1. Do you guarantee a time limit on getting referral/treatment routine, urgent, emergency? If not, how many days does it take?
Aetna: Our internal policy is five days for routine, three days for urgent precertification, and one day for urgent concurrent. No referral is required for emergency care.
Anthem Blue Cross: Authorization by the PMG/IPA requires a decision in the following time frames: five business days for non-urgent; 72 hours for an urgent request; 14 calendar days for specialty referrals; and no prior authorization is required for emergency services.
Blue Shield: Fourteen to 30 days for routine; one day for urgent; immediately for an emergency; in 30 days for a check-up or non-symptomatic preventive care visit with a personal physician; seven days for a routine, symptomatic visit with personal physician; 14 days for routine, symptomatic care with a specialist, and 24 hours for urgent care with any practitioner.
CIGNA: Fourteen days for routine care; 24 to 48 hours for urgent care, depending on the specific circumstances; and immediately for emergency care.
Health Net of CA: For urgent requests, a decision must be made on the same calendar day and verbal notification made to the provider and member in 24 hours of the decision. For routine service requests, a decision must be made in 48 hours of receiving all clinical information.
Kaiser Permanente: No, our members have open access to all primary care services. Pre-authorizations are not required for urgent and emergency care. The maximum wait time is 30 days. However, most routine appointments are scheduled within two to three weeks. It is usually within 24 to 48 hours for urgent care problems that are not emergencies, but require medical attention. Members can call the urgent care number at the facility closest to their home, the office of their physician or nurse practitioner, or they can call the advice nurse. Emergency care is available immediately at plan hospital emergency departments, which are listed in “Your Guidebook to Kaiser Permanente Services.”
PacifiCare: No, HEDIS reporting has eliminated this measure; therefore, we are no longer tracking actual appointment wait times.
2. Do you have any conditions/diagnoses/symptoms that are referred automatically?
Aetna: Yes.
Anthem Blue Cross: the PCP, PMG/IPA determines automatic referrals for conditions, diagnoses, and symptoms. Members can self-refer to a contracted OB/GYN provider. Provider groups can participate in the Speedy Referral and Direct Access programs for referral of certain types of specialties for initial consultation and evaluation. There are also requirements for standing specialist referrals for chronic conditions and HIV/AIDS diagnoses.
Blue Shield: Yes, members have access to services through our Access+ Specialist self-referral process. They have direct access to OB/GYN care and second opinion specialists outside the IPA/medical group. Likewise, they can be referred automatically to mental health and substance abuse services provided by our Managed Behavioral Health Organization. Otherwise, the IPAs/medical groups determine their referral policy for our HMO network.
CIGNA: Yes.
Health Net of CA: Health Net delegates medical management activities to participating provider groups (PPGs). Each PPG has its pre-certification requirements and systems, which can include direct access to specialty care. Authorization for specialty consultations is not required for membership that is not delegated to a PPG for management, such as Health Net’s Direct Network HMO membership or other fee-for-service membership.
Kaiser Permanente: Yes, our plan physicians refer to some conditions, diagnoses, and symptoms automatically. Members have direct access to all primary care services and can easily self-refer to specialty care in the Obstetrics/Gynecology, Optometry, Psychiatry, and Chemical Dependency/Addiction Medicine Departments. At some facilities, members may also self-refer for mammograms and Ophthalmology and Dermatology Department services.
PacifiCare: Yes, we refer claims for review if they have affected any of the following areas:
• Nursing care
• Home healthcare
• Skilled nursing facilities
• Speech therapy, physical, occupational, chiropractic and vision therapy
• Single code edits identify specific services for review before payment determination-review for coverage. These edits can also identify and deny services automatically that are never covered by the benefit plan or are always considered unproven or cosmetic.
• Any kind of complex claim review.
3. Can a pregnant member go directly to a gynecologist without waiting for approval?
Aetna: Yes.
Anthem Blue Cross: Yes, pregnant members can self-refer to an obstetrician/gynecologist in the PMG/IPA.
Blue Shield: Yes, women can self-refer to an obstetrician or OB/GYN or family practice physician in their PCP’s IPA or medical group for OB/GYN services. The member pays the regular office visit co-pay since this is not considered an Access+ self-referral. Additionally, the OB/GYN can be chosen as a primary care physician if a network IPA or medical group contracts with an OB/GYN physician as a network PCP.
CIGNA: Yes.
Health Net of CA: Yes.
