California Broker’s Annual HMO Survey–Part I
Welcome to the 17th annual agents’ guide to managed care. Each year California Broker surveys health maintenance organizations (HMOs) in the state with direct questions about their plans. We then present the answers to such questions here for you—the professional agent or broker. We hope that this valuable information will help you serve your savvy healthcare clients better.
Note: Anthem Blue Cross is not participating in the HMO survey this year.
1. Do you guarantee a time limit on getting referral/treatment routine, urgent, emergency? If not, how many days does it take?
Aetna: Our internal policy is five days for routine, two days for urgent pre-certification, and no referral is required for urgent or emergency care.
Blue Shield of California: Our appointment wait time standards are as follows:
• Preventive care (annual physical, annual GYN exam): within 30 calendar days
• Non-acute and routine care with personal physician: within 7 calendar days
• Non-acute or routine care with a specialist: within 14 calendar days
• Urgent care appointment: within 24 hours
• Emergency care (acute, life-threatening): immediately.
Cigna: While we don’t guarantee a time limit on getting appointments or referrals, we do have appointment accessibility standards and we monitor performance against these standards annually. Performance is monitored by analyzing several questions on the annual CAHPS (customer satisfaction) survey and reviewing customer concerns regarding appointment access.
Kaiser Permanente: Emergency care is provided 24 hours a day, seven days a week from any Kaiser Permanente Medical Center or Plan Contracted Hospital. Standards for appointment availability were developed by the California Department of Managed Health Care (DMHC); and we’re committed to offering members a timely appointment when they need care. Our telephone advice nurses are available 24 hours a day.Health Net of CA: For urgent pre-service requests, a decision must be made in a timely fashion appropriate for the member’s condition, not to exceed 72 hours after receipt of the request. The practitioner needs to be notified within 24 hours of the decision, not to exceed 72 hours of receipt of the request (for approvals and denials). For non-urgent, elective or routine pre-service referrals, the decision is made within five days. The member is to be notified within 72 hours of the request (for approval decisions). For standing referrals, a decision must be made in a timely fashion appropriate for the member’s condition, not to exceed three business days from receipt of the request.
UnitedHealthcare: Optimally, the specialist referral process should take less than 30 days from referral to appointment. We monitor this standard annually using the Consumer Assessment of Health Plans Survey (CAHPS) member satisfaction survey. We adjust our goals by market depending upon past performance and national percentile benchmarks. Our standards are as follows: Routine Appointment less than 30 days, specialist appointment less than 30 calendar days, and urgent care less than 24 hours. We also have the Express Referrals program that streamlines the referral process. A primary care physician (PCP) in a participating Express Referrals provider group may refer a member to a specialist in one of many specialties in their group without prior authorization from the group’s utilization review committee. Members pay their normal office visit co-payment for a referral to a specialist.
2. Do you have any conditions/diagnoses/symptoms that are referred automatically?
Aetna: Yes.
Blue Shield of California: No; however, Blue Shield requires that our contracted IPAs and medical groups employ a standard referral processing guideline of 24 hours from the time the necessary information is received.
Our Access+ HMO plan has been designed to ensure members have a great deal of flexibility in accessing care inside the HMO network. Each Access+ HMO member chooses a primary care physician from an extensive network of general and family practitioners, internists, pediatricians, and OB/GYNs. We also ask our HMO physicians to refer members to specialists within their IPA or medical group; since we fully capitate all professional services, in-network referrals help control cost and utilization.
Cigna: Yes.
Health Net of CA: Health Net delegates medical management activities to participating physician groups (PPGs). Each PPG has its pre-certification requirements and systems, which may include direct access to specialty care. For members who are not delegated to a PPG for management, such as Health Net’s Direct Network HMO membership or other fee-for-service membership, authorization for specialty consultations is not required. Members with a chronic condition or disease that requires continuing specialized medical care are eligible for a standing referral to a specialist. A standing referral allows extended access to a specialist for members who have life-threatening, degenerative or disabling conditions.
Kaiser Permanente: Members identified with specific chronic or high-risk conditions diagnoses, or symptoms are automatically referred for enrollment in whichever care management programs are appropriate. Participation in these programs is completely voluntary and if a member chooses not to participate, they may easily opt-out, though less than 1 percent chose to do so. Members also have direct access to all primary care services and can easily self-refer to specialty care in the Obstetrics/Gynecology, Optometry, Psychiatry, and Chemical Dependency/Addiction Medicine Departments. At some facilities, members may also self-refer for mammograms and Ophthalmology and Dermatology Department services.
UnitedHealthcare: Yes.
3. Can a pregnant member go directly to a gynecologist without waiting for approval?
Aetna: Yes.
Blue Shield of California: Yes, female members may self-refer to an OB/GYN in their personal physician’s Medical Group or IPA for an annual routine well-woman examination. Alternatively, if an IPA or medical group contracts with an OB/GYN as a network primary care physician, female members may select the OB/GYN as a primary care physician, as well.
Cigna: Yes
Kaiser Permanente: Yes, members have direct access to all primary care services and may self-refer for many types of specialty care including Obstetrics/Gynecology.
Health Net of CA: Yes.
UnitedHealthcare: Yes.
4. Do you have self-referral to a gynecologist for an annual well-woman exam?
Aetna: Yes.
Blue Shield of California: Yes.
Cigna: Yes.
Health Net of CA: Yes.
Kaiser Permanente: Yes, Routine Ob/Gyn care often includes basic health maintenance counseling and screening such as recommendations and reminders for immunizations, managing cholesterol, smoking cessation, and mammograms.
