest health insurer in the United States, has established an innovative, patient-centered primary care program that will increase the company's investment in the practices of primary care physicians (PCPs) and in the health of their patients.

WellPoint Press Release (1/27/12)

The program will be initiated in the 3rd quarter of 2012 with anticipation of 100% implementation in all WellPoint states (14) by 2014.

Participating physicians will be able to earn additional revenue in the following ways:

*General increase to the regular fees paid to physician practices for specific services.

*Payment for “non-visit” services currently not reimbursed, with an initial focus on compensation for preparing care plans for patients with multiple and complex conditions.

*Shared saving payments for quality outcomes and reduced medical costs.


California Child-Only Health Insurance Refresher

Apparently there is a great deal of confusion with regard to child-only individual health insurance policies in California. I thought it would be a good idea to review it here.

Under SB 2244, all children in California under age 19 are eligible to purchase a child-only health insurance plan and they cannot be denied coverage for pre-existing conditions.

It is very important to understand that there is no guaranteed-issue application nor pricing level for children as a direct purchase. Children under 19 applying for individual health coverage must apply for underwritten coverage just like everyone else. If the insurance carrier determines that the child is an acceptable risk then they will issue coverage at the appropriate rating level relative to the risk.

Only if the child is DECLINED for coverage through underwriting do the guaranteed-issue rules come into play. It's not like HIPAA or Major Risk (PCIP or MRMIP) with direct guaranteed-issue pricing and application. Children M…

Anthem Medicare Advantage LPPO and Sutter Health Group

Sutter Health Group and Anthem Blue Cross MAPD LPPO (Medicare Preferred PPO and Medicare Preferred Select LPPO) have been unable to reach agreement on a new contract.

As of February 1, 2012, Sutter will no longer be a participating provider for Anthem Blue Cross CA hospital and professional network. The ancillary services for Sutter will continue to be a participating provider.

Again, this contract issue affects Medicare Advantage PPO and Medicare Advantage LPPO subscribers. The following Sutter Health facilities are affected:

Sutter Roseville Medical Center - Roseville, CA
Alta Bates Summit Medical Center - Alta Bates/Herrick - Berkeley, CA
Alta Bates Summit Medical Center - Summit Campus - Oakland, CA
California Pacific Medical Center - California - San Francisco, CA
California Pacific Medical Center - Davies - San Francisco, CA
California Pacific Medical Center - Pacific -San Francisco, CA
California Pacific Medical Center - St. Lukes - San Francisco, CA
Eden Hospital Medical Cente…

Blue Shield CA Holding Medicare Supplement Rates

Blue Shield of California has a rate change scheduled for March 1, 2012 for Individual & Family health insurance plans. This rate change does not apply to Medicare Supplements.

Blue Shield of California passed on a Medicare Supplement rate change last August and continued to pass on a rate change again for March 1. 2012.

Current Blue Shield of California Medicare Supplement rates are from 2010 and have not been changed nor adjusted. As of today, Blue Shield of California has no plan to make any rate changes to their Medicare Supplement plans.

I would expect this to be addressed again for August, 2012.


California Mandatory Maternity Benefits SB 222

Effective July 1, 2012, all individual & family health insurance plans in California must provide maternity coverage to subscribers.

The Bill, SB 222, was passed into law in late 2011 and requires all individual & family health insurance plans in California to include coverage for maternity including prenatal and postnatal. This includes plans registered with both the CA Dept of Managed Health Care (DMHC) and the CA Dept of Insurance (CDI). The law, signed by Gov Brown in 2011, estimates an average cost increase (premium) of about $7 per month per subscriber.

As of this date none of the California health insurance carriers selling individual & family coverage have announced how they intend to implement the new benefits. I expect most if not all carriers will simply add the benefit to existing plans without creating a new series of "open" plans to accommodate the new benefit.

This benefit additiona affects all individual & family health plans. Anyone curren…

Express Scripts and Walgreens

Effective January 1, 2012, Walgreens is no longer contracted with Express Scripts.

For those with health insurance plans using Express Scripts as the pharmacy contract provider (Anthem Blue Cross, TRICARE), you will be required to change your provider pharmacy if you are using Walgreens pharmacy.