Kaiser Permanente: Yes, members can self-refer to some of our specialty and diagnostic services including obstetrics/gynecology.
PacifiCare: Yes.
4. Do you have self-referral to a gynecologist for an annual well-woman exam?
Aetna: Yes.
Anthem Blue Cross: Yes.
Blue Shield: Yes.
CIGNA: Yes.
Health Net of CA: Yes.
Kaiser Permanente: Yes, members can self-refer to some of our specialty and diagnostic services including obstetrics/gynecology.
PacifiCare: Yes.
5. Can a member with severe back pain get an appointment with an orthopedist immediately?
Aetna: The PCP determines this.
Anthem Blue Cross: The PMG/IPA/PCP will evaluate the member’s conditions and symptoms and assess the need for a specialist visit following the group’s process for referrals as necessary.
Blue Shield: Yes.
CIGNA: Members in our Open Access Plus and PPO products can go directly to any specialist. Other members should confer with their primary care physician who can contact an orthopedist or other specialist (neurosurgeon, neurologist) to arrange for an immediate appointment. At the direction of the physician, a member can also be enrolled in CIGNA HealthCare’s WellAware disease management program for lower back pain. A registered nurse helps coordinate timely care.
Health Net of CA: Yes, as an emergency.
Kaiser Permanente: Yes, our primary care physicians can refer to appropriate specialists internally and without prior authorization.
PacifiCare: Yes, with a primary care physician (PCP) referral.
6. How long does it take to get an MRI or equivalent test when a lump is found in a member’s breast or uterus?
Aetna: The PCP determines this.
Anthem Blue Cross: The PMG/IPA/PCP determines whether to make an urgent referral for diagnostic tests and whether an authorization is needed. It can require a 72-hour response time for authorization of services.
Blue Shield: Seven days or immediately in an emergency.
CIGNA: The member’s physician determines the exact time
frame. But, an appointment can be made immediately if medically necessary.
Health Net of CA: Health Net delegates utilization manage-
ment activities to medical groups. Therefore, if the member belongs to a delegated participating provider group (PPG), the PPG has its own precertification requirements and an MRI may require precertification. Precertification is required for MRIs if the member does not belong to a delegated PPG and Health Net is responsible for conducting utilization management. Health Net processes urgent precertification requests in 72 hours of receiving all information. Requests for elective MRIs are processed in five business days.
Kaiser Permanente: Members get MRIs or equivalent tests based on their physician’s clinical decision without the need of heath plan authorization. The wait time for a test is based on clinical urgency and can be shortened at the referring physician’s request.
PacifiCare: Immediately. While we do not have a specific time-frame, members are scheduled as soon as appointment times permit.
7. Can the member get a second opinion outside of the IPA or the medical group?
Aetna: When medically appropriate
Anthem Blue Cross: Yes, members have the right to a second opinion from a qualified healthcare professional in the Anthem network as long as they have already gotten one from their PCP or a SCP in the group’s network. A second medical opinion is a reevaluation of your condition or healthcare.
Blue Shield: Yes, all Access+ HMO members have the right to get a referral for a second opinion from their personal physician. A physician in the same medical group/IPA generally provides second opinions of care from a personal physician. Any specialist of the same or equivalent specialty in Blue Shield’s HMO network can provide second opinions of care from a specialist. All second opinion consultations require Blue Shield authorization.
CIGNA: Yes.
Health Net of CA: Yes, a member’s authorized representative or provider can request a second opinion for medical, surgical, or behavioral health conditions.
Kaiser Permanente: Yes, however as a multi-specialty group model health plan, second opinions outside of our medical group are not generally required. Our members can get a second medical opinion from a plan physician upon request. Physicians can refer members to non-plan providers for a second opinion when medical expertise relevant to the member’s condition is not available internally.
PacifiCare: Members can get a second opinion in accordance with the specifications of the Evidence of Coverage and Disclosure Form as summarized below. A qualified healthcare professional (of the member’s choice) in the same contracted provider group can provide second medical opinions about care from a PCP. If the PCP is contracted independently with PacifiCare, the member can request a second opinion from any PCP or specialist listed in our provider directory. A healthcare professional (of the member’s choice) in the contracted provider network and in the same or an equivalent specialty can provide second medical opinions about care from a specialist.
8. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?
Aetna: For our delegated groups, the PCP makes decisions with their PMG/IPA. The health plan makes this determination for non-delegated groups.
