2013 PPO Survey


PPOPowerPPO Power – Welcome to Our 13th Annual PPO Survey


Welcome to our 13th annual PPO survey. For this survey, seven 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.

Is an Approval Procedure required for Getting a Specialist Referral or a Diagnostic Test or Treatment In-Network or Out-of-Network?

Aetna: There is a high-tech radiology pre-certification requirement for some customers.
Anthem Blue Cross: It is not required for PPO plans, but the member ends up paying more if they go out-of-network without getting an out-of-network approval.
Blue Shield: No, PPO plan members can generally self-refer to any doctor for care. They can choose to use in-network or out-of-network providers 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. Customers are covered whether or not they get care from PPO network providers. Customers who use services from an in-network provider may have reduced co-payments and lower out-of-pocket costs.
Health Net: There are no approval procedure requirements for visits to in-network or out-of-network specialists. A prior authorization list for diagnostic tests or treatments is included in the member’s evidence of coverage (EOC).
Kaiser Permanente: No, the PPO plan does not require a referral to see a Specialist. Diagnostic tests are covered provided they are ordered by an insured’s doctor, are a covered benefit, and are deemed medically necessary. If a test or treatment is on the pre-certification list (e.g, MRIs and CT scans), it requires pre-certification.
UnitedHealthcare: To strengthen the patient-physician relationship, primary physicians are not required to request an authorization when they refer a patient to a network specialist for an office visit. Primary physicians are very effective at ensuring that our enrolled individuals receive medically appropriate and necessary specialty care. In fact, practice pattern analysis shows that primary physician referrals to network specialists have been almost 100 percent effective and medically appropriate.

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 benefit, may arrange their own second surgical opinion with a non-participating provider.
Anthem Blue Cross: No, not for the PPO.
Blue Shield: No, a member may 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’s payment and the billed amount.
Cigna: There are no restrictions. The PPO is an open access plan, allowing customers to seek care in-network and out-of-network at any time. When accessing medical services, customers have the option to decide whether to use a network provider. By using a network provider, customers have lower out-of-pocket costs.
Kaiser Permanente: Second medical opinions are covered. Coverage is limited to charges for physician consultation and 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 obtained as part of the original medical opinion and/or for which Kaiser Permanente Insurance Company (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.
Health Net: Health Net members may see any in-network or out-of-network provider for a second opinion without obtaining a referral. Members are encouraged to call our Customer Contact Center with any questions regarding their benefits.
Kaiser Permanente: Second medical opinions are covered. Coverage is limited to charges for physician consultation and 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 obtained as part of the original medical opinion and/or for which Kaiser Permanente Insurance Company (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.
UnitedHealthcare: A second opinion is not mandatory under our plans. Our UnitedHealthcare Options PPO product is open access. Members may seek second opinions from any participating or non-participating physician. The member’s benefit level will vary depending on the physician’s participation status.

3. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?

Aetna: Our patient-management staff is regionally located. The region is determined by the location of the customer.
Anthem Blue Cross: Members may see specialists without referrals. Our Medical Management Department handles the review and approval for services that require pre-authorization.
Blue Shield: Treatment decisions such as these are made between the patients and their doctors. In the case of surgery, hospitalization, or major diagnostic tests, Blue Shield’s prior authorization process is used to review the proposed treatment for medical necessity.
Cigna: These decisions are made by a customer’s physician in conjunction with the customer.  Cigna’s clinical programs, nurse case managers and health coaches can help individuals make decisions about their care. Cigna also offers award-winning online quality and cost information tools to help customers make informed choices.  Some types of services require prior authorization by Cigna in order for the services to be covered under the individual’s plan. Customers can call Cigna Customer Service 24 hours a day, seven days a week with any questions about how their specific plan works.
Health Net: Decisions regarding specialty referrals for testing, treatment, surgery or hospitalization are made with the member, the member’s physician and Health Net’s Care Management team.  Members may also call Nurse24 SM, a nurse-driven telephonic support program that empowers participants to better manage their health.   Nurse24 SM offers assistance to participants coping with chronic and acute illness, episodic or injury-related events and other health care issues. Highly trained registered nurses are available 24/7 to monitor and process health care inquiries that help participants make informed health care decisions.
Kaiser Permanente: In most cases, the insured does not need a referral to see a specialist. Decisions regarding testing, treatment, surgery, and hospitalization are made by the insured and his or her physician. The insured is required to obtain pre-certification for any hospitalization or certain special procedures as defined in the insured’s Certificate of Insurance. Pre-certification to verify the medical necessity of a particular service or procedure ordered by a physician for an insured is performed by Permanente Advantage.
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 member’s summary plan description.