UnitedHealthcare: Yes.
5. Can a member with severe back pain get an appointment with an orthopedist immediately?
Aetna: The PCP determines this.
Blue Shield of California: Yes, Blue Shield developed Access+ Specialist for those times when HMO members want direct access to a specialist or physician other than their personal physician. For a slightly higher fixed co-payment, members can go directly to a specialist or primary care physician in the same medical group or IPA as their personal physician without a referral. To use the Access+ Specialist option, members simply call the physician they wish to see to schedule an appointment. Members can also choose to go through their personal physician to request a specialty referral and pay their usual office visit co-payment.
Cigna: Yes, customers should consult their primary care physician who can contact an orthopedist or other specialist (neurosurgeon, neurologist) to arrange for an immediate appointment. At the direction of the physician, a customer can also be enrolled in Cigna’s chronic condition management program for lower back pain. A registered nurse helps coordinate timely care.
Health Net of CA: Yes, as an emergency.
Kaiser Permanente: Most back pain can be managed best by the PCP in while ensuring the treatment does not impact a person’s other medical conditions. When back pain does not follow the expected course, or is unusual in presentation, our orthopedists are available for consultation.
UnitedHealthcare: Yes, with a PCP referral.
6. How long does it take to get an MRI or equivalent test when a lump is found in a member’s breast or uterus?
Aetna: The PCP determines this.
Blue Shield of California: Authorization turnaround time for an urgent request is 72 hours. In special cases, Blue Shield attempts to process the request immediately
Cigna: The customer’s physician determines the exact time frame. But, an appointment can be made immediately if medically necessa
Health Net of CA: Health Net delegates utilization management activities to medical groups. Therefore, if the member belongs to a delegated participating physician group (PPG), the PPG has its own pre-certification requirements, and an MRI may or may not require pre-certification. If the member does not belong to a delegated PPG and Health Net is responsible for conducting utilization management, MRIs require pre-certification. Health Net processes urgent pre-certification requests within 72 hours of receipt of all information. Requests for elective MRIs are processed within five business days.
Kaiser Permanente: Except for very rare exceptions, the discovery of a lump in a woman’s breast would not prompt the use of magnetic resonance imaging (an MRI) as a diagnostic tool but the patient would immediately receive a mammogram to better understand the nature of the lump. Similarly, the discovery of an unusual uterine growth would be investigated with more direct methods.
UnitedHealthcare: Immediately.
7. Can the member get a second opinion outside of the IPA or the medical group?
Aetna: When medically appropriate
Blue Shield of California: Yes, per benefit mandate H&S §1374.55, Blue Shield will provide or authorize a second opinion by an appropriately qualified health care professional when requested by an enrollee or participating health professional (PCP or specialist) who is treating the enrollee.
Cigna: Yes.
Health Net of CA: Yes, a member, his or her authorized representative or a provider may request a second opinion for medical, surgical or behavioral health conditions. If the member has an HMO or POS plan and requests a second opinion about care from a Primary Care Physician (PCP), the second opinion should be authorized by the delegated participating physician group (PPG) and provided by another qualified health care professional within the PPG. If the member requests a second opinion about care from a specialist, the member may request a second opinion from any provider of the same or equivalent specialty from within the PPG or IPA. Such specialist referrals within the PPG must be authorized by the PPG. However, if the request is for a specialist outside of the PPG, the referral must be authorized by Health Net.
Kaiser Permanente: Yes, our doctors can refer members to non-plan providers for second opinions when medical expertise relevant to their condition is not available through Kaiser Permanente providers. Any non-emergent out of plan care must be authorized by Kaiser Permanente in order to be covered by the member’s health plan benefits.
UnitedHealthcare: Members can get a second opinion in accordance with the specifications of the evidence of coverage (EOC) and disclosure form, as summarized below. A second medical opinion is a reevaluation of your condition or health care treatment by an appropriately qualified provider. This provider must be either a primary care physician or a specialist acting within his or her scope of practice, and must possess the clinical background necessary for examining the illness or condition associated with the request for a second medical opinion. Upon completing the examination, the provider’s opinion is included in a consultation report. Either the patient or the treating participating provider may submit a request for a second medical opinion. For additional information, please refer to “evidence of coverage” brochure.
8. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?
Aetna: For our delegated groups, the PCP makes decisions with their PMG/IPA. The health plan makes this determination for non-delegated groups.
Blue Shield of California: These types of decisions are made by our contracted IPA/medical groups, and involve Blue Shield if there is a question about appropriateness, or if a member is dissatisfied.
Cigna: Primary and specialty care physicians make decisions about referrals, testing, and treatment. At times, they can coordinate care with their medical groups or IPAs. Hospitalization can require authorization from Cigna.
Health Net of CA: A Health Net member’s participating physician group (PPG) authorizes all treatment, including specialty referrals for testing, treatment, surgery or hospitalization. A member with a chronic condition or disease requiring continuing specialized medical care is eligible for a standing referral to a specialist. A standing referral allows extended access to a specialist for members with life-threatening, degenerative or disabling conditions. The member’s PCP will refer the member to practitioners who have demonstrated expertise in treating a condition or disease involving a complicated treatment regimen requiring ongoing monitoring.
Kaiser Permanente: Typically, the member’s primary care physician (PCP) makes the decisions about specialist referrals, testing, treatment, surgery, and hospitalization and do not need authorization to put these decisions into action.