Anthem Blue Cross: Delegated PMGs/IPAs make decisions about utilization management approval and denial. The provider group’s medical director makes all denial decisions. The plan performs audits to ensure compliance with accrediting and regulatory requirements and standards related to these decisions.
Blue Shield: These decisions are made at the IPA/medica group level. Blue Shield can be involved if there is a dispute about appropriateness or if a member is dissatisfied.
CIGNA: Primary and specialty care providers make decisions about referrals, testing, and treatment. At times, they can coordinate care with their medical groups or IPAs. Hospitalization can require CIGNA authorization.
Health Net of CA: A Health Net member’s PCP and participating provider group (PPG) authorize all treatment, including referrals. A member with a chronic condition or disease who needs continuing specialized medical care is eligible for a standing referral to a specialist. A standing referral allows members with life-threatening, degenerative, or disabling conditions to have extended access to a specialist. Health Net refers members to practitioners with expertise in treating a condition or disease involving a complicated treatment regimen that requires ongoing monitoring.
Kaiser Permanente: The member’s primary care physician makes the decisions about specialist referrals, testing, treatment, surgery, and hospitalization. Our physicians do not need authorization for their medical decisions.
PacifiCare: Our contracted PCPs serve as gatekeepers, acting as the point of contact, resource, and consultation for all health services provided to members including specialty referrals and treatment decisions.
9. What criteria are used to authorize or deny specialist referrals, treatments, or tests?
Aetna: There are a variety of reference tools, including Milliman and many that the plan has developed and copyrighted. A medical director must make all denials for medical necessity. In addition, the plan has adopted an external review process for all fully insured members.
Anthem Blue Cross: Referral processes are delegated to PMGs/IPAs. Provider groups are required to use evidence based utilization management criteria, which has been reviewed annually, approved, and adopted for use by their utilization management committee. If Anthem Blue Cross has a medical policy concerning a specific service, test or procedure, the provider groups are required to follow these policies. They are posted under the provider access area of the Anthem website.
Blue Shield: In addition to their own medical necessity criteria, Blue Shield’s contracted IPA/medical groups are required to refer to the Blue Shield Medical Policy and HMO Benefit Guidelines in authorizing/denying specialist referrals, treatments, or tests. The IPA/medical groups’ criteria must be consistent with Blue Shield’s criteria. Blue Shield of California uses nationally recognized utilization management criteria, such as InterQual Criteria, to determine medical necessity. Medical literature and patient clinical information are considered.
CIGNA: CIGNA uses Milliman care guidelines. In addition, CIGNA continually assesses developing technologies using evidence-based medicine and independent expert opinion to develop coverage positions, which are posted on the Internet. All medical decisions are based on clinical guidelines. A physician who is knowledgeable in the area makes the decisions.
Health Net of CA: Health Net uses established written guid lines, such as InterQual Clinical criteria, along with the Health Net Medical Policy Manual, clinical practice guidelines, and the Schedule of Benefits.
Kaiser Permanente: Our physicians are not required to seek authorization for medical services.
PacifiCare: Provider groups are required to demonstrate the use of appropriate medical management guidelines. We conduct annual reviews of written procedures and consider the following factors for cases that cannot meet criteria: age, co-morbidities and complications, response to treatment, the psychosocial situation, and home environment. We use written criteria based on sound clinical evidence. We use specific procedures for applying the criteria to make utilization decisions. In addition, we apply objective and evidence-based criteria and consider individual circumstances and the local delivery system. We require our delegated providers to do the same.
10. Are you monitoring the length of time for referral authorizations? What are you doing to reduce or eliminate delays?
Aetna: Yes, timeliness of decisions is part of monthly case assessment audit. Turn-around time is monitored by annual audits and quarterly report submissions. Audits and training address performance gaps.
Anthem Blue Cross: PMGs/IPAs must have systems to monitor utilization review activities. Anthem evaluates compliance with standards for regulatory and accrediting timeliness through annual on-site audits. If there are issues with non-compliance, the provider group is educated at the audit and a corrective action plan is requested. A subsequent audit is conducted in 180 days. Anthem also monitors this process through the member grievance process. Anthem and the PMGs/IPAs also evaluate this through provider satisfaction surveys.
Blue Shield: Blue Shield’s contracted IPA/medical groups are responsible for the timeliness of decisions about referral authorization. They must comply with our standard of two working days to get all necessary information for a non-urgent referral, one calendar day for urgent referral/treatment, and immediately for emergency care. Blue Shield-delegated oversight consultant nurses perform annual audits to ensure that standards for timeliness are met. An IPA/medical group that does not meet timeliness standards for utilization management must take corrective action.
