Do you see TRICARE patients? Check out CMA's new toolkit to assist physicians with the transition On January 1, 2018, Health Net Federal Services (HNFS) will begin providing managed care services to 2.9 million TRICARE beneficiaries in the 21 western states, including California. HNFS took over the contract previously held by UnitedHealthcare Military and Veterans’ Services. In preparation for the transition, the California Medical Association (CMA) has prepared a TRICARE Transition Guide to help physicians understand the impact the transition will have on their practices. The guide is available free to members in the CMA resource library. December 28, 2017 Managed Care Health Net, TRICARE 0 0 Comment Read More »
Updated payor profiles for 2017 now available The California Medical Association’s (CMA) Center for Economic Services is publishing updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, UnitedHealthcare, Medicare/Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical directors, provider relations, and other key contacts. Don’t waste your time searching the internet for this information – members can download CMA’s Payor Profiles free of charge in the CMA Resource Library. August 1, 2017 CMA, Managed Care, Medi-Cal, Medicare Aetna, Anthem Blue Cross, Blue Shield, Cigna, Health Net, Insurance, Medi-Cal, Medicare, Noridian, Payor, Payor Profiles, Running a Practice, UnitedHealthcare 0 0 Comment Read More »
State's high court rules health plans cannot negligently delegate payment responsibility The California Supreme Court today ruled that health plans cannot absolve themselves of the responsibility to pay claims for emergency care by noncontracted providers by negligently delegating that responsibility to a risk-bearing organization that it knows—or should have known—to be financially insolvent. "Today's ruling is a huge victory for physicians," said Francisco Silva, Senior Vice President and General Counsel for the California Medical Association (CMA). "California's high court is unequivocally telling health plans they cannot get away with this morally blameworthy behavior. They cannot irresponsibly delegate risk and leave physicians unpaid for services provided in good faith to their enrollees." CMA filed an amicus brief in this case, Centinela Freeman Emergency Medical Assocs. v. Health Net et al., on behalf of a broad coalition of out-of-network health care providers who were left unpaid for emergency medical care when La Vida Independent Practice Association (IPA) went bankrupt in 2010. The IPA, a risk-bearing organization (RBO) that provided health care coverage to hundreds of thousands of patients in Southern California, was contracted by HealthNet and six other health plans to pay insurance claims to providers. Existing law insulates health plans from payment responsibility for medical claims once they enter into a delegation arrangement with an RBO. Notwithstanding such law, the providers in Centinela sought reimbursement from the health plans on the theory that they negligently delegated to La Vida, because they continued to send patients to the IPA when they knew or should have known of its financial distress and impending insolvency. CMA's amicus briefs urged a fair and just interpretation of provisions within the Knox-Keene Act that permit health plans to delegate payment responsibility to risk-bearing organizations. CMA recognizes the viability of the delegation model and accepts that, generally, health plans are absolved of liability after they delegate to an RBO. When health plans delegate negligently, however, CMA believes they must be held accountable for their own misconduct—and the California Supreme Court agrees. "We conclude that a health care service plan may be liable to noncontracting emergency service providers for negligently delegating its financial responsibility to an IPA or other contracting medical provider group that it knew or should have known would not be able to pay for emergency service and care provided to the health plan's enrollees," the court wrote in its ruling. "We further conclude that…a health care service plan may be liable to noncontracting emergency service providers for negligently continuing or renewing a delegation contract with an IPA when it knows or should know that there can be no reasonable expectation that its delegate will be able to reimburse noncontracting emergency service providers for their covered claims." “Imposing a duty on plans to act reasonably in choosing an IPA or other RBO will promote a healthy functioning of the managed health care model endorsed by the Knox-Keene Act. Indeed, a requirement that health care service plans reasonably select financially solvent delegates will more likely result in timely processing and ultimate payment of covered emergency service claims, which will in turn support the continuing availability and provision of such emergency services.” Contact: CMA Center for Legal Affairs, (800) 786-4262 or legalinfo@cmanet.org. November 21, 2016 Managed Care Amicus Briefs, California Supreme Court, Health Net, Legal Advocacy 0 0 Comment Read More »
Health Net Federal Services awarded Tricare contract beginning late 2017 Health Net Federal Services (HNFS) has been awarded the contract for managed care support (MCS) for the Tricare West Region, replacing the current MCS contractor, United Military and Veteran Services. Under the $17.7 billion contract, HNFS will provide direct medical care and administrative support services to Tricare beneficiaries throughout the 19 state western region, which includes California. According to HNFS, a nine-month transition period is expected, with an anticipated start of health care delivery sometime in mid-2017. HNFS has been the managed care contractor for the Tricare North Region since 2004, servicing approximately 2.8 million beneficiaries in 22 states and the District of Columbia. August 9, 2016 Managed Care Tricare, Health Net 0 0 Comment Read More »