UnitedHealthcare: Our contracted PCPs act as the single point of contact, resource, and consultation for all health services provided to members, including specialty referrals. We believe this approach promotes familiarity with the member’s medical history and permits a single physician to monitor the member through complete episodes of care. These physicians look at the whole medical picture, as opposed to looking at symptoms from a specialist’s point of view. This method reinforces a strong doctor-patient relationship, provides early detection of medical problems, and ensures that medical referrals are appropriate and necessary.
9. What criteria are used to authorize or deny specialist referrals, treatments, or tests?
Aetna: There are a variety of reference tools, including Milliman and many that the plan has developed and copyrighted. A medical director must make all denials for medical necessity. In addition, the plan has adopted an external review process for all fully insured members.
Blue Shield of California: We use nationally recognized, evidence-based industry sources to identify services subject to precertification or prior authorization, including:
• Milliman Guidelines
• Thompson Length of Stay Criteria
• St. Anthony’s Guidelines to Medicare Coverage
• Guide to Preventive Services: Report of U.S. Preventive Services Task Force
• Medicare Guidelines
• BlueCross BlueShield Association Technology Evaluation Center
• California Technology Assessment Forum
• Third party review agencies
• Blue Shield Medical Policy and Medication Policy
• Internally developed guidelines
Our Utilization Management Committee (UMC) is responsible for developing and maintaining the policies and procedures that define utilization management authority, including prior authorization. Comprised of Blue Shield senior management executives (including physician representation) and functioning as the steering committee for quality activities, the UMC is responsible for reviewing on an annual basis our prior authorization policy and, if necessary, updating our list of services requiring authorization.
For HMO plans, Blue Shield may delegate prior authorization responsibilities to a medical group contracted to Blue Shield for HMO business. Under this arrangement, the group is responsible for processing and monitoring prior authorization requests for providers, except for experimental or investigational procedures, for which Blue Shield provides the authorization. Blue Shield monitors delegated medical groups to ensure that all utilization management activities are timely, effective, and consistent with Blue Shield’s internal program.
When prior authorization is delegated, the personal physician submits a service request to the delegated IPA/medical group. The delegated IPA/medical groups will issue a determination and contact the requesting provider by telephone/fax within 24 hours of the decision to inform the physician of the status of the authorization request.
For non-delegated HMO medical groups, Blue Shield is responsible for processing and monitoring prior authorization requests, and evaluating referrals for specified services, procedures, or drugs that require authorization. Prior authorization determinations are made by licensed review nurses or pharmacists, and decisions are based on medical necessity and appropriateness, reflecting the application of Blue Shield’s approved review criteria and guidelines.
Cigna: Cigna uses Milliman care guidelines. In addition, Cigna continually assesses developing technologies using evidence-based medicine and independent expert opinion to develop coverage positions, which are posted on our website. All medical decisions are based on clinical guidelines. A physician who is knowledgeable in the specialty area makes the decisions.
Health Net of CA: Health Net utilizes established written guidelines, such as InterQual Clinical criteria, along with the Health Net Medical Policy Manual, clinical practice guidelines, and the Schedule of Benefits.
Kaiser Permanente: Our doctors are not required to seek authorization for the vast majority of medical services so long as the medical specialty, treatment, or test is available within our plan.
UnitedHealthcare: We require our provider groups to demonstrate the use of appropriate medical management guidelines. We conduct annual reviews of written procedures and consider the following factors for cases that may not meet criteria: age, co-morbidities and complications, response to treatment, the psychosocial situation, and home environment. We use written criteria based on sound clinical evidence and specific procedures for applying the criteria to make utilization decisions. In addition, we apply objective and evidence based criteria and consider individual circumstances and the local delivery system. We require our delegated providers to do the same.
10. Are you monitoring the length of time for referral authorizations? What are you doing to reduce or eliminate delays?
Aetna: Yes, timeliness of decisions is part of a monthly case assessment audit. Turn-around time is monitored by annual audits and quarterly report submissions. Audits and training are used to address performance gaps.
Blue Shield of California: Blue Shield’s contracted IPA/medical groups are responsible for the timeliness of decisions about referral authorization. They must comply with our standard of two working days to get all necessary information for a non-urgent referral, one calendar day for urgent referral/treatment, and immediately for emergency care. Blue Shield-delegated oversight consultant nurses perform annual audits to ensure that standards for timeliness are met. An IPA/medical group that does not meet timeliness standards for utilization management must take corrective action.
Cigna: Cigna works closely with physicians and medical groups to expedite referrals and measures customer satisfaction with the referral process on a regular basis.
Health Net of CA: Yes, it is done through access audit reports, member satisfaction surveys, HEDIS indicators, physician profiles, medical group comparison reports and member complaints. Delays are remedied through corrective action.
Kaiser Permanente: Our doctors are not required to seek authorization for the vast majority of member’s medical services. Practically every aspect of a member’s encounter with their health care team will later go through our internal utilization review process. If there are any factors found to be slowing the processing of referrals steps are taken to remove or change those factors.
11. What are the criteria and processes for getting a referral to a specialist outside of the MG/IPA or plan?
Aetna: Out-of-plan approval is done if one or more of these criteria are met: required services are not available in the group or network; required non-emergency service is available in the plan option, but is not accessible in reasonable timeframe; or the patient is a new member and was receiving services from an out-of-plan provider (reviewed on case-by-case basis).
Blue Shield of California: Personal physicians can refer patients out of the network with the agreement of the IPA/medical group or authorization from Blue Shield. Blue Shield is involved in referrals only when an IPA/medical group wants to refer out-of-network and not be financially responsible. The IPA/medical group would then contact Blue Shield for authorization and request that Blue Shield be financially liable.