CIGNA: CIGNA works closely with physicians and medical groups to expedite referrals and measures member satisfaction regularly with the referral process.
Health Net of CA: Yes, it is done through access audit reports, member satisfaction surveys, HEDIS indicators, physician profiles, medical group comparison reports, and member complaints. Delays are remedied through corrective action.
Kaiser Permanente: Yes, we review our wait time constantly and develop tools to reduce that wait time that are appropriate to each medical center.
PacifiCare: Yes, to reduce delays, we monitor referral turn around and several other measures with our Quality Index profile. We reward best-in-class provider performance with our quality incentive program and we measure plan performance with the annual CAHPS survey.
11. What are the criteria and processes for getting a referral to a specialist outside of the MG/IPA or plan?
Aetna: Out-of-plan approval is done if one or more of these criteria are met: required services are not available in the group or network; required non-emergency service is available in the plan option, but is not accessible in reasonable timeframe; or the patient is a new member and was receiving services from an out-of-plan provider (reviewed on case-by-case basis).
Anthem Blue Cross: If a needed specialty is not available in an assigned PMG/IPA, the provider group must arrange for the member to be seen by the appropriate specialist. The Anthem Transition Assistance Unit facilitates second opinions outside of the provider group when the member or provider requests it and a PCP or specialist in the provider group’s network has already seen them.
Blue Shield: Personal physicians can refer patients out of the network with the agreement of the IPA/medical group or authorization from Blue Shield. Blue Shield is only involved in referrals when an IPA/medical group wants to refer out of network and not be financially responsible. The IPA/medical group would then contact Blue Shield for authorization and request that Blue Shield be financially liable.
CIGNA: A primary care physician can request referral for service outside the medical group or plan when the service is not available. Members can also contact CIGNA directly to arrange a second opinion.
Health Net of CA: Health Net’s contracted participating provider groups (PPGs) provide member care including all specialty referrals. If the PPG does not have a particular kind of specialist with which it contracts, the PPG is still responsible for finding a specialist for the member out of its network. The PPG is financially responsible for paying the specialist. The PPG can deny the request if it has a particular kind of specialist in its network and a member requests to see a specialist outside of the PPG’s network. The member can appeal the denial with Health Net.
Kaiser Permanente: Our physicians handle all referrals within our medical groups. Any Kaiser Permanente physician can request necessary care from an outside provider.
PacifiCare: When services are not available in the member’s provider group, the member is referred to a provider or specialist in another PacifiCare contracted provider group. PacifiCare or the delegated medical group’s review committee will assess the medical necessity for these requests and authorize care as necessary.
12. Which complementary medical disciplines are covered or will be covered?
Aetna: Chiro rider. Acupuncture is covered when administered Anthem Blue Cross: Anthem offers coverage for medically necessary chiropractic, acupuncture, and biofeedback based on a member’s plan design. We offer a variety of discounted complementary products and services through our HealthyExtensions program, such as massage therapy and hypnotherapy. We also offer a complementary glucometer through LifeScan, One Touch, Roche, or Accu-Chek.
Blue Shield: Substance abuse rider; chiropractic care rider; acupuncture services; specialty dental care coverage; discount programs for chiropractic, acupuncture and massage therapy; and vision supplies and services. Resources are available to members on the phone, online (www.blueshieldca.com) and in person including nurses and counselors and health-management programs for chronic diseases, childbirth, newborns, and recovery from surgery.
CIGNA: When medically necessary, some members can access acupuncture and chiropractic services as a component of short-term rehabilitation. Other benefit plans offer homeopathic and naturopathic services as riders. In addition, CIGNA’s Healthy Rewards program offers members alternative/complementary medicine and other health related discount programs for the following services: acupuncture, chiropractic services, fitness club membership, hearing care/instruments, laser vision surgery, massage therapy, vitamins, herbal supplements, non-prescription medications, Mayo Clinic books on health, and smoking cessation programs.
Health Net of CA: Health Net of California offers chiropractic and acupuncture benefits as supplemental benefit riders to its traditional medical benefit plans. The riders can be purchased with the HMO and POS medical plans. They are designed to complement the benefit plans, rather than replace them. The rider is only available to groups. A variety of benefit plan designs is available including chiropractic only, acupuncture only, and a combination of chiropractic and acupuncture.
