Welcome to our 14th 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.
1. 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.
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: PPO members do not need a referral to obtain care from specialists. Most diagnostic tests are covered, provided they are ordered by an insured’s doctor, are a covered benefit, and are deemed medically necessary. However, if a test or treatment is on the precertification list (e.g, MRIs and CT scans), precertification is required.
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.
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 regardless of the provider’s network affiliation. As in all cases, charges will be lower when care is received from a participating network provider. Members are encouraged to contact Member Services for a full explanation of their benefits. The physician offering the second medical opinion should 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 the 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.
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, Health Net’s Care Management team and, if the member chooses, our external vendor AlereTM’s Nurse24SM nurseline clinicians, who will provide additional information to help the member through the decision-making process.
Kaiser Permanente: Decisions regarding testing, treatment, surgery, and hospitalization are made by the insured and his or her physician. Referrals are not needed to see a specialist. The insured is required to obtain precertification to ensure certain services are both medically necessary and cost effective. This includes any hospitalization and certain special procedures as defined in the insured’s Certificate of Insurance.
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.
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 Power Healthy Discounts program at www.healthnet.com. Health Net members receive discounts when they choose selected complementary health care services from chiropractors, acupuncturists, and massage therapists participating in American Specialty Health’s ChooseHealthy networks. Through this program, members receive direct access to chiropractors, acupuncturists, and massage therapists. Members may find American Specialty Health providers listed on 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 also provides Health Net members with discounts of up to 50% on a vast selection of vitamins, supplements, and other health and wellness-related products. Healthy Discounts offers discount savings on these products through American Specialty Health via www.ChooseHealthy.com. Members have direct access to products through the ChooseHealthyTM website, including vitamins and minerals, herbal supplements, yoga, relaxation products, books and videos. The website also provides educational information on a wide range of complementary health care topics.
Kaiser Permanente: The availability of complementary medicine depends on the plan and options selected by the member’s employer. All plans offer physical, speech, and occupational therapies as base benefits. Coverage for chiropractic care and acupuncture can be added by the employer.
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.
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 PPO coverage for mammograms remains as follows: One baseline mammogram between the ages of 35 and 39; one mammogram every one to two calendar years for women between the ages of 40 and 49; and one mammogram every calendar year for women age 50 and older.
Kaiser Permanente: Mammograms are covered as part of the adult preventive screenings benefits for women beginning at age 35. Frequency increases with age or as medically necessary.
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.
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 for men age 50 and above, tests and procedures, including, but not limited to, prostate-specific antigen testing (PSA) and digital rectal examinations are covered.
Kaiser Permanente: Yes. PSA tests are covered as part of the adult preventive screenings benefits, which are available at age 18 when medically necessary and consistent with good professional practice.
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.