Cigna: A primary care physician can request a referral for service outside the medical group or plan when the service is not available. Customers can also contact Cigna directly to arrange a second opinion.
Health Net of CA: Health Net’s contracted participating physician groups (PPGs) are delegated to provide member care, including all specialty referrals. If the PPG does not have a particular kind of specialist with which it contracts, the PPG is still responsible to find a specialist out of its network for the member. The PPG has the financial responsibility for paying the specialist. The PPG may deny the request if it has a particular kind of specialist within its network and a member requests to see a specialist that is outside the PPG’s network. The member has the option to appeal the denial with Health Net.
Kaiser Permanente: If a member needs specialty care not available within our plan the chief of the appropriate specialty service is required to approve the referral. With a large group of our specialists practicing in more than 75 specialties and subspecialties, Kaiser Permanente is able to minimize outside referrals significantly.
UnitedHealthcare: Our contracted provider network is comprehensive and provides a qualified specialist for every covered benefit. When a service is not available within a member’s provider group, the member receives a referral to a qualified provider or specialist outside the member’s provider group, but contracted with UnitedHealthcare. Either the provider group or we will assess the medical necessity for these requests and authorize care as necessary.
Referrals to non-contracted providers rarely happen, generally only in emergencies or for specialized services not available through a contracted provider; therefore, we do not track this statistic
12. Which complementary medical disciplines are covered or will be covered?
Aetna: Chiro rider. Acupuncture is covered when administered.
Blue Shield of California: Screening for prostate cancer is covered beginning at age 40, if at increased risk. Increased risk factors for prostate cancer include African-American men and men with a family history of prostate cancer.
Cigna: When medically necessary, some customers can access acupuncture and chiropractic services as a component of short-term rehabilitation. Other benefit plans offer homeopathic and naturopathic services as riders. In addition, Cigna’s Healthy Rewards(r) program offers customers discounts on alternative/complementary medicine services and other health-related programs for acupuncture, chiropractic services, fitness club membership, hearing care/instruments, laser vision correction, massage therapy, vitamins, herbal supplements, non-prescription medications, and smoking cessation programs, among other programs. More information on the Cigna Healthy Rewards program is available to customers through their personalized online portal on mycigna.com.
Health Net of CA: Health Net offers chiropractic and acupuncture benefits as supplemental benefit riders to its traditional medical benefit plans. The riders may be purchased with the HMO and POS medical plans. They are designed to complement the benefits plans, rather than replace them. The rider is only available to groups. A variety of benefit plan designs is available, including chiropractic only, acupuncture only, and a combination of chiropractic and acupuncture.
Kaiser Permanente: American Specialty Health Plans of California, Inc. (ASH) helps members with selecting services from a range of wellness disciplines that include acupuncture, chiropractic care, exercise centers, fitness clubs, massage therapy, and naturopathy, available as optional benefits.
UnitedHealthcare: UnitedHealthcare of California does not offer alternative medicine benefits as part of its design. However, all members have access to discounts on alternative medicine benefits through an affinity program. Employer groups can purchase supplemental plans that cover acupuncture and chiropractic benefits.
13. Do you cover blood tests for prostate cancer for non-symptomatic men? If so, at what age?
Aetna: Yes, age 40+.
Blue Shield of California: Screening for prostate cancer is covered beginning at age 40, if at increased risk. Increased risk factors for prostate cancer include African-American men and men with a family history of prostate cancer.
Cigna: Yes, for men over 50 annually or more frequently when medically indicated.
Health Net of CA: Yes, beginning at age 40 as determined by the PCP.
Kaiser Permanente: Yes, prostate cancer screenings are part of our basic coverage regardless of a man’s age, personal medical history, or the medical history of his family. Early detection of prostate cancer can lead to better outcomes. Members do not need a referral to make an appointment for a prostate cancer screening.
UnitedHealthcare: Yes, these blood tests are covered benefits. The member’s primary care physician determines the necessity of this and all other blood tests.
14. Do you cover mammograms for women with no history of breast cancer?
Aetna: Yes, age 40+.
Blue Shield of California: Yes, upon referral by a nurse practitioner, certified nurse midwife, or physician, providing care to the patient and operating within the scope of practice provided under existing law for breast cancer screening or diagnostic purposes.
Cigna: Yes, for women over 40 annually or more frequently as directed by their physician.
Health Net of CA: Yes, typically, every one to two years from ages 40 to 65+, but the PCP may authorize mammograms at his or her discretion.
Kaiser Permanente: Yes, mammograms are part of our basic coverage regardless of a woman’s personal or family history of breast cancer. Members do not need a referral to make an appointment for a mammogram
UnitedHealthcare: Yes, mammograms for women with no history of breast cancer are covered in accordance with U.S. Preventive Services Task Force Guidelines
15. Do you have an open drug formulary?
Aetna: Yes.
Blue Shield of California: The Blue Shield Drug Formulary is a list of preferred generic and brand name drugs that have been reviewed for safety, efficacy, and bio-equivalency, and are approved by the Federal Food and Drug Administration (FDA). This formulary is developed and maintained by the Blue Shield Pharmacy and Therapeutics (P&T) Committee, which meets on a quarterly basis. The P&T Committee consists of independently licensed physicians and pharmacists in community practice and who are not employed by Blue Shield. A drug prior authorization program is available for selected drugs on the formulary as well as for non-formulary drugs to promote appropriate first-line therapy or to reserve use of certain medications with specialized uses or significant potential for misuse or overuse.