Kaiser Permanente: We offer a supplemental chiropractic benefit. Kaiser Permanente also covers acupuncture when medically necessary as part of a pain-management program.
PacifiCare: PacifiCare’s supplemental chiropractic benefit and supplemental acupuncture benefit are available through ACN Group. Inc.
13. Do you cover blood tests for prostate cancer for non-symptomatic men?
If so, at what age?
Aetna: Yes, age 40+.
Anthem Blue Cross: Yes, preventative care guidelines address the appropriate frequency of different testing schedules. We cover prostate cancer screenings including, but not limited to, prostate specific antigen (PSA) testing when medically necessary and consistent with good professional practice, regardless of age.
Blue Shield: Yes, regardless of age.
CIGNA: Yes, for men over 50 annually or more frequently when medically indicated.
Health Net of CA: Yes, as determined by the PCP.
Kaiser Permanente: Yes, we cover blood tests for prostate cancer for non-symptomatic men at any age.
PacifiCare: Yes, we have no age limit for such blood tests.
14. Do you cover mammograms for women with no history of breast cancer?
Aetna: Baseline at age 35, annually 40+.
Anthem Blue Cross: Yes, if the employer group or member purchases coverage with basic preventive health coverage, these are covered for all women at the age of 40 and older.
Blue Shield: Yes, with a personal physician referral.
CIGNA: Yes, for women over 40 annually or more frequently as directed by their physician.
Health Net of CA: Yes, typically, every one to two years from ages 40 to 65+, but the PCP can authorize mammograms at his or her discretion.
Kaiser Permanente: Yes, we cover mammograms for women with no history of breast cancer.
PacifiCare: Yes, per U.S. Preventive Services Task Force Guidelines.
15. Do you have an open drug formulary?
Aetna: Yes.
Anthem Blue Cross: Yes, Anthem offers a comprehensive formulary with various benefit designs. Options may include an open formulary, a closed formulary, and a selective or partially closed formulary.
Blue Shield: Blue Shield’s Access+ HMO plans include a two tier (generic and brand) closed formulary benefit that requires prior authorization of non-formulary drugs or a three-tiered open formulary benefit.
CIGNA: We traditionally use a closed drug formulary. However, employers can choose a three-tier or two-tier pharmacy plan if specified and agreed to in the contract. The three-tier plan offers non-formulary drug coverage without submission of a non-formulary request, but at a higher co-payment.
Health Net of CA: Yes, typically, every one to two years from ages 40 to 65+, but the PCP can authorize mammograms at their discretion.
Kaiser Permanente: No, we do not have an open drug formulary.
PacifiCare: No, we use several managed (closed) formularies at different tier levels, but we do not offer an open formulary.
16. If a closed formulary, what happens if a non-formulary drug is necessary?
Aetna: Not applicable.
Anthem Blue Cross: Non-formulary drugs may be approved upon review through a prior authorization process when a medical need exists.
Blue Shield: The physician can request prior authorization for medical reasons, such as documented treatment failure or adverse drug reactions to formulary drugs, for non-formulary drugs that are not covered. The HMO plan with a three-tier co-payment benefit provides the same coverage as does a two-tier benefit, but it has coverage for non-formulary brand name drugs. In all plans, select formulary drugs, non-formulary or drug dosages/quantities require prior authorization for medical necessity.
CIGNA: The member or their physician can ask for an exception to get a non-formulary drug. CIGNA HealthCare’s clinical staff reviews the request.
Health Net of CA: Drugs that are not listed in our recommended drug list can be covered through our prior approval process when medically necessary. That is unless specifically excluded or limited in the evidence of coverage. The normal process is to have the prescribing physician provide the medical reasons for the non-formulary medication. Physicians can prescribe non-recommended drug list medications, but some drugs can require prior authorization to determine appropriate medical indications. If a medication is denied, members are notified that they are entitled to appeal the decision according to procedures in the Evidence of Coverage. Every member can appeal a non-formulary, non-covered request. Members with a three-tier benefit can get drugs that are not on the recommended drug list at a higher co-payment.
Kaiser Permanente: Our physicians manage the drug formulary and have the discretion to prescribe all medically necessary non-formulary drugs. If it is not medically appropriate to change a patient’s prescription from a non-formulary to a formulary drug, the physician can authorize the use of the non-formulary drug. With this authorization, the member gets the non-formulary drug at the regular co-payment. If the member prefers a non-formulary drug that is not medically necessary, the member pays the full member price for the prescription.