4. Which complementary medical disciplines are covered under the PPO or will be covered under the PPO?

Aetna: Members can 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.
Anthem Blue Cross: Physical therapy, occupational therapy, chiropractic care, speech therapy, DME, and acupressure/acupuncture.
Blue Shield: We offer the following:
• All members in our fully insured PPO groups are covered by our disease and case management programs.
• LifeMAP and Guided Imagery Program.
• Our Wellness Assessment customizes referrals to lifestyle management programs. There are cash incentives to reward participation – available as a buy-up option.
• CareTips for Physicians: This clinical messaging program sends patient-specific messages highlighting gaps in care to the member’s primary care physician.
• LifeReferrals 24/7 to experts in financial planning, education, and law, along with personal consultations. It is included with all fully insured PPO plans and is available as a buy-up option for self-insured plans.
• Self-funded groups may now purchase the Managed Behavioral Health buy-up package. This program is included with all fully insured PPO plans and is available as a buy-up option for self-insured plans.
• All members can search our Health Library; sign up for Blue Shield condition management and wellness programs; and subscribe to the Health Update eNewsletter. Online decision making tools allow members to compare hospitals, explore treatment options for their condition, and learn more about prescription drugs.
• Members can get 25% off or more from published fees for acupuncture, chiropractic, and massage therapy. Members can also get up to 40% off of selected vitamins, herbal supplements, homeopathic remedies, diet and sports nutrition, yoga and fitness equipment, personal body care, and health and wellness books, audio, and DVD products. (free shipping in most cases.)
• Wellness Discount Programs on Weight Watchers, 24-Hour Fitness, Drugstore.com, and LASIK.
A Discount Vision Program.
• Chiropractic Network: Blue Shield has a directly contracted statewide network with more than 5,000 licensed chiropractors.
• Blue Shield Centers of Expertise and Blue Distinction Centers: Members can find facilities and doctors that meet high-quality standards for transplant, cardiac, and bariatric surgeries within California.
Cigna:  This depends on the plan selected by the employer.  Cigna also offers its Healthy Rewards discount program, which provides discounts for many types of complementary and alternative treatments.
Health Net: Complementary medical disciplines vary by each employer contract. If an employer chooses to offer complementary medicine, Health Net’s program offers direct referral to chiropractic and acupuncture care.
All Health Net members, whether HMO or PPO, can access Health Net’s Decision Powers Healthy Discounts program at www.healthnet.com. The Healthy Discounts program provides Health Net members with discounts when they receive selected complementary health care services from American Specialty Health Plans (ASHP) providers.
The Healthy Discounts program offers direct access to chiropractors, acupuncturists and massage therapists. Members may find ASHP providers via www.healthnet.com or by calling (877) 335-2746. The member assumes liability for claims and is responsible to pay the provider directly on a cash-pay basis at a pre-negotiated fee schedule.
Healthy Discounts provides Health Net members with discounts of up to 50 percent on a vast selection of vitamins, supplements and other health and wellness-related products. Healthy Discounts offers discount savings on these products through ASHP via www.choosehealthy.com. Members have direct access to products through www.choosehealthy.com for vitamins and minerals, herbal supplements, yoga, relaxation products, books and videos. The Healthy Discounts website also provides educational information on a wide range of complementary health care topics.