Blue Shield offers the following types of outpatient prescription drug benefit
• A closed formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs and most specialty drugs are covered only when prior authorization is approved.
• An incentive formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs are also covered for a higher co-payment. Prior authorization may be required to cover some specialty and certain non-formulary drugs. If coverage for a non-formulary drug requiring prior authorization is approved, the member is responsible for the non-formulary co-payment.
Cigna: We typically use a closed drug formulary. However, employers can choose a three-tier or two-tier pharmacy plan if specified and agreed to in the contract.
Health Net of CA: Health Net offers a 3-tier Recommended Drug List, an open formulary that includes most generics on Tier 1, recommended brands on Tier 2 and some generics and brands on Tier 3.
Kaiser Permanente: No, our formulary is maintained and regularly updated by our doctors and pharmacists working in tandem with our Drug Information Services Team. The team independently analyzes data and reports on new drugs while doctors and pharmacists research the effectiveness and safety of each. Whenever therapeutically appropriate, we include the generic medicines in our formulary.
UnitedHealthcare: No, we use several managed formularies at different tier levels, but we do not offer an open formulary.
16. If a closed formulary, what happens if a non-formulary drug is necessary?
Aetna: Not applicable.
Blue Shield of California: For selected formulary, non-formulary and specialty drugs to promote patient safety, appropriate first-line therapy, we have drug prior authorizations for medical necessity in place to promote patient safety, appropriate first-line therapy, to manage use of specialized, high cost or highly addictive or habit forming medications, and to help keep the cost of healthcare affordable.
The P&T Committee is responsible for establishing and overseeing drug prior authorization policies and procedures. Coverage criteria are developed under evidence-based medicine principles and current medical literature. Requests for prior authorization are considered for the following reasons:
• The requested drug, dose, and/or quantity are safe and medically necessary for the specified indication
• Formulary alternative(s) have failed or are inappropriate
• Treatment is stable and a change to an alternative may cause immediate harm
• Step therapy requirements have been met
• Relevant clinical information supports the use of the requested medication over formulary alternatives
Physicians may contact Blue Shield pharmacy services directly through a toll-free phone or fax number to request prior authorization. Some drugs may be limited to a maximum quantity and require prior authorization if a given drug’s limit is exceeded. The P&T Committee may also determine that a certain quantity of a given medication may need prior authorization to review for medical appropriateness.
All prior authorization requests are reviewed by pharmacists and pharmacy technicians to determine if the criteria approved by the P&T Committee for the requested drug meets the criteria for an exception. A coverage determination can be made via telephone within minutes if all required information is provided. Urgent prior authorization requests sent via fax are reviewed within three business days, while non-urgent requests are reviewed in no more than five business days. The member’s clinical information must be received by Blue Shield in order to start the review process. If the physician does not submit the required information, Blue Shield will send a follow-up request to the doctor. Delays sometimes occur if the physician does not provide the required information in a timely manner. If a non-formulary drug requiring prior authorization is approved under the closed formulary plan, the member is responsible for the applicable brand co-payment. If a non-formulary drug requiring prior authorization is approved under the incentive formulary plan, the member is responsible for the applicable non-formulary co-payment.
If a request from a physician for a drug that requires prior authorization for medical necessity is denied, a denial letter is mailed to the member. Included with the denial letter is the reason for denial, alternative covered therapy, if appropriate, and the Blue Shield Appeals and Grievance procedures. The physician also receives notification of the denial along with a list of preferred formulary alternatives.
Cigna: The customer or their physician can ask for an exception to get a non-formulary drug. Cigna’s clinical staff reviews the request.
Health Net of CA: N/A
Kaiser Permanente: It is at the medical discretion of our doctors to prescribe any FDA-approved non-formulary drug if its use is in the best medical interest of the member. In these cases, the member would pay their usual cost-sharing fee as opposed to the full price they would be charged for a non-formulary medicine.
UnitedHealthcare: Medically necessary non-formulary medications can be approved through our preauthorization exceptions process.
17. Do you have an experimental/investigative exclusion? If so, how does it work?
Aetna: Yes. For the welfare of our members, experimental or investigational procedures are excluded from our health plans. However, the exclusion would not apply with respect to services or supplies (other than drugs) received in connection with a disease, if we determine that: the disease can be expected to cause death within one year, in the absence of effective treatment; and the care or treatment is effective for that disease or shows promise of being effective for that disease as demonstrated by scientific data. In making this determination we would take into account the results of a review by a panel of independent medical professionals. They would be selected by Aetna. This panel would include professionals who treat the type of disease involved. Also, this exclusion would not apply with respect to drugs that have been granted a treatment status of an investigational new drug (IND) or Group c/treatment IND; are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute; or if we have determined that available scientific evidence demonstrates that the drug is effective or the drug shows promise of being effective for the disease.
Blue Shield of California: Yes. Blue Shield does not cover experimental procedures, defined as those which are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of the illness, injury, or condition at issue.
Based on the BlueCross BlueShield Association assessment criteria for health outcomes, our drug formulary does not cover drugs that are considered experimental or investigational or that are not recognized in accordance with generally accepted medical standards.
Cigna: Cigna medical directors make decisions about an experimental/investigational request based on medical literature, expert opinion, and the facts of the specific situation. Coverage positions are developed regularly, which assess emerging technologies. They are posted on our website. Physicians can access Cigna’s online health care professional portal to request reviews of technologies for which coverage positions have not yet been developed. Cigna also uses a formal independent expert review process when appropriate.