PacifiCare: If a participant submits a claim for a non-formulary drug, we route the claim to the preauthorization unit and call the physician. Our PBM will authorize non-formulary drugs and reimburse the participant for one of the following criteria: No formulary alternative is appropriate and the drug is medically necessary for patient care as determined by PacifiCare, consistent with professional practice. The formulary alternative has failed after therapeutic trial. The physician provides a copy of the medical chart notes specifically stating treatment failure with the formulary alternative. The formulary alternative is not appropriate as determined by a review notes from physician charts. The participant has been under treatment and remains stable on a non-formulary prescription drug and conversion to a formulary drug would be medically inappropriate. The participant has experienced typical allergic reaction or established adverse effects relating to the pharmacological properties of the formulary drug, which attributes to formulations or differences in absorption, distribution or elimination. The participant’s physician provides evidence in the form of documents, records or clinical trials, establishing that use of the requested non-formulary drug over the formulary drug is medically necessary as determined by PacifiCare.
17. Do you have an experimental/investigative exclusion? If so, how does it work?
Anthem Blue Cross: Yes, however, all treatment decisions are based on medical necessity as it applies to a member’s condition. A request would be denied for a procedure that is considered experimental or investigative for a member whose condition has no unique or discerning characteristics. The member can request an independent medical review if we determine that a requested procedure does not meet our medical necessity criteria. Our Corporate Medical Policy and Technology Assessment Committee evaluate new procedures for incorporation into benefit plans.
Blue Shield: Yes, the plan has adopted BlueCross BlueShield Association technology assessment criteria to evaluate whether technology improves health outcomes. Blue Shield’s formulary does not cover drugs that are considered experimental or investigational or that are not recognized in accordance with generally accepted medical standards.
CIGNA: CIGNA HealthCare regularly evaluates it coverage policies to ensure that they are up-to-date. CIGNA medical directors make evidence-based decisions about an experimental/investigational request based on medical literature, expert opinion, and the facts of the case. Coverage positions are developed regularly, which assess emerging technologies. They are posted on the Internet. Providers can access CIGNA HealthCare’s Web-based provider portal to request reviews of technologies for which coverage positions have not yet been developed. CIGNA HealthCare also uses a formal independent expert review process when appropriate.
Health Net of CA: Health Net does not cover experimental or investigational drugs, devices, procedures, or therapies. The member can request an independent medical review of Health Net’s decision from the California Department of Managed Healthcare if Health Net denies or delays coverage for a requested treatment on the basis that it is experimental or investigational. The member can request the review if the following criteria are met:
• The member has a life-threatening or seriously debilitating condition.
• The member’s physician certifies to Health Net that the member has a life-threatening or seriously debilitating condition for which standard therapies have not been effective or are otherwise medically inappropriate.
• There is no more beneficial therapy covered by Health Net.
• The member’s physician certifies that the proposed experimental or investigational therapy is likely to be more beneficial than what is available from standard therapies. As an alternative, the member can submit a request for a therapy that is likely to be more beneficial than available standard therapies based on documentation presented from the medical and scientific evidence.
Kaiser Permanente: Yes, services or supplies are considered experimental if generally accepted medical standards do not recognize them as safe and effective for treating the condition or if government approval has not been obtained when the services or supplies are to be provided. Some members are eligible for independent external review of plan denials.
PacifiCare: Yes, experimental or investigational procedures, items and treatments are not covered unless required by an external, independent review panel as described in the combined evidence-of-coverage and disclosure form. Unless otherwise required by federal or state law, a PacifiCare medical director or designee determines whether a particular treatment is experimental or investigational and therefore not a covered benefit.
18. Which requested procedures are denied most frequently based on experimental/
investiga
tive or not medically necessary exclusions?
Aetna: This information is not readily available.
Anthem Blue Cross: It includes the artificial disc for degenerative disc disease, since this new device does not have sufficient long-term studies to show efficacy. The most frequently denied requested service under not medically necessary is the referral to a non-contracted provider when a qualified contracted provider is available.
Blue Shield: The following are most frequently denied procedures due to the absence of medical necessity or because they are considered experimental/investigational:
• Bariatric surgery – Morbid obesity surgery
• Reduction mammoplasty
• Varicose Veins
• MRI of the Breast
• Pet Scan for Breasts
CIGNA: This data is not available.
