Tag Archive: Anthem Blue Cross

California fines top health insurers for overstating Obamacare networks – LA Times

California regulators fined two insurance giants for overstating their Obamacare doctor networks, and said the companies will pay out millions of dollars in refunds to patients.The errors by Blue Shield of California and Anthem Blue Cross caused major frustration for consumers statewide during the rollout of the Affordable Care Act in 2014.The inaccuracies in their provider networks led to big unforeseen medical bills for some patients who unwittingly went out of network for care. The California Department of Managed Health Care said Tuesday that it has levied fines of $350,000 against Blue Shield and $250,000 for Anthem.

Source: California fines top health insurers for overstating Obamacare networks – LA Times

Among the moving parts of the Patient Protection and Affordable Care Act’s health insurance market reforms there are bound to be friction points. One such problematic interface exists between payers and providers participating in California’s health benefit exchange, Covered California, as this report illustrates.

In non-integrated, narrow network health plans like these where payers and providers function as separate entities (unlike integrated care systems like Kaiser Permanente), it’s critical that interface function properly lest it threaten to bring the entire reform mechanism to a grinding halt. Continuing the mechanical metaphor, the narrowness of the provider networks has little tolerance space — and room for error– between the working components. One area where the gears frequently grind in narrow networks is hospital care where the hospitals and physicians are contracted with disparate plans and not necessarily participating in the same plan covering a patient as this Modern Healthcare article explains in detail.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Aetna, Hill Physicians Medical Group and Dignity Health’s Hospitals and Medical Foundation Form Accountable Care Collaboration in Northern California

The agreement features a new payment model to reward Hill Physicians and Dignity Health for meeting quality, efficiency and patient satisfaction measures, including:

  • The percentage of Aetna members who get recommended preventive care and screenings;
  • Better management of patients with chronic conditions, such as diabetes and heart failure;
  • Reductions in avoidable hospital readmission rates; and
  • Reductions in emergency room visits.

via Aetna, Hill Physicians Medical Group and Dignity Health’s Hospitals and Medical Foundation Form Accountable Care Collaboration in Northern California – The Health Section.

 

This agreement affects Aetna’s group market; the insurer withdrew from California’s individual health insurance market as of 2014.

The move follows by two weeks the unveiling of an individual market Accountable Care Organization (ACO) formed by Anthem Blue Cross and 6,000 doctors and 14 hospitals across seven Southern California health systems.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

New Anthem Blue Cross plan takes on Kaiser – LA Times

Overall, Vivity will comprise 6,000 doctors and 14 hospitals across the seven health systems.But Anthem wants to work with these medical centers to keep as many patients as possible from ever setting foot inside the hospital.

“Under the current model, hospitals want to keep occupancy rates up,” said Pam Kehaly, Anthem’s west region president and a key architect of this deal. “This is in complete opposition to that. For this joint venture to succeed, we have to keep occupancy rates down.”

Susan Ridgely, a senior policy analyst at the Santa Monica think tank Rand Corp., said these hospitals are probably betting that they can attract enough new patients and referrals through Vivity to offset the gradual decline in inpatient admissions.via New Anthem Blue Cross plan takes on Kaiser – LA Times.

Anthem Blue Cross is adopting an accountable care organization (ACO)-like strategy in Southern California where it and hospitals jointly benefit from reducing costly patient admissions. It reverses the current economic model in which health plan issuers and hospitals have conflicting interests to one based on the principle that enhanced access to lower cost care is better for both payers and providers than costlier hospital admissions. An innovative development worth watching.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Double digit premium increases for California grandfathered plans

The “trend” as it’s known in health coverage refers to the underlying cost of providing medical services to policyholders or managed care plan members, an expense that is reflected in premium rates. That trend remains in the positive double digits for two of the Golden State’s biggest health plan issuers, Anthem Blue Cross and Blue Shield of California. Even for grandfathered plans in effect prior to the 2010 enactment of the Patient Protection and Affordable Care Act that may not include the full panoply of benefits and deductible limits required by the ACA. The Los Angeles Times reports Anthem Blue Cross will increase premiums for these plans effective April 1, 2014 by an average of 16 percent and as much as 25 percent for some plans. Blue Shield of California is upping premiums for grandfathered plans by an average of 10 percent, according to The Times.