Health Net modifying exchange/mirror products Health Net recently announced changes to its exchange/mirror products offered for 2015. In a notice mailed to select physicians, the insurer said it will be offering an Exclusive Provider Organization (EPO) and a Health Care Service Plan (HSP) for its individual exchange/mirror products effective January 1, 2015. Though not explicitly stated in the notice, the California Medical Association (CMA) has confirmed the insurer will not be offering a PPO product in the individual exchange/mirror market. The EPO will be called PureCare One and the HSP will be called PureCare. Patients will be able to select one of these new plans during the next Covered California open enrollment period, which begins November 15. Both of the new products will utilize a narrowed provider network. The new EPO and HSP products function similar to an HMO in that they do not offer out of network benefits. Additionally, individuals who select the PureCare HSP will be required to select a primary care physician (PCP). The Purecare One EPO plan, however, does not require individuals to select a PCP. Health Net will offer the PureCare HSP and HMO products in Southern California counties and will offer the PureCare One EPO product in the other counties in which it offers an exchange/mirror product. The payor has confirmed there are no changes to its HMO product for 2015. Health Net’s 2015 individual exchange/mirror products will be as follows: Individual Exchange Rating Region/County Exchange Products 2 - Napa, Sonoma, Solano and Marin EPO 4 - San Francisco EPO 5 - Contra Costa EPO 7 - Santa Clara EPO 8 - San Mateo EPO 9 - Santa Cruz EPO 10 - San Joaquin, Stanislaus, Merced, Tulare EPO 14 - Kern EPO 15 - Los Angeles (Northern: High Desert/Antelope Valley and Eastern metropolitan half of county, including San Gabriel Valley) HSP and HMO 16 - Los Angeles (Western and Downtown Los Angeles County, covering the central and southern metropolitan portions of the county, excluding Catalina Island) HSP and HMO 17 - San Bernardino and Riverside HSP and HMO 18 - Orange HSP and HMO 19 - San Diego HSP and HMO In addition to the above changes for the individual market, Health Net has advised CMA it will begin offering the EPO product along with the PPO product in the SHOP market, which is offered in all counties. Physicians who received the notice were also advised that they were automatically being opted into the provider networks for Health Net’s new products and will be paid at 100 percent of their current contracted PPO/EPO rates. Practices who did not receive the notice are encouraged to confirm their participation status with Health Net by calling Provider Services at (800) 641-7761 as Health Net’s online directory had not been updated to reflect the new products at the time of publication. Health Net has advised the California Medical Association that it will still offer the individual PPO product, however individuals who select that product will not be eligible to receive Covered California premium subsidies. Practices with questions about the notice can contact Health Net Provider Services Center at (800) 641-7761. November 5, 2014 Managed Care Health Insurance Exchange, Health Net, Covered California 0 0 Comment Read More »
Three major exchange plans provide guidance for physicians Three major managed care payors offering coverage through Covered California have provided additional information to their contracted providers on their exchange/mirror products. Together, these three payors – Health Net, Anthem Blue Cross and Blue Shield of California – account for approximately 75 percent of enrollment in Covered California products to date. The notices, sent to physicians within the past few weeks, were cobranded with Covered California and contain additional information to help providers navigate the exchange. The Health Net notice, sent on March 7, includes information such as the exchange/mirror products in which the physician is listed as participating, the product types that are offered in different regions and what information is on patient ID cards. Blue Shield sent two notices, one for its EPO and one for its PPO. The notices, sent on March 14, were very comprehensive, containing clarification on “mirror” products, a plan summary that includes copayment, coinsurance and deductible information, sample ID cards, answers to frequently asked questions, a map indicating which product types are offered by county and additional useful tools. Anthem Blue Cross's notice, sent on March 17, includes answers to frequently asked question, clarifies that it is offering a narrowed network for its exchange/mirror product enrollees, a breakdown of products sold by county, reported provider network size and a helpful plan name guide to assist practices in identifying their exchange/mirror product patients. While the notices were only sent to contracting physicians, the information may also be helpful to non-contracting physicians. To help practices navigate the exchange, CMA has also published several “Surviving Covered California,” tip sheets, which are available free to members in CMA's exchange resource center at www.cmanet.org/exchange. There you will also find many other exchange resources, including a comprehensive exchange toolkit, "CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange.” Contact: CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. March 20, 2014 Managed Care Blue Shield, Covered California, Health Insurance Exchange, Health Net, Anthem Blue Cross 0 0 Comment Read More »