Kaiser Permanente: The PPO plan does not currently offer coverage for any complementary and alternative medicine (CAM) services. The insured can, however, choose to purchase the chiropractic/acupuncture rider. The rider offers a variety of plans with different benefit maximums or visit limit.
UnitedHealthcare: American Chiropractic Network, a business segment of UnitedHealth Group, provides chiropractic benefits as well as discounts for the following complementary alternative medicine services to our enrolled individuals:
• Acupuncture
• Massage therapy
• Nutritional counseling
• Naturopathic medicine services (in states where naturopathic physicians are licensed).
UnitedHealthcare also offers employers an optional acupuncture benefit. Finally, 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 annually beginning at age 40. This is only part of physical exam  benefit when the customer’s benefit plan does not include a separate  benefit.
Anthem Blue Cross: Once a year routine mammograms when ordered by a physician. No limit in frequency, meaning as medically necessary when ordered by a physician.
Blue Shield: One annual mammography test is covered for screening and diagnostic purposes without illness or injury being present.
Cigna: Mammograms are covered annually for women age 40 and over or more frequently and at younger ages when medically indicated.
Health Net: Health Net’s preventive care and diagnostic procedures for adults (age 17 and older) are covered at a physician’s direction.  When medically indicated, one mammography every calendar year for women.  HMO members must obtain a referral from their primary care physicians to receive the preventative care service.
Preventive care services for adults and for children include annual preventive physical examinations and preventive hearing and vision screening examinations.  Preventive care services for adults also include immunizations, well-woman examinations, mammograms, cervical cancer screening tests, pelvic exams, breast exams, colorectal cancer screening and screening and diagnosis of prostate cancer.
Preventive care is not covered if provided by an Out-of-Network Provider.
Kaiser Permanente: Mammograms are covered as part of the adult preventive screenings benefits as follows:
• For women age 35 to 39, one baseline mammogram.
• For women age 40 to 49, one mammogram every two years, or more frequently upon recommendation of a physician.
• For women age 50 and older, one yearly mammogram.
UnitedHealthcare: Options PPO provides coverage for mammograms as part of our standard outpatient surgery, diagnostic, and therapeutic services benefit. It is covered both as a preventive and diagnostic service.
6. Do you cover PSA tests for non-symptomatic men? If so, at what age?
Aetna: Yes. If a state has specific legislation, we will pay it in accordance with the law. There is no age limit unless it’s being paid under a specific benefit (like the Trust benefit), which has a contractual limit.
Anthem Blue Cross: Yes, at age 50 or when 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: These tests are covered based on the treating physician’s recommendations.
Health Net: Preventive care and diagnostic procedures for adults (age 17 and older) are covered at a physician’s direction.  When medically indicated, screening and diagnosis of prostate cancer includes: tests and procedures for the screening and diagnosis of prostate cancer, including but not limited to, prostate-specific antigen testing and digital rectal examinations.
HMO members must obtain a referral from their primary care physicians to receive the preventative care service.
Preventive care is not covered if provided by an Out-of-Network Provider.
Kaiser Permanente: The following prostate-specific antigen (PSA) tests are covered as part of the adult preventive screenings benefits, which are available at age 18: screening and diagnosis of prostate cancer, including but not limited to PSA 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.
UnitedHealthcare: Network physicians are encouraged to follow 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.