Health Net of CA: Health Net does not cover experimental or investigational drugs, devices, procedures, or therapies. The member may request an independent medical review of Health Net’s decision from the California Department of Managed Health Care if Health Net denies or delays coverage for a requested treatment on the basis that it is experimental or investigational. The member may request the review if the following criteria are met:
• The member has a life-threatening or seriously debilitating condition
• The member’s physician certifies to Health Net that the member has a life-threatening or seriously debilitating condition for which standard therapies have not been effective or are otherwise medically inappropriate.
• There is no more beneficial therapy covered by Health Net.
• The member’s physician certifies that the proposed experimental or investigational therapy is likely to be more beneficial than available standard therapies. As an alternative, the member may submit a request for a therapy that is likely to be more beneficial than available standard therapies based on documentation presented from the medical and scientific evidence.
Kaiser Permanente: Yes, we do. However, in keeping with our commitment to health care research, we take a systematic, evidence-based approach to evaluating and implementing new technologies and new applications of existing technologies. This helps ensure members have timely access to new safe and effective treatments. Our integrated health care delivery system enables the coordination of national and regional processes and provides the operational support and infrastructure needed to quickly and effectively review the broad array of new technologies being developed. At the local level, we’re able to deploy new technologies in pilot programs at our medical centers to obtain real-world data on outcomes and effectiveness.
UnitedHealthcare: Yes, we have an experimental/investigative exclusion. Experimental and/or investigational procedures, items and treatments are not covered unless required by an external, independent review panel as described in Section Eight of the Combined Evidence of Coverage and Disclosure Form. Unless otherwise required by federal or state law, decisions as to whether a particular treatment is experimental or investigational and therefore not a covered benefit are determined by a UnitedHealthcare medical director, or his or her designee. For the purposes of the Combined Evidence of Coverage and Disclosure Form, procedures, studies, tests, drugs or equipment will be considered Experimental and/or Investigational if any of the following criteria/guidelines is met:
• It cannot lawfully be marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use.
• It is a subject of a current investigation of new drug or new device (IND) application on file with the FDA.
• It is the subject of an ongoing clinical trial (Phase I, II or the research arm of Phase III) as defined in regulations and other official publications issued by the FDA and Department of Health and Human Services (DHHS).
• It is being provided pursuant to a written protocol that describes among its objectives the determination of safety, efficacy, toxicity, maximum tolerated dose or effectiveness in comparison to conventional treatments.
• Other facilities studying substantially the same drug, device, medical treatment or procedures refer to it as experimental or as a research project, a study, an invention, a test, a trial or other words of similar effect.
• The predominant opinion among experts as expressed in published; authoritative medical literature is that usage should be confined to research settings.
• It is not Experimental or Investigational itself pursuant to the above criteria, but would not be Medically Necessary except for its use in conjunction with a drug, device or treatment that is Experimental or Investigational (such as, lab tests or imaging ordered to evaluate the effectiveness of an Experimental therapy).
The sources of information to be relied upon by UnitedHealthcare in determining whether a particular treatment is Experimental or Investigational, and therefore not a covered benefit under this plan, include but are not limited to the following:
• The Member’s medical records
• The protocol(s) pursuant to which the drug, device, treatment or procedure is to be delivered.
• Any informed consent document the Member, or his or her representative, has executed or will be asked to execute, in order to receive the drug, device, treatment or procedure.
• The published authoritative medical and scientific literature regarding the drug, device, treatment, or procedure.
• Expert medical opinion
• Opinions of other agencies or review organizations, e.g., ECRI Health Technology Assessment Information Services, HAYES New Technology Summaries or MCMC Medical Ombudsman.
• Regulations and other official actions and publications issued by agencies such as the FDA, DHHS and Agency for Health Care Policy and Research AHCPR.
• A Member with a Life Threatening or Seriously Debilitating condition may be entitled to an expedited external, independent review of UnitedHealthcare’s coverage determination regarding Experimental or Investigational therapies as described in Section Eight: Overseeing Your Health Care, Experimental or Investigational Treatment.
18. Which requested procedures are denied most frequently based on experimental investigative or not medically necessary exclusions?
Aetna: This information is not readily available.
Blue Shield of California: The following are the most frequently denied procedures due to the absence of medical necessity or because they are considered experimental/investigational:
• Bariatric surgery – morbid obesity surgery
• Reduction mammoplasty
• Varicose veins
• MRI of the breast
• PET Scan of the breasts
Cigna: This data is not available.
Health Net of CA: The most frequently denied requested procedures are those that are not FDA approved/accepted in the medical community as standard, safe and effective.
Kaiser Permanente: If a plan physician determines that a procedure or service is medically appropriate for a member and its omission would adversely affect the member’s health, then it is considered medically necessary. As a result, we do not consider a medically necessary service or procedure to be an exclusion. Additionally, we do not deny experimental or investigative procedures if they are considered medically necessary and appropriate for the member’s care. All procedures and treatments are reviewed on a case-by-case basis with the determination for care made by the doctor often in consultation with the chiefs of service for their own area of practice and other related areas of practice.
UnitedHealthcare: This information is not available. We do not track the number of most frequently denied investigational/experimental or not medically necessary procedures. We do track appeals and grievances. If a member appealed a denial, and it was due to one of the above reasons, we may be able to provide that procedure; however, it would not apply to our book of business.
19. What is the standard hospitalization for normal and a Caesarean birth?
Aetna: The physician determines it.
Blue Shield of California: The standards are two days for a normal birth and four days for a Caesarean.