If the trend is in the positive double digits even for grandfathered plans that are less generous than ACA-compliant plans, it could be even higher among richer ACA-compliant plans that must provide a broader scope of essential health benefits and more limited deductibles. That will put to the test the buy side market power of California’s health benefit exchange marketplace, Covered California, to exert downward pressure on premiums as it prepares this year to negotiate rates with health plan issuers looking to offer plans through the exchange in 2015. Covered California’s negotiating clout in those negotiations will turn on how many individuals it enrolls in 2014 plans during the initial open enrollment period that ends March 31, 2014. Rates negotiated by the exchange will also affect some plans sold outside the exchange marketplace. Health plan issuers participating in the exchange marketplace must market their exchange plans outside the exchange at the same premium rate.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

WellPoint’s Anthem Blue Cross spurns Calif. small-business exchange – latimes.com

Health insurance giant Anthem Blue Cross said it won’t participate in California’s new insurance market for small businesses.

Anthem, a unit of WellPoint Inc., is California’s largest insurer for small employers. This surprising move could hamper the state’s ability to enroll businesses in its new exchange called Covered California that opens Jan. 1 as part of the federal healthcare law.

Instead, Anthem said it will keep selling coverage to small firms outside the exchange in direct competition with the state-run market. Anthem also remains one of 13 health insurers that will offer policies to individuals in Covered California.

via WellPoint’s Anthem Blue Cross spurns Calif. small-business exchange – latimes.com.

This development isn’t a propitious one for the California Small Business Health Options Program (SHOP) exchange marketplace. Not having a payer with such a significant market share could make it harder for the SHOP to attract small employers. Unlike the individual exchange marketplace, the SHOP relies almost completely on market aggregation forces to improve affordability, competition and choice in this market segment. Covered California is expected to announce participating SHOP plans for 2014 early next month.

In 2011, the California HealthCare Foundation estimated Anthem Blue Cross had 22 percent of the Golden State’s small group market, covering 548,000 enrollees.

 

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Insurance Commissioner Worried About United’s Departure From Individual Market – California Healthline

United has a limited presence in the state’s individual market, according to Jones, with about 8,000 people currently insured in its subsidiary PacifiCare. And, he said, Aetna also casts a relatively small shadow in the individual market, with approximately 50,000 people insured in the state.

Dave Jones mentioned a little-known detail about a tax break for other insurers that might have placed United and Aetna at a competitive disadvantage.

According to Jones, a $100 million tax break enjoyed by two other insurers, Anthem and Blue Shield, gives them a competitive break and led to the withdrawal from the individual market by United and Aetna.

via Insurance Commissioner Worried About United’s Departure From Individual Market – California Healthline.

Jones is California’s elected insurance commissioner. While not specifically detailed in the story, the “tax break” refers to a difference between what a health plan issuer pays to sell an indemnity health insurance plan regulated by the California Department of Insurance (CDI) and a managed health care service plan regulated by the state’s Department of Managed Health Care (DMHC).  California’s Constitution subjects insurance policies to a 2.35 percent premium tax, while managed care plans are assessed a $2,000 base fee plus $0.0048 per enrollee under California Health & Safety Code Section 1356(c).

One year ago, CDI revealed Blue Shield of California would have only three individual insurance plans open for enrollment after it closed nearly two dozen existing plans effective July 2012.  At the time, CDI noted Blue Shield had filed applications with DMHC to nearly double its roster of managed care plans to 20.