7. Describe your drug formulary. (Three tier etc.) If it’s a closed formulary, what happens if a non-formulary drug is needed?

Aetna: The formulary may be open or closed, depending on the benefit plan. In plans with an open formulary, both formulary and non-formulary drugs are generally covered subject to applicable limitations and conditions. With a closed formulary, formulary and non-formulary drugs are generally covered, except for drugs on the formulary exclusions list. Formulary exclusions provide less overall value than therapeutically equivalent formulary drugs. The member’s physician can request approval for coverage for a formulary exclusion.
Anthem Blue Cross: We offer both open formulary and closed formulary benefit options. Non-formulary or non-preferred drugs are covered at the tier 3 copay level on an open formulary benefit.   On a closed formulary benefit, non-formulary or non-preferred drugs are not covered unless nonformulary exception criteria are met.
Blue Shield: The Blue Shield Drug Formulary is a list of preferred generic and brand name drugs that have been reviewed for safety, efficacy, and bio-equivalency, and are approved by the Federal Food and Drug Administration (FDA). This formulary is developed and maintained by the Blue Shield Pharmacy and Therapeutics (P&T) Committee, which meets on a quarterly basis. The P&T Committee consists of independently licensed physicians and pharmacists in community practice and who are not employed by Blue Shield. A drug prior authorization program is available for selected drugs on the formulary as well as for non-formulary drugs to promote appropriate first-line therapy or to reserve use of certain medications with specialized uses or significant potential for misuse or overuse.
Blue Shield offers these types of outpatient prescription drug benefits:
• A closed formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs and most specialty drugs are covered only when prior authorization is approved.
• An incentive formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs are also covered for a higher copayment. Prior authorization may be required to cover some specialty and certain non-formulary drugs. If coverage for a non-formulary drug requiring prior authorization is approved, the member is responsible for the non-formulary copayment.
Cigna: We offer several kinds of formulary including open, closed, and tiered.
Health Net: Health Net of California’s most common benefit structure is a three-tier open formula.  Tier 1 (lowest copay) includes most generic, Tier 2 (next higher copay) contains preferred brands and Tier 3 (highest copay) is comprised of non-preferred brands and generics.
Kaiser Permanente: The PPO plan has an open formulary, which means most FDA-approved drugs, with the exception of those listed in the Optional Prescription Drug Exclusions and Limitations are covered for the insured. The insured pays a copay based on whether the drug is generic or brand. Self-injectable drugs are also covered at a coinsurance.
UnitedHealthcare: Unlike a formulary, the prescription drug list does not imply any drug therapy recommendations. Rather, we assign prescription medications a co-payment tier based on an evaluation of clinical, economic, and pharmacoeconomic evidence. Unlike our competitors, some brand drugs are placed in Tier 1 and some generic drugs are placed in Tier 2 or Tier 3 based on the overall value (for example, the lowest net cost that they offer our clients). UnitedHealth Pharmaceutical Solutions (UHPS) offers a three-tier plan and an open benefit design. Tier 1 drugs represent the lowest co-payment option and include many generic drugs. Tier 2 drugs represent a middle co-payment option and include many brand name drugs. Tier 3 drugs represent the most costly drugs, often with Tier 1 or Tier 2 alternatives, and have the highest co-pay option. A drug’s tier placement is subject to change when its value changes as a result of a patent expiration, new product introduction, or other important clinical, safety, or economic information. When a generic drug is more costly than the brand drug, UHPS may place the generic in Tier 2 and move the generic to Tier 1 once the price decreases.

8.Which Requested Procedures are Denied Most Frequently on the Basis of “Experimental/Investigative” or “Not Medically Necessary” Exclusions?

Aetna: We seek to minimize the number of claims denied based on medical necessity through our extensive patient management program, which includes features such as pre-certification, concurrent review, and close communication among our staff and attending physicians.
Blue Cross: It varies greatly. Each request is reviewed on a case-by case basis to determine medical necessity based on the latest medical standards. Factors that might influence the decision would be the season, say during flu season, or the age of the member for a certain procedure.
Blue Shield: Each request is reviewed on an individual basis to determine medical necessity. We do not have statistics on which procedures are most frequently denied.
Cigna: CIigna has a comprehensive policy for ensuring the efficacy of the latest medical treatments. We have an extensive process that includes review of outside, professional literature and input from physicians to determine the safety and efficacy of procedures and interventions. We work closely with customers and physicians to help determine treatment protocols that ensure appropriate and quality care while reducing the number of denials.
Health Net: N/A.
Kaiser Permanente: Requests are received on a case-by-case basis.
UnitedHealthcare: UnitedHealthcare does not deny procedures on the basis of medical necessity and our benefit plans do not contain medical necessity exclusions. We believe that healthcare consumers and their doctors are best qualified to make decisions about healthcare. Denials on the basis of “experimental or investigative” are very rare. If an individual has a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), we may determine that an experimental, investigational, or unproven service meets the definition of a covered health service for the sickness or condition. This determination is based on whether we find the procedure or treatment to be promising and that we find that the service uses research protocol that meets standards equivalent to those defined by the National Institutes of Health.

9.Do You Capitate PPO Providers? If Not, How Are They Compensated?

