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Health-Go-Round
The Latest Spin on PPOs! Our Annual PPO SurveyWelcome to Part I of our seventh annual PPO survey. For this survey, 10 PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions. We hope this information will help the professional agent or broker better serve sophisticated healthcare clients. We offer a special thanks to the insurance carriers that took the time to answer our lengthy questionnaire. We interpret their careful responses as a sure sign of their high level of commitment to the professional agent. Look for Part II in our April issue.
1. Is an approval procedure required for getting a specialist referral or a diagnostic test or treatment in-network or out-of-network?
Aetna: No.
Blue Cross: No.
Blue Shield: No, PPO plan members
can generally self-refer to
any doctor for care. They can choose to use in-network and out-of-network benefits with claims reimbursement based on their benefit plan. Out-of-network services are usually subject to a higher deductible and co-payment amount.
Cigna: No referrals or approvals are required
since the PPO benefit plan is an open-access program. Members are covered whether or not they get care from PPO network providers. Members who use services from an in-network provider may have reduced co-payments and lower out-of-pocket costs.
Health Net: No, members
have access to the entire Health Net of California contracted specialist physician network. There are no requirements for prior authorization for visits to contracted specialists.
Interplan Health Group: The group medical plan generally deter-
mines if a review or authorization is required for referral to a specialist or diagnostic tests. Interplan Health Group does offer utilization review services, which can be customized to meet the clientีs needs and comply with the summary plan description.
Kaiser Permanente: No, the PPO plan does not require a referral to see a specialist. Diagnostic tests would be covered if they were ordered by their PCP, were a covered benefit, and were medically necessary.
Nationwide Health Plans: No, but some services require prior
authorization.
Nippon Life: No.
UnitedHealthcare: UnitedHealthcare Options PPO provides cov-
erage for mammograms as part of our standard outpatient surgery, diagnostic, and therapeutic services benefit. It is covered as a preventive and diagnostic service.2. Are there any restrictions on getting second opinions from an in-network provider or an out-of-network provider?
Aetna: A member, who has the option of an out-of-network ben-
efit, may arrange his or her own second surgical opinion with a non-participating provider.
Blue Cross: No.
Blue Shield: A member can get a second opinion from any in--
network or out-of-network provider. When an out-of-network provider is used, the member is responsible for any difference between Blue Shield of Californiaีs payment and the billed amount. There would be no restrictions of this kind since Blue Shield does not require physicians to belong to certain IPAs or medical groups in order to participate in our PPO network.
Cigna: No, the PPO is an open access plan, allowing members
to seek care in-network and out-of-network at any time. By using a network provider, members have a lower out-of-pocket cost for each service.
Health Net: No, Health Net members may see contracting spe-
cialists without getting a referral.
Interplan Health Group: If the group medical plan requires sec-
ond opinions, Interplan Health Groupีs utilization review program will help the patient find the appropriate physician to do the review. IHG will refer to in-network providers whenever possible.
Kaiser Permanente: No, there is coverage for a second medical
opinion, limited to charges for physician consultation and for any additional x-rays, laboratory tests, and other diagnostic studies. Benefits will not be payable for x-ray, laboratory tests, or diagnostic studies that are repetitive of those received as part of the original medical opinion and those for which KPIC has paid benefits. For benefits to be payable, the second medical opinion must be rendered by a physician who agrees not to treat the covered person's diagnosed condition. The physician offering the second medical opinion may not be affiliated with the physician offering the original medical opinion.
Nationwide Health Plans: No.
Nippon Life: No.
UnitedHealthcare: A second opinion is not mandatory under our
plans. Our UnitedHealthcare Options PPO product is open access and members may seek second opinions from any participating or non-participating physician. The memberีs benefit level will vary depending on the physicianีs participation status.3. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?
Aetna: Our patient-management staff is centrally located. The
region is determined by the location of the customer.
Blue Cross: Members may see specialists without referrals. In
patient hospital services and some diagnostic services may require pre-authorization by utilization management.
Blue Shield: Physician members and participating ancillary
providers are expected to refer to other network providers for services. However, members can see out-of-network specialists if they choose, and pay higher coinsurance. Generally, Blue Shieldีs PPO plans do not require authorizations in the referral process.
