New provider networks will support health plans sold on and off the Health Insurance Marketplace

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1 Health Insurance Exchange October 2013 New provider networks will support health plans sold on and off the Health Insurance Marketplace Anthem Blue Cross and Blue Shield and our subsidiary HMO Nevada (Anthem) has developed new individual and small group health benefit plans that will be sold on and off the Health Insurance Marketplace (also commonly called the Exchange). Effective dates for these new health plans begin January 1, We ve developed new provider networks to support many of these new health plans. The following FAQs provide important information about the new health plans and the supporting provider networks. (Please note: our existing provider networks will still be available.) Please read this information carefully. These new networks utilized for products purchased on the exchange will be identified on the member ID cards by the network name Pathway X. It may be indicated as Pathway X - HMO or Pathway X - PPO. The X designates that a product was purchased on the Exchange. Currently a PPO product is not being offered on the exchange as of January 1, 2014, but a Pathway X PPO network is in place if a PPO product is expanded at future date. We have also developed new and separate networks for products that are purchased off the exchange and were available starting September 1, If a provider was selected to participate in these new networks utilized for products purchased off the exchange, the network name which will be used on the member ID cards will include the name Pathway (without an X ). For new off Exchange products: Pathway - HMO will be available for Individual, Small Group and Large Group products and Pathway - PPO will be available for Small Group and Large Group products. Please note that the Pathway and Pathway X networks are separate networks and require either a new Agreement or a notice of participation to be included in these networks. Anthem s Pathway and Pathway X networks are statewide networks. What makes these networks unique as compared to Anthem s standard HMO and PPO networks is the networks will: Be limited to a subset of PCPs and specialists in the current network; Limited subset of Hospitals, LTAC s, Rehab, and Ambulatory Surgery Centers Includes all SNFs, hospice, home health in the current network; Includes selected ancillary providers in the current network (PT/OT/ST, home infusion, DME, lab, etc.); Includes selected behavioral health providers in the current network (both professional and facility); The Pathway HMO and Pathway X - HMO networks are open access; which means members will still need to choose a Primary Care Physician (PCP), but do not need a referral from their PCP to see any of the respective Pathway HMO or Pathway X HMO providers. Page 1 of 6

2 Identifying Pathway Members: Alpha Prefix Health Benefits Plan Option Product Type Network Name (which will appear on Member ID cards) YFI, YFQ Individual (Exchange) HMO Pathway X HMO YFM Small Group (Exchange) HMO Pathway X - HMO YFC Individual (OFF Exchange) HMO Pathway - HMO YFH Small Group (OFF Exchange) HMO Pathway - HMO YFA Large Group (OFF Exchange) HMO Pathway - HMO YFD Small Group (OFF Exchange) PPO Pathway - PPO YFB Large Group (OFF Exchange) PPO Pathway - PPO Provider Network Questions Q1: What is the name of the provider network that will support plans purchased on the Exchange? A1. The Pathway X HMO network will support plans purchased on the Exchange. Note: Currently a PPO product is not being offered on the exchange as of January 1, 2014, but a Pathway X PPO network is in place if a PPO product is expanded at future date. Provider Agreements or Notifications of Participation reference both a Pathway X HMO and Pathway X PPO network for this purpose. Q2. What is the name of the provider network that will support plans purchased off the Exchange? A2. The Pathway HMO and Pathway PPO networks will support new plans purchased off the Exchange. Off the exchange, Anthem will offer a full suite of products including products utilizing the Pathway network. Anthem s Individual products off exchange will be the same as on the exchange (the only difference being that members who purchase off of the exchange will not have access to premium subsidies or other federal cost sharing subsidies). Anthem s Small Group products off exchange will provide a full range of network and product solutions including HMO products utilizing our Pathway HMO network, as well as HMO and PPO products attached respectively to our standard HMO and PPO networks. Q3. Which providers are participating in the Pathway and Pathway X networks? A3. The Pathway and Pathway X networks are a subset of Anthem s standard HMO and PPO network of participating doctors, hospitals and other health care professionals. Page 2 of 6

3 What makes these networks unique as compared to Anthem s standard HMO and PPO networks is the Pathway and Pathway X networks will: Be limited to a subset of PCPs and specialists in the current network; Limited subset of Hospitals, LTAC s, Rehab, and Ambulatory Surgery Centers Includes all SNFs, hospice, home health in the current network; Includes selected ancillary providers in the current network (PT/OT/ST, home infusion, DME, lab, etc.); Includes selected behavioral health providers in the current network (both professional and facility); Note: All other Anthem networks are still currently in place. Q4. How do I know if I am participating in the Pathway network? A4. Providers selected to participate in one of these networks were either sent a new Agreement, which included an introduction letter outlining the Pathway and Pathway X networks; or Notice of Participation letter outlining the Pathway and Pathway X networks. Please note that notification was only sent to providers that are participating in the Pathway and/or Pathway X network. Providers not participating in the Pathway or Pathway X networks will remain participating providers in Anthem s other provider networks, as applicable, under their existing provider agreements. Beginning in October providers will be able to confirm their participation status by using the Find a Doctor tool at anthem.com. You ll be able to search by a specific provider name, or view a list of local in-network providers using search features such as provider specialty, zip code, and plan type. Accessing the Online Provider Directory: Go to anthem.com Select the Provider link in the top center of page Select Nevada from drop down list and enter From the Provider Home tab, select the blue box titled Find a Doctor to search our online Provider Directory How to search for a Pathway or Pathway X network provider: o Enter which type of provider for your inquiry o Enter information about the provider (optional) o Enter the location for your inquiry o Enter the insurance plan information: Select I d like to search by selecting a plan option Under state, select Nevada Page 3 of 6