Aetna: No. Physicians are paid based on a negotiated fee schedule,  which compensates physicians at the lesser of their usual charge or the negotiated fee. Each of our networks has a unique fee structure. We incorporate the federal government’s RBRVS methodology for procedure-related services while allowing for local differences for office and hospital visit services.
Blue Cross: No, payment is determined by applying available member benefits to a pre-determined fee schedule.
Blue Shield: Blue Shield does not capitate PPO providers. PPO contracted providers (physicians and ancillary providers) have agreed to accept Blue Shield’s allowances as payment in full, which are valued-based and reviewed annually.
Cigna: No, we reimburse physicians on a maximum allowable fee schedule or a discounted fee-for-service arrangement. For physicians who are part of our collaborative accountable care initiatives, we also provide reimbursement for care coordination services and have a pay for performance component if physicians meet  targets for improving quality and lowering medical costs.
Health Net: PPO physicians are typically reimbursed at a discounted contract-fee schedule
Kaiser Permanente: No, our PPO providers are part of the Private Healthcare Systems (PHCS) Network. PHCS Network contracts with the Providers to negotiate a lower rate for services rendered. Providers are paid based on claims submitted for covered services.
UnitedHealthcare: The majority of physicians in our networks are reimbursed according to a Maximum Allowable Fee Schedule based on the Resource Based Relative Value Scale Fee Schedule (RBRVS). Our fee schedule is established by applying a conversion factor to RBRVS values. The conversion factor is based on competitive market conditions, medical expense expectations, and physician acceptance. The advantage of this funding arrangement is that we reimburse physicians only for services rendered based on time and intensity with adjustments for geographical differences. For some high-cost specialists, we employ prepayment (capitation). This ensures that we are able to manage expenses for high-cost services to a planned target.

10. What Happens When a Member Provider Bills a Participant Inappropriately for Services?

Aetna: Balance billing of the patient is not permitted. The provider-relations staff monitors compliance and educates providers. A provider who is found to have inappropriate balance billing may have his or her contract terminated in some cases.
Blue Cross: Customer service works with the member and provider to resolve billing issues. Dispute-resolution procedures are available to members and providers.
Blue Shield: Network providers are prohibited from balance billing patients. When a member is billed inappropriately for services, Blue Shield customer service representatives can usually resolve the issue by contacting the provider’s office to clarify the member’s benefit and the Blue Shield reimbursement schedule.
Cigna:  Our contracts prohibit balance billing by physicians. The customer  should contact us about the issue and we will investigate. Our customer service associates are available by phone 24 hours a day, seven days a week.
Health Net: Health Net will intervene on the member’s behalf by working directly with the provider’s office.
Kaiser Permanente: In the unfortunate event that a provider bills an insured inappropriately, the insured should contact the KPIC customer service line at 1-800-788-0710. If the issue requires any type of special handling, KPIC operations staff will intervene and assist in reconciling the claim.
UnitedHealthcare: Our physician and other healthcare professional contracts preclude physicians and other healthcare professionals from balance billing enrollees. The contracts also address how physicians and other healthcare professionals must submit claims. We take appropriate action if network physicians or other healthcare professionals attempt to balance bill enrollees or to bill enrollees for covered services in breach of their contract requirements. We protect our customers from claims liability by fulfilling all state mandates concerning participation in guaranty associations, maintaining state contingency reserve requirements or obtaining reinsurance agreements. Our standard hospital contracts also contain provisions to protect individuals receiving health services from balance billing when an insurer becomes insolvent. If a network physician or other healthcare professional becomes insolvent or otherwise unable to continue to render healthcare services to individuals, we help reassign individuals enrolled in our plans to other physicians.