Health Net of CA: The most frequently denied requested procedures are not FDA approved/accepted in the medical community as standard, safe and effective.
Kaiser Permanente: If a plan physician determines that a procedure or service is medically appropriate for a member and its omission would adversely affect the member’s health, then it is considered medically necessary. As a result, we do not consider a medically necessary service or procedure to be an exclusion. Additionally, we do not deny experimental or investigative procedures if they are considered medically necessary and appropriate for the member’s care. All procedures and treatments are reviewed on a case-by-case basis with the determination for care made by the physician.
PacifiCare: Due to state regulations, PacifiCare cannot deny medically necessary procedures. We do not maintain a list of frequently requested procedures presently denied on the basis of experimental or investigative. But we generally exclude experimental, investigational, and unproven services from coverage.
19. What is the standard hospitalization for normal and a Caesarean birth?
Aetna: the physician determines it.
Anthem Blue Cross: Two days after normal birth and five days after Caesarean birth.
Blue Shield: Two days for a normal birth and four days for a Caesarean.
CIGNA: Typical hospitalization is at least 48 hours for normal vaginal delivery and at least 96 hours for a Caesarian section. But, this can be modified based on the physician’s recommendations.
Health Net of CA: Standard hospitalization is two days for normal birth and four days for Caesarean birth.
Kaiser Permanente: In N. CA, it is 1.91 for a normal birth and 3.49 for a Caesarean. In S. CA, it is 1.87 for a normal and 3.26 for a Caesarean. (Data source: YE2006 HEDIS)
PacifiCare: The average length of stay is two days for a normal birth and four days for a Caesarean.
20. How many hospital days are utilized in a year for every thousand members?
Anthem Blue Cross: Our HMO bed days for California-all inpatient excluding POS:
CY2006- 207.3 days/1000
CY2007- 201.0 days/1000
Blue Shield: 194.12, as of our most recent HEDIS reporting year for inpatient days per 1,000 members.
Health Net of CA: 204.45
Kaiser Permanente: In Northern California, it is 1.91 for a normal birth and 3.49 for a Caesarean. In Southern California, it is 1.87 for a normal and 3.26 for a Caesarean. (Data source: YE2006 HEDIS)
PacifiCare: Our total in-patient utilization in 2007 was 143.50 days per 1,000 members.
21. What are your loss ratios, administration/medical?
Health Net of CA: Medical: 84.99%/administrative: 10.48%
Kaiser Permanente: Operating expense as a percentage of revenue is not available. Administrative expense as a percentage of revenue is 3.55%. Medical and hospital expense as a percentage of revenue is 93.13%. (Data source: Current DMHC Report - Please note that the full Department of Managed Healthcare filing includes the regions of Northern and Southern California and Hawaii combined.)
PacifiCare: As of December 31, 2007 our administrative loss ratio was 9.01 percent and our medical loss ratio was 86.67%.
22. Is your plan NCQA accredited?
Aetna: Yes, Aetna Health of CA Inc is accredited and has got Quality Plus distinction in Care Management, Physician and Hospital Quality.
Anthem Blue Cross: NCQA has awarded Anthem Blue Cross of California’s Commercial HMO/POS products its highest accreditation status of Excellent for service and clinical quality.
Blue Shield: Yes, In August 2008, the National Committee for Quality Assurance awarded Blue Shield its highest rating of Excellent Accreditation for Commercial HMO/POS and Medicare Advantage products.
CIGNA: Yes, CIGNA HealthCare has an Excellent accreditation designation.
Health Net of CA: Yes, commercial HMO and POS and Medicare lines of business have got the excellent accreditation status from the National Committee for Quality Assurance (NCQA).
Kaiser Permanente: Kaiser Permanente in Northern and Southern California earned ratings of “Excellent” in the most recent surveys by the NCQA in the commercial HMO and Medicare-contracted product lines.
PacifiCare: Yes, PacifiCare of California has an Excellent accreditation rating from the NCQA.
23. What is your ratio of PCPs vs. specialists?
Aetna: 1/3.7
Anthem Blue Cross: As of September 2008, Anthem Blue Cross’ ratio is 1/4.
Blue Shield: 1/1.81
CIGNA: 1/2.72
Health Net of CA: 1/2.5
Kaiser Permanente: Our ratio of PCPs to specialists is approximately 6/10 statewide: 4:7 in Northern California and 2/3 in Southern California, as of year end 2007
PacifiCare: As of December 31, 2007 our ratio of PCP’s to
specialists is 1:4.