Cigna: Typical hospitalization is at least 48 hours for normal vaginal delivery and at least 96 hours for a Caesarean section. But this can be modified based on the physician’s recommendations.
Health Net of CA: Standard hospitalization for normal birth is two days and four days for Caesarean birth.
UnitedHealthcare: The average length of stay is two days for a normal birth and four days for a Caesarean.
20. How many hospital days are utilized in a year for every thousand HMO members?
Blue Shield of California: Our most recently reported utilization rate for inpatient days per 1,000 was 157.79.
Cigna: Data not available
Health Net of CA: 2012: 200.9 days per 1,000 HMO members.
UnitedHealthcare: Our total in-patient utilization in 2009 was 160.92 per 1,000 members.
21. What are your loss ratios, administration/medical?
Aetna:
• Overall loss ratio (Health Care Costs and Current & Future Benefits/Total Premiums) o 2011
• Administrative loss ratio (Total operating expense ratio – GAAP measure) 2011″
• Medical loss ratio (MBR) 2011
Blue Shield of California: For IFP plans regulated by the Department of Insurance (DOI), we spent 78.2% on medical and 21.8% on administrative, and we met or exceeded medical loss ratios for our IFP, small group, and large group plans regulated by the Department of Managed Healthcare (DMHC).
Cigna: This information is publicly available through reports we submit to federal and state regulators.”Health Net of CA: In 2012, the medical care ratio was 87.7% and the administrative loss ratio was 10.3%.
UnitedHealthcare: As of December 31, 2010, our commercial medical loss ratio for UnitedHealthcare of California is 85.3%. The administrative ratio is 7%.
18. Which requested procedures are denied most frequently based on experimental investigative or not medically necessary exclusions?
Aetna: This information is not readily available.
Blue Shield of California: The following are the most frequently denied procedures due to the absence of medical necessity or because they are considered experimental/investigational:
• Bariatric surgery – morbid obesity surgery
• Reduction mammoplasty
• Varicose veins
• MRI of the breast
• PET Scan of the breasts
Cigna: This data is not available.
Health Net of CA: The most frequently denied requested procedures are those that are not FDA approved/accepted in the medical community as standard, safe and effective.
Kaiser Permanente: If a plan physician determines that a procedure or service is medically appropriate for a member and its omission would adversely affect the member’s health, then it is considered medically necessary. As a result, we do not consider a medically necessary service or procedure to be an exclusion. Additionally, we do not deny experimental or investigative procedures if they are considered medically necessary and appropriate for the member’s care. All procedures and treatments are reviewed on a case-by-case basis with the determination for care made by the doctor often in consultation with the chiefs of service for their own area of practice and other related areas of practice.
PacifiCare: This information is not available. We do not track the number of most frequently denied investigational/experimental or not medically necessary procedures. We do track appeals and grievances. If a member appealed a denial, and it was due to one of the above reasons, we may be able to provide that procedure; however, it would not apply to our book of business.
19. What is the standard hospitalization for normal and a Caesarean birth?
Aetna: The physician determines it.
Blue Shield of California: The standards are two days for a normal birth and four days for a Caesarean.
Cigna: Typical hospitalization is at least 48 hours for normal vaginal delivery and at least 96 hours for a Caesarean section. But, this can be modified based on the physician’s recommendations
Health Net of CA: Standard hospitalization for normal birth is two days and four days for Caesarean birth
Kaiser Permanente: According to our 2012 HEDIS scores, in Northern California the average length of hospital maternity stay for all types of births is 2.41 days and 2.48 days in Southern California. We no longer separately track hospitalization stays for C-section deliveries.
PacifiCare: The average length of stay is two days for a normal birth and four days for a Caesarean.
20. How many hospital days are utilized in a year for every thousand HMO members?
Blue Shield of California: Our most recently reported utilization rate for inpatient days per 1,000 was 157.79.
Cigna: Data not available
Health Net of CA: 2012: 200.9 days per 1,000 HMO members.
Kaiser Permanente: According to our 2012 HEDIS scores, in Northern California, the ratio is 3.32 hospital days per 1,000 members and 3.37 hospital days for Southern California
PacifiCare: Our total in-patient utilization in 2010 was 160.92 per 1,000 members.
21. What are your loss ratios, administration/medical?
Blue Shield: Our medical loss ratio (MLR) percentages filed for 2012 are as follows:
MLR by Lines DMHC-regulated CDI-regulated of Business Plans Plans
Individual and Family 81.3% 78.0%
Small Group 76.6% 84.2%
Large Group 89.4% 84.8%
Cigna: This information is publicly available through reports we submit to federal and state regulators.
Health Net of CA: In 2012, the medical care ratio was 87.7% and the administrative loss ratio was 10.3%.
Kaiser Permanente: Based on our 2011 DMHC Annual Report, our administrative loss ratio plan-wide was 4.33 percent and our medical loss ratio was 94.63 percent. It should be noted that we no longer use the phrase “Medical Loss Ratio,” using instead “Medical Benefit Ratio” (MBR) whenever possible. Along with many others in health care, we feel that MBR is a more accurate and descriptive means of describing this important ratio.
PacifiCare: As of December 31, 2011, our commercial medical loss ratio for PacifiCare of California is 85.4 percent. The administrative ratio is 7 percent.
22. Is your plan NCQA accredited?
Aetna: Yes, Aetna Health of CA Inc is accredited and has got Quality Plus distinction in Care Management, Physician and Hospital Quality.
Blue Shield of California: Yes.