11. Do You Have a Registered Nurse on Call 24 Hours a Day for Questions at the Plan Level and the PPO Level?

Aetna: Yes, nurses provide information on a broad spectrum of health issues virtually 24 hours a day, seven days a week. They also provide ongoing follow-up information as needed and perform customized research when appropriate. Standard service is included in the full-risk, prospectively rated PPO plan. The informed Health Line may be purchased as an additional service for self-funded or retrospectively rated PPO plans with over 1,000 or more total enrolled employees. The minimum group size can be a mix of active employees and retirees (e.g., 800 active and 200 retirees).
Blue Cross: Yes, most PPO members have access to professional, reliable healthcare information toll-free, 24 hours a day, seven days a week. Registered nurses answer questions and help with decisions. Members also have access to educational audiotapes on more than 200 health topics.
Blue Shield: Yes, Blue Shield’s NurseHelp 24/7 is a service for all of our fully insured groups and is available as a buy-up for self-insured groups. It provides a nurseline, which is staffed 24 hours a day, seven days a week with registered nurses and master’s-level counselors. Any member of a fully insured Blue Shield health plan can take advantage of this service at no extra charge.
Cigna: Yes, Cigna’s customer service line is open 24/7 365 days a year. We also offer a 24-hour Health Information Line staffed by nurses.
Health Net: Yes, Nurse24 is a nurse-driven telephonic support program that empowers participants to better manage their health. Nurse24 SM offers assistance to participants coping with chronic and acute illness, episodic or injury-related events and other health care issues. Highly trained registered nurses are available 24/7 to monitor and process health care inquiries that help participants make informed health care decisions. The Nurse24 SM program is accredited by both URAC and NCQA.  Access to evidence-based, reliable clinical support for decision support after hours increases the likelihood that our members will seek care at the appropriate level when their physician is not available to support the decision.  Seeking care at the appropriate level increases the efficiency and reduces the cost of after-hours care. Program highlights include:
• Chat capability from our website with Nurse24 SM clinicians
• Health information managers with experience in health issue discovery and trained in telephone triage
• Improved continuity of care – integration with Decision Power disease management services
• Significant cost savings potentia – convenient and useful alternative help to reduce excessive or unnecessary emergency room visits
• Access to nationally recognized  Healthwise(r) Knowledgebase with more than 5,500 health topics
Kaiser Permanente: The insured have access to Kaiser Permanente Healthy Solutions, which will give them access to a personal health coach, online health and wellness programs and information, and the Kaiser Permanente Healthwise Handbook online. (Services under the Healthy Solutions program are value-added services provided by Kaiser Permanente Healthy Solutions, an affiliate of Kaiser Foundation Health Plan Inc. (KFHP). These services are not in lieu of any services covered under the PPO Group Policy. Likewise utilization of these services does not constitute receipt of benefits under the PPO Group Policy. The Kaiser Permanente PPO Plan is underwritten by Kaiser.)
UnitedHealthcare: Optum, the UnitedHealth Group care management company, provides toll-free, 24-hour, 365-day access to the “NurseLine.” Experienced registered nurses discuss treatment options and help individuals get the appropriate level of care. NurseLine gives individuals information that helps them make educated decisions about their personal health and use of medical resources. Some services must be purchased as a buy-up based on the funding arrangement of the plan.

12. What is the Plan or PPO Doing to Have Online Systems for Eligibility, Administrative Changes, Referrals, Etc.?

Aetna: EZLink streamlines several benefits and HR functions. It links to our enrollment and billing systems and provides real-time eligibility; online enrollment, account maintenance, online billing, and electronic-funds transfer for payment.
Blue Cross: Our Website offers online services to providers and members for eligibility, claim status, and benefit inquiries. Other features include a provider finder and a wide variety of Web and organizational resources.
Blue Shield: Our website has a password-protected section with personalized member health plan account information. Members can view detailed benefit information and find customer service phone numbers and addresses. Via e-mail, they can reach customer service, submit changes to account information, request new member ID cards, download claim forms, and request a new personal physician. Blue Shield can offer online enrollment to all our employer groups through our partnership with leading online vendors. This partnership gives benefit administrators direct access to the eligibility system as set up by the vendor allowing for functions such as employee eligibility tracking, plan enrollment, open enrollment, and life event enrollment transactions. Additionally, the use of an outside vendor allows for incorporation of benefit design from more than one carrier, providing employer groups with a single online enrollment service.
Cigna: The Cigna for Health Care Professionals website (www.cignaforhcp.com) offers secure and easy access to real-time transactions such as pre-certification, claim status, eligibility, and benefits. Information on Cigna policies and procedures is also available. In addition, Cigna has enhanced the myCigna.com portal, which enables members to personalize their site for their individual use. Information includes the ability to review hospital and provider quality data, gather specific disease information, track claims and explore drug alternatives that might be a cost savings.
Health Net: Health Net’s website, www.healthnet.com, is a secure website that requires a personalized identification number (PIN). Members, employers, providers and brokers can perform a wide range of online administrative functions. Members in an active or COBRA program can view or modify their enrollment information. Providers can verify eligibility, find specialists for referrals, and submit and check claims status. Health Net’s  Online Billing and Enrollment for members, brokers, and employers offers 24-hour online account access to process enrollment and maintain member’s eligibility; users can also view, print and pay billing. Enhancements for both sites are ongoing.
Kaiser Permanente: Kaiser Permanente offers online billing and administration functions to its employer groups through a system called Online Account Services-www.kp.org/accountservicestour.
UnitedHealthcare: Members, physician, and employers have access to their data and the capability to communicate directly with us online. Our consumer Internet solution – myuhc.com – allows people to do the following:
• Choose a plan.
• Locate network professionals.
• Access claims history and explanations of benefits (EOBs).
•Complete a health assessment and develop an action plan.
•Order ID cards and print temporary ones.
•Communicate with a nurse.
• Compare hospitals.
Healthcare professionals can do the following:
•Verify patient eligibility, applicable co-payment amounts, and YTD and out-of-pocket accumulators.
•Search the notification database and complete multiple notifications in one session
•Submit claims.
•Receive payment statements and reimbursement.
•Perform online reconciliation and electronic funds transfer.
•Submit credentialing data online.