Given the shift toward managed care plans dominated by California’s market share leaders Kaiser Permanente, Blue Shield and Anthem Blue Cross along with the move by the state’s exchange marketplace, Covered California, to require HMO-like standardized benefit designs for plans it sells, Aetna and United likely concluded they could not economically pick up a sufficient number of new policyholders via the exchange marketplace to justify remaining in the Golden State.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Covered California announces participating health plan issuers, premium rates

California’s health benefit exchange marketplace, Covered California, today unveiled the health plan issuers that will participate in the marketplace for plan year 2014:

  • Alameda Alliance for Health
  • L.A. Care Health Plan
  • Anthem Blue Cross of California
  • Molina Healthcare
  • Blue Shield of California
  • Sharp HealthCare
  • Chinese Community Health Plan
  • Valley Health Plan
  • Contra Costa Health Services
  • Ventura County Health Care Plan
  • Health Net
  • Western Health Advantage
  • Kaiser Permanente

For the Covered California news release, click here.

The 13 plan issuers — less than the 32 plans that had initially expressed interest in participating — represent a broad mix of statewide for profit and nonprofit entities as well as plans serving distinct metro areas of the state or solely public sector employees in a given region such as Valley Health Plan operating in Santa Clara County.  Three — Kaiser Permanente, Anthem Blue Cross of California and Blue Shield of California — together account for 87 percent of the 1.6 million Golden State residents covered by individual plans in 2011, according to the California HealthCare Foundation. None of the plan issuers are Consumer Operated and Oriented Plan (CO-OP) plans under Section 1332 of the Patient Protection and Affordable Care Act.  The plans will contract with Covered California only through December 31, 2014 and not for a three-year term as originally planned.

Rates for selected plans:

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

California’s largest individual health plan issuers file double digit 2013 rate hikes

The Los Angeles Times reports Blue Shield of California is proposing to up individual plan premiums by an average of 12 percent in 2013, the penultimate year heading up to the launch of the California Health Benefit Exchange (Covered California) in 2014.  Blue Shield’s rate hike is somewhat lower than California’s individual market share leader, Anthem Blue Cross, which last month informed regulators it would boost 2013 rates between 15 and 18 percent for its plans.

Both payers cite rising medical treatment costs for the rate increases.  According to the Times story, Blue Shield is also boosting its reserves to cover claims costs from an expected influx of new customers in 2014, when payers must accept all applicants without medical underwriting and the state’s health benefit exchange will offer income tax credit subsidies to defray premium costs. “It’s a once-in-a-lifetime change in the healthcare market that will bring a lot of volatility, and we need higher reserves for that,” Blue Shield spokeswoman Lindy Wagner told the Times.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Health insurance rates could shoot up – SFGate

Trummel, grappling with his second increase of the year, isn’t holding his breath. But he’s hoping that the new state-run marketplace where people will be able to buy health insurance under the federal health law in 2014 will yield an option that offers him some relief until he qualifies for Medicare.

“If I could get into that (the marketplace), I might have only one more year of this agony with Anthem Blue Cross,” Trummel said. “I’m just holding on until either the health law or Medicare will kick in.”

via Health insurance rates could shoot up – SFGate.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Anthem Blue Cross seeks to raise individual policyholders’ rates – latimes.com

In its rate request, Anthem said its medical costs for this segment of the business are increasing nearly 11% and what it actually pays is rising 13.5% after adjusting for its portion after customer deductibles.

With those cost pressures, Anthem said that the profit margin on its individual insurance business in California is less than 1% this year and that it expects to lose money next year even with these proposed rate increases.

In addition to the 18% rate increase for about 630,000 customers, Anthem is seeking a separate rate hike of 15%, on average, for an additional 100,000 policyholders whose plans are regulated by the California Department of Managed Health Care. An agency spokeswoman said it is reviewing Anthem’s proposed rate increase and those of other companies.

via Anthem Blue Cross seeks to raise individual policyholders’ rates – latimes.com.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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