2-50: More HCR Updates to PPO Products

Jan 20, 2011

Additional HCR Updates to Small Group PPO Products
Anthem Blue Cross recentily issued retroactive changes to a few of their Small Group plans. Clarification on the updates is provided below.

Effective November 1, 2010

As a result of Anthem's filing with the California Department of Insurance (CDI), additional benefit changes are required to a select number of their Small Group PPO Products.

The combination of a per day maximum and a limit on days or visits per year results in an annual benefit maximum that is prohibited by Health Care Reform. As a result, the following changes are being made to comply effective November 1, 2010.

The mental health benefit (excluding severe mental illness) is being changed to remove the per day maximum for facility and per visit maximum for professional services effective November 1, 2010.
- Facility services removes $175/day maximum and replaces with the plan coinsurance based on covered expense after annual deductible. The benefit will continue to be limited to 30 days per calendar year (in and out of network combined).
- Professional services removes $25/visit maximum and replaces with the plan coinsurance based on covered expense after annual deductible. The benefit will continue to be limited to one visit per day and 20 visits per calendar year (in an out of network combined).
- IMPACTED PLANS (grandfathered and non-grandfathered): PPO $20 Copay, GenRx, Solution, Lumenos, Elements Hospital, and Hospital BeneFits Plans.
- IMPACTED PORTFOLIOS: Small Group EmployeeElect, BeneFits and EmployeeChoice.

Effective February 1, 2011

As a result of the limit combination stated above, the following changes are being made to comply effective February 1, 2011.

DMHC plans will be updated with the mental health (excluding severe mental illness) benefit change to remove the per day maximum forfacility and per visit maximum for professional services effectiveFebruary 1, 2011.
- Facility services removes $175/day maximum and replaces with the plan coinsurance based on covered expense after annual deductible. The benefit will continue to be limited to 30 days per calendar year (in and out of network combined).
- Professional services removes $25/visit maximum and replaces with the plan coinsurance based on covered expense after annual deductible. The benefit will continue to be limited to one visit per day and 20 visits per calendar year (in and out of network combined).
- IMPACTED PLANS (grandfathered and non-grandfathered): Premier PPO Plans, PPO $30 and $40 Copay Plans, and High Deductible EPO Plan.
- IMPACTED PORTFOLIOS: Small Group EmployeeElect, EmployeeChoice and Indian Tribes.

The skilled nursing facility and home health benefits are being changed to remove the per day/visit maximum for in-network services effective February 1, 2011.
- Skilled nursing facility benefit removes in-network $540/day maximum. Benefit will be plan coinsurance based on negotiated fee rate after annual deductible. The benefit will continue to be limited to 100 days per calendar year (in and out of network combined).
- Home health benefit removes in-network $137.50/visit maximum. Benefit will be plan coinsurance based on negotiated fee rate after annual deductible. The benefit will continue to be limited to 100 four-hour visits per calendar year (in and out of network combined).
- IMPACTED PLANS (grandfathered and non-grandfathered): Elements Hospital, and Hospital BeneFits Plans
- IMPACTED PORTFOLIOS: Small Group EmployeeElect, Small Group MHP EmployeeElect, EmployeeElect 51-99, and BeneFits.

Clarification - There has been confusion on when the updated Mental Health benefits will go into effect. In addition to the mental health change, there is also an update to Skilled Nursing Facility/Home Health benefits (SNF/HH) for Elements and BeneFits on 2/1/11.

Mental Health benefits effective: 11/1/10 for CDI plans; 2/1/11 for DMHC plans

Skilled Nursing Facility/Home Health benefits effective: 2/1/11 for Elements and BeneFits plans only (CDI plans)

November Change Example: If the group has a plan that is in the 11/1/10 folder (CDI plan), and they are a 10/1 group, they will not get that benefit update until 10/1/2011 (their next anniversary after 11/1/10). 11/1 groups and after will get that 11/1/10 plan benefit change on their anniversary. Any incorrectly processed claims will be adjusted.

February Change Example: If the group has a plan that is in the 2/1/11 folder (DMHC plan), and they are a 1/1 group, they will not get that benefit update until 1/1/2012 (their next anniversary after 2/1/11).

Contact any member of your b&p Sales Team at 888.722.3373 for assistance with Small Group plan summaries and EOCs.