Complete online CE programs
The following features are available through Employer eServices:
•Receive Web-based eligibility management.
•Get simplified invoices, real-time calculations, and downloadable data.
•Do Customer reporting
•Get Claim status information.

13.What is the Relationship of your HMO Provider Network (if you have one) to Your PPO Provider Network? Do HMO Providers Have to Participate in the PPO Network? How big is your PPO Network compared to your HMO Network?

Aetna: Standard provider contract provisions generally apply to all of our plans and products that the provider participates in. However, it is not mandatory for a provider to participate in all products.
Blue Cross: All of our California networks are proprietary, whether they are PPO/HMO/EPO etc. A provider may participate in one or more of our plan products, but it is not mandatory for a provider to participate in all products. Our physician network has more than 57,000 members.
Blue Shield: Blue Shield’s HMO and PPO networks are separate. The HMO network is capitated based on medical group and IPA contracts throughout the state with some directly contracted networks in specific geographies.
With the PPO, there are value-based allowances and contracts with individual physicians and medical groups. HMO providers do not have to participate in our PPO network, though many of them do.
Blue Shield’s PPO network has 65,000 physicians (defined by access points) and 350 hospitals, and our HMO network has 32,000 physicians (defined by access points) and 300 hospitals.
Cigna: Cigna does not require PPO network physicians to participate in the HMO (or vice versa). The HMO network is contracted with Cigna HealthCare of California Inc. The PPO network is contracted with Connecticut General Life Insurance Company, a Cigna company. While there is considerable overlap, we have many physicians just in one network (e.g. PPO only). In California, our HMO network is about 80% of the size of our PPO Network.
Health Net: Health Net of California has taken a multi-product approach in contracting with providers, with approximately 65% of Health Net’s PPO network practitioners also participating in the HMO network. While HMO providers are not required to participate in Health Net’s PPO network, approximately 88% of them do so. Health Net of California’s HMO network includes more than 49,000 Primary Care Physicians and specialists in the California 30-county HMO service area and more than 65,500 Primary Care Physicians and specialists in the PPO network.
Kaiser Permanente: Our PPO and HMO networks are not affiliated. For our PPO, KPIC contracts with PHCS Network to provide access to providers and facilities nationwide. They currently have more than 658,000 providers and 4,200 acute care facilities nationally and more than 68,000 providers in California. Our HMO offers more than 9,100 providers and more than 160 facilities in California.
UnitedHealthcare: UnitedHealthcare’s network includes 570,000 physicians and healthcare professionals and 4,800 hospitals nationwide. In general, UnitedHealthcare’s contracts apply to all of our commercial products ensuring that employees have a consistent experience throughout the country. Providers are not required to participate in all our products, but the majority of them do. The UnitedHealthcare Select or Choice HMO networks apply locally and are subject to state laws.