Cigna: These decisions are made with a member's physician in
partnership with the member and the CIGNA nurse and physicians.
Health Net: Decisions about specialty referrals for testing, treat-
ment, surgery, or hospitalization are made with the member, the memberีs physician, Health Netีs care management team and, if the member chooses, Health Netีs Decision Power health coaches, who provide additional information to help the member through the decision-making process.
Interplan Health Group: The final decisions about specialist
referrals, testing, treatment, surgery, and hospitalization are typically made by the patient and treating healthcare provider and benefit plan design. Interplan Health Group offers utilization review services to help in the process.
Kaiser Permanente: Decisions are made by the memberีs
physician. The member does need to get pre-certification for any hospitalization or certain special procedures as defined in the members COI. Pre-certification is performed by SHPS.
Nationwide Health Plans: The member makes the decision. The
level of benefits helps them to make that decision. Our medical-management team includes case managers and a medical director. The team gets involved with case management, treatment plans, surgeries, and extended hospitalizations.
Nippon Life: Insureds call our health information hotline to get
approval for hospital admission and some surgeries. Failure to get approval results in a financial penalty, but coverage is still provided subject to medical necessity.
UnitedHealthcare: The treating healthcare professional and the patient make decisions about providing specialist referrals, testing, treatment, surgery, and hospitalization. We determine whether such services are covered by referencing the memberีs summary plan description.4. Which complementary medical disciplines are covered under the PPO or will be covered under the PPO?
Aetna: Members get special rates on visits to acupuncturists,
chiropractors, massage therapists, and nutritional counselors, which they pay directly to the participating provider. Participating providers and vendors in the alternative healthcare programs are solely responsible for their products and services. We have not credentialed or reviewed them. Members can save on over-the-counter vitamins and supplements, aromatherapy, foot care, and natural body-care products.
Blue Cross: Physical therapy, occupational therapy, chiropractic care, and acupressure/acupuncture are covered.
Blue Shield: Resources include the following:
ฅ Alternative health and wellness services are available through credible providers that donีt cost employers more money. With mylifepath, Blue Shield members living in California can get discounts of 25% or more on alternative services, such as acupuncture, chiropractic, and massage therapy.
ฅ Blueshieldca.com provides personalized information on fitness and nutrition, parenting, womenีs health, pregnancy, alternative health, and more. It also includes Mayo Clinicีs Health Topics AะZ.
ฅ Information and brochures are available on preventative health.
ฅ With LifeMAP Member Advocacy Program PPO, members who are scheduled for selected surgeries get printed reference and recovery materials and phone calls from registered nurses who coordinate care and answer general questions.
ฅ Pre-surgical guided imagery through an audio tape or compact disc.
ฅ Lifepath Advisers provide high-level work-life support, online and telephone access to experts in financial planning, education, law, along with personal consultations, and a nurse line for health questions.
ฅ Additionally, Blue Shield has a directly contracted statewide network with more than 5,000 licensed chiropractors who deliver services for our members with our PPO benefit plans.
Cigna: Complementary medical disciplines such as acupuncture, massage therapy, and chiropractic care may be covered if they meet CIGNA's evidence-based medical necessity guidelines, which are accessible online. Healthy Rewards offers savings of up to 25% on alternative therapies, such as massage, acupuncture, and chiropractic care. It also offers discounts on laser vision correction, fitness club memberships, hearing care products and services, guided imagery, mind body techniques, and vision care. Healthy Rewards also offers savings of up to 40% on herbals, vitamins, and non-prescription health and beauty products. CIGNA's enhanced personal Web portal, myCIGNA.com, gives members access to online provider directories, benefit and claim information, pharmacy services, and specific health information (including complementary medicine topics), among other things.
Health Net: Complementary medical disciplines vary by employ-
er contract. However, all PPO members may access www.healthnet.com for information and discounts on chiropractic, acupuncture, relaxation and massage therapy, hearing aids and screenings, childrenีs health products, and many other services.
Interplan Health Group: Complementary medical disciplines
include PT, OT, chiropractic care, and acupressure/acupuncture.