4 Under Plan Type/Network, select Pathway HMO, Pathway PPO, or Pathway X HMO Under the Plan Name, you will see each Pathway X Enhanced or Pathway Enhanced product option under the drop down list. Select the appropriate option (as identified above the Network Name on the member ID card). Or, select Search by your plan using the first three letters of your Member ID Enter alpha prefix option. This will allow you to ensure you are looking at the appropriate network for a specific member. Reminder: While a referral is not required; if you are referring a member to a specialist, please ensure the specialist is in the member s appropriate network. Q5. As a non-participating provider of one of these Pathway or Pathway X networks, what should I know if a member presents at my office? A5. Since each of these Pathway or Pathway X networks are a subset of our standard HMO and PPO networks, many of the new health plans utilizing these networks will include little or no out-ofnetwork benefits, so your office will need to be able to identify these members. You can easily identify these members by the Pathway or Pathway X network name field on the member ID card, which will indicate one of the network names noted above. As with other Anthem products, services rendered by non-contracted providers will be processed as out-of-network. Providers should continue to verify eligibility and benefits for all members. New Health Plan Questions Q6. In general, what will the benefits for the new health plans be like (copayments, member out of pocket, etc.)? A6. Member benefits for the new individual and small group health plans will vary based on options that are available for the member. In general, health plans purchased on the Exchange will have a slightly higher out of pocket, some plans will have little or no out-of-network benefits, lean pharmacy benefits, and a more focused provider network. Page 4 of 6 Health plans purchased off the Exchange will look a lot like they do today, but there will be options which have more focused provider networks and select drug lists. All individual and small group health plans will include Essential Health Benefits (or EHBs). Large group benefit plans are not subject to many of the new requirements for individual and small group plans. Providers should continue to verify eligibility and benefits for all members. Benefit information for these new health plans, like existing plans, will be available on Availity Web Portal and ProviderAccess*. Please note: While Eligibility and Benefits inquiry is currently available on ProviderAccess, we are in process of transitioning this functionality exclusively to Availity Web Portal in the very near future.

5 Q7. Will the new health plans have new names? A7. Yes, new health plans sold on and off the Exchange will have new product names. While the product names will vary, the network names will be included separately from the product name to help providers identify whether or not they are participating for that particular member. Health plans purchased on the Exchange will indicate a metal level in the product name on the member ID card. Q8. How will providers identify these new health plans? A8. Member ID cards for the new individual and small group health plans will include information to help providers identify these members. For example, the Pathway or Pathway X network name will be indicated on the member ID card, identifying the member s supporting provider network. For plans purchased on the Exchange, the product name on the ID card will include a metal level bronze, silver, gold or platinum. Metal levels indicate the richness of the benefits associated with a product or health plan. Sample member ID cards will be shared with providers as soon as they are finalized and available. Q9. Will the new health plans purchased on and off the Exchange have out-of-network benefits? A9. For products purchased on the Exchange, all new health plans utilizing the Pathway X - HMO network will be HMO products and will not have out of network benefits, except for urgent and emergent services. For products purchased off the Exchange, some PPO products may have out-of-network benefits, but the HMO products will not have out of network benefits, except for urgent and emergent services. Providers should continue to verify eligibility and benefits for all members. Benefit information for these new health plans, like existing plans, will be available on Availity Web Portal and ProviderAccess*. Please note: While Eligibility and Benefits inquiry is currently available on ProviderAccess, we are in process of transitioning this functionality exclusively to Availity Web Portal in the very near future. Reminder: Anthem will continue to offer a full range of network and product solutions, some of which may have out-of-network options. Q10. Will emergency care services be covered as in-network under the new individual and small group health plans? A10. Emergency care services are covered under the new plans. If a member is seen by an out-ofnetwork provider for emergency services (due to the seriousness of the illness or injury), these charges will be covered as in-network benefits. However, if the visit is not a medical emergency, a claim may deny and the member may be responsible for costs incurred, depending on the member s benefit plan. Page 5 of 6

6 Q11. Are members required to have a primary care physician (PCP) and referrals to specialists? A11. The new health plans developed around the Pathway X HMO and Pathway HMO network are open access; which means members will still need to choose a Primary Care Physician (PCP), but do not need a referral from their PCP to see any of the respective Pathway X HMO or Pathway HMO providers. Q12. How will you help members understand their new policy and benefits? A12. After a new plan is selected, members will receive either a Welcome Kit by mail or information by . Welcome Kits provide members with benefit information and coverage details to help them understand their copays, deductibles, and coinsurance responsibilities. These kits also include information about health and wellness programs, and online tools to help members find innetwork providers. When members prefer electronic communications, they receive an with details about how to access all of this information and more through our member website. Additional Information Q13: How will Anthem keep Providers updated? A13: To learn more about the Exchange networks, we have created a dedicated webpage on our website. Go to anthem.com, and select the Provider link at the top center of the page. Select Nevada from the drop down list, and enter. From the Provider Home page, under the Communication and Updates section, select the link titled Health Insurance Exchange information. New information will be posted to this web page, as it becomes available. Please bookmark this page for future reference. In addition to the website, and our Network Update provider newsletter, we will also use our service, Network eupdate to communicate critical updates about Health Insurance Exchanges. If you are not yet signed up to receive Network eupdates, we encourage you to enroll now so you will receive all information shared about Exchanges. To sign up, follow the instructions above to Communication and Updates section from our Provider Home page, and select the link titled Anthem Network eupdate (registration form). Page 6 of 6