Cigna: Yes, our HMO plan has received NCQA’s accreditation level of Commendable. In addition, Cigna has earned NCQA’s Physician and Hospital Quality (PHQ) Certification. These standards assess how well a plan provides individuals with information about physicians and hospitals in its network to help them make informed health care decisions. Cigna has also earned an NCQA quality rating for its health and wellness programs, and all four of our behavioral health care centers nationwide have earned full accreditation from NCQA.
Health Net of CA: Yes. Commercial HMO, PPO and POS lines of business have received the “Commendable” accreditation status from the National Committee for Quality Assurance (NCQA), and Health Net’s Medicare HMO received the “Excellent” accreditation status.
Kaiser Permanente: Yes, we are. As of the third quarter of 2013, all of our service areas across the country have NCQA ratings of “Excellent,” their highest possible rating, for our HMO and Medicare lines.
PacifiCare: Yes. PacifiCare of California maintains an excellent accreditation rating.
23. What is your ratio of PCPs vs. specialists?
Blue Shield of California: 1/2.09
Cigna: Data not available
Health Net of CA: 2013: 1 to 3.0 specialists.
Kaiser Permanente: The statewide ratio in California of primary care physicians to specialists is approximately 1 PCP to 1.8 Specialists. Primary Care includes general practice, family medicine, general Internal Medicine, and general Pediatrics. Specialty care includes OB/Gyn.
PacifiCare: As of June 30, 2011, our ratio of PCPs to specialists is 1 to 3.1.
24. What is your ratio of members to PCPs?
Aetna: 21:3
Blue Shield of California: 79.46/1
Cigna: 14/1
Health Net of CA: 2013: 51.0 members to 1 PCP.
Kaiser Permanente: We don’t ordinarily release information on our member-to-doctor ratio. Physician and care provider totals are based on current and projected membership numbers. Providing members with access to physicians is essential to delivering high-quality care and to ensure it, we have developed access standards to help meet our members’ needs. Monitored continuously, these standards are used to help determine the number of physicians and care providers needed as well as the location and size of our medical facilities. As dictated by membership growth and increased volume of patient visits, additional primary care physicians and specialists are added to our professional roster as needed.
PacifiCare: As of June 30, 2011, our ratio of members to PCPs is 131 to 1.
25. Does your contract include binding arbitration?
Aetna: Yes.
Blue Shield of California: No, Blue Shield members are not subject to binding arbitration and there is no arbitration provision in the Evidence of Coverage (EOC) provided to members. However, the majority of our contracts with providers include binding arbitration to resolve disputes.
Cigna: Yes.
Health Net of CA: Yes.
Kaiser Permanente: Yes, we use binding arbitration to resolve disputes. We find arbitration to be more attuned to the discussion of sensitive matters such as medical and more appropriate for the resolution of disputes with persons who, in many cases, continue to be Health Plan members. Other than Small Claims Court cases, claims subject to a Medicare appeal procedure, or ERISA-regulated benefit claims, arbitration is used to resolve disputes such as those for premises or professional liability matters, including claims alleging medical malpractice.
PacifiCare: Yes, our contract includes binding arbitration.
26. How often can members change their PCP at will?
Aetna: There is no limit.
Blue Shield of California: Access+ HMO members can change their personal physician without cause once a month. This change is effective the first day of the month following notice of change.
Cigna: We encourage our customers to stay with one primary care physician to ensure more effective care management. We also recommend that people not change their doctor while in the middle of care to the extent possible. Customers may request a PCP change once per quarter and/or if their residence or work location changes. Additionally, if a customer has a concern about care quality, he or she can change PCPs after notifying us of the concern.
Health Net of CA: Members may change PCPs within a physician group or from one physician group to another once per month.
Kaiser Permanente: Members can change their PCP at any time and as often as they like. Members can change their PCP online at kp.org, by calling the Physician Selection Service or Appointment/Advice line at their local medical facility, or through the Member Services Department at their local medical facility. Studies have shown that a positive, ongoing relationship with their PCP helps to improve health outcomes and member satisfaction, so we encourage members to choose a PCP who’s right for them and provide the support and systems to make it easy for them to do so.
PacifiCare: Members may request a change of individual provider or provider group at any time, for any reason. Requests received between the first and the 15th of a month take effect on the first day of the next month. Requests received between the 16th and the end of the month take effect on the first day of the second month. Members must select participating providers accepting new patients within 30 miles of their home or work and can identify which providers are accepting new patients by calling our Customer Service department, looking in our provider directory or visiting our Web site.
27. Do you offer a performance guaranty, such as employees will be on the computer by a certain date or have ID cards by a certain date, for example?
Aetna: Yes, we can offer standard performance guarantees to our clients; guarantees may also be customized on a case-by-case basis.
Blue Shield of California: Yes, we offer performance guarantees for groups with a qualifying minimum subscribership.
Cigna: Yes, in most instances, we can work with a company to develop appropriate performance guarantees.
Health Net of CA: Yes, Health Net of California negotiates performance guarantees with clients based on our Corporate Performance Standards, which are derived from marketplace expectations balanced with internal administrative capabilities. An employer group must have and maintain after the plan’s effective date a minimum of 1,000 subscribers in a Health Net of California plan to qualify for performance guarantee consideration. Once the client has been deemed eligible for performance guarantee consideration, Health Net is willing to discuss and negotiate the specifics of a performance guarantee package including appropriate target levels for standards of concern. Health Net of California provides customers with specific performance guarantees in the area of claims administration, including processing turnaround time (measured within 30 calendar days) and transactional accuracy (i.e. financial, payment, coding and