Kaiser Permanente: The PPO plan does not offer coverage for any CAM services. However, they can choose to purchase the chiropractic/acupuncture rider. The rider offers a combined $1,000 benefit maximum and the member pays coinsurance for services received.
Nationwide Health Plans: Acupuncture and chiropractic care.
Nippon Life: Chiropractic and physical therapy are covered.
Coverage up to $500 per calendar year is provided for acupuncture.
UnitedHealthcare: American Chiropractic Network, a business
segment of UnitedHealth Group, provides chiropractic benefits and discounts for the following complementary alternative medicine services to our enrolled individual:
ฅ Acupuncture
ฅ Massage therapy
ฅ Nutritional counseling
ฅ Naturopathic medicine services (in states where naturopathic physicians are licensed).
UnitedHealthcare also offers employers an optional acupuncture benefit. Through UnitedHealth Wellness programs, we provide discounts on products and services for nutrition, weight-management, fitness, stress management, and other wellness products and services.5. Describe Your Coverage For Mammograms.
Aetna: Mammograms are included in the clinical screening once from 35 to 39 and annually beginning at age 40. This is only part of physical exam benefit when the customerีs benefit plan does not include a separate benefit.
Blue Cross: Routine mammograms are covered when ordered
by a physician.
Blue Shield: One annual mammography test is covered for
screening and diagnostic purposes without the presence of illness or injury.
Cigna: There is coverage for a baseline mammogram for women
35 to 39 and then annually for women 40 and over or more frequently if recommended by a physician.
Health Net: We cover one baseline mammogram from 35 to 39,
one mammogram every one to two calendar years for women from 40 to 49, and one mammogram every calendar year for women age 50 and over.
Interplan Health Group: It is determined by the plan design.
Kaiser Permanente: Mammograms are covered as part of adult
preventive screenings as follows: breast exams for women age 35 to age 39, one baseline mammogram for women age 40 to 49 one mammogram every two years or more frequently upon recommendation of a physician; and one yearly mammogram for women age 50 and older.
Nationwide Health Plans: A routine annual mammogram is
covered under the preventive care benefit. Mammograms for illness are covered under the regular medical benefits, subject to deductible, then coinsurance.
Nippon Life: Mammograms are covered the same as any other condition.
UnitedHealthcare: UnitedHealthcare Options PPO provides
coverage for mammograms as part of our standard outpatient surgery, diagnostic, and therapeutic services benefit. It is covered as a preventive and diagnostic service.6. Do you cover PSA Tests for non-symptomatic men? If so, at what age?
Look for Part II of Our Annual Survey in the April Issue
Aetna: Yes, if a state has specific legislation, we will pay it in
accordance with the law. There is no age limit unless itีs being paid under a specific benefit (like the trust benefit), which has a contractual limit.
Blue Cross: Yes, when it is ordered by a physician.
Blue Shield: Coverage includes, but is not limited to, prostate
specific antigen testing and digital rectal examinations, when medically necessary and consistent with good professional practice. There is no age limit for PSA testing when billed with a preventive-care diagnosis.
Cigna: It is covered based on the treating physicianีs determ
nation.
Health Net: Preventive care and diagnostic procedures for
adults (age 17 and older) are covered at a physician's direction. Tests and procedures for the screening and diagnosis of prostate cancer include, but are not limited to, prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with good professional practice. Interplan Health Group: It is determined by plan design.
Kaiser Permanente: PSA tests are covered as part of the
adult preventive screening benefits as follows: screening and diagnosis of prostate cancer, including prostate-specific antigen testing and digital rectal examination when medically necessary and consistent with good professional practice. This coverage does not cover the surgical and other procedures known as radical prostatectomy, external beam radiation therapy, radiation seed implants, or combined hormonal therapy.
Nationwide Health Plans: Yes, under the adult (18 +) preventive-care benefit. If the preventive-care benefit is maximized, PSA is covered under the regular medical benefits, subject to deductible and then coinsurance.
Nippon Life: There is no age requirement.
UnitedHealthcare: Network physicians are encouraged to fol-
low the Guide to Clinical Preventive Services of the United States Preventive Services Task Force (USPSTF) as the basis for preventive care. We cover PSA tests regardless of age even though the USPSTF indicates this screening lacks clinical value.