24. What is your ratio of members to PCPs?
Aetna: 31.1/1
Anthem Blue Cross: 2007 provider availability ratio assessent indicates one full-time equivalent PCP to 120 HMO members and full-time equivalent PCP to 11 POS members.
Blue Shield: 100.75/1
CIGNA: 35/1
Health Net of CA: 84/1
Kaiser Permanente: Our ratio of members to PCPs in Northern California is 1845/1 and 1875/1 in Southern California, as of YE2007.
PacifiCare: As of December 31, 2007 our member to PCP ratio is 131.74/1.
25. Does your contract include binding arbitration?
Aetna: Yes.
Anthem Blue Cross: Yes.
Blue Shield: Yes, the majority of our contracts with providers do require binding arbitration to resolve disputes.
CIGNA: Yes.
Health Net of CA: Yes.
Kaiser Permanente: Yes
PacifiCare: Yes.
26. How often can members change their PCP at will?
Aetna: There is no limit.
Anthem Blue Cross: Our HMO member may change to another PCP without restriction. Members may change to a PCP at another PMG/IPA by completing a membership change form and submitting it to their employer, or by calling customer service directly. Because we are concerned with continuity of care, members cannot switch medical groups during a “course of treatment;” however, based on individual need, changes to a PMG assignment can be made effective the first day of the following month after the request is made. Please note: members may only change to a medical group that is within 30 miles of their residence or work address.
Blue Shield: Access+ HMO members can change their personal physician without cause once a month. This change is effective the first day of the month following notice of change.
CIGNA: There are no specific limits. However, we encourage our members to stay with one primary care physician to ensure more effective care management. We also recommend that our members do not change their doctor while in the middle of care to the extent possible. Otherwise, a member can change their primary care physician effective the first of the month following the request.
Health Net of CA: Members can change PCPs in a physician group or from one physician group to another once per month.
Kaiser Permanente: There is no limit. Members can change their physician at any time.
PacifiCare: Members can request a change of PCP or provider group at any time, for any reason, by calling customer service. Members can make unlimited changes to their PCP
27. Do you offer a performance guaranty, such as employees will be on the computer by a certain date or have ID cards by a certain date, for example?
Anthem Blue Cross: Yes, we can offer standard performance guarantees to our clients; guarantees may also be customized on a case-by-case basis.
Blue Shield: Yes, we offer performance guarantees for groups with a qualifying minimum subscribership.
CIGNA: Yes, in most instances, we can work with a company to develop appropriate performance guarantees.
Health Net of CA: Yes, we are willing to place an appropriate amount at risk for compliance with performance standards that Health Net and the employer group have established and agreed upon. The standards, methodology and breakdown of amounts at risk can be negotiated once all performance guarantees are finalized and the group meets the eligibility requirements for performance standard consideration. An employer group must maintain a minimum of 1,000 subscribers in a Health Net plan to be eligible to participate in performance guarantees. All standards and guarantees need to be finalized at least three months before the group’s effective date and are in force for one plan year. Due to the evolving nature of our industry, Health Net reserves the right to re-negotiate performance guarantees at the end of each plan year.
Kaiser Permanente: Yes, we offer a performance guaranty on a group-by-group basis.
PacifiCare: We do not generally commit to financially based performance guarantees, as we will make every effort to exceed the service requirements set forth by our customers. However, we can accommodate requests to offer specific performance guarantees based on our corporate guidelines.
28. When a member moves out of state, is any transition coverage available?
Anthem Blue Cross: The utilization management process is delegated to the PMGs/IPAs for our HMO product. They must have established review mechanisms, such as evidenced-based decision criteria and guidelines, which align with accepted medical practice. PMGs/IPAs maintain structured processes for referral management, pre-service, concurrent, and post-service review. Routine and active oversight is conducted to ensure compliance with regulatory and accrediting agency standards.
Blue Shield: Yes, if a subscriber moves out of state to an area served by another Blue Cross and/or Blue Shield plan, the subscriber’s coverage can be transferred to the plan serving his new address. The new plan must offer the subscriber at least its group conversion policy.
CIGNA: Yes, if we offer similar coverage to the account in that state.
Health Net of CA: Yes, through PPO, POS, and indemnity lines of business.
Kaiser Permanente: Yes, transition coverage is available to members.
PacifiCare: Yes, we offer a conversion policy to eligible members as mandated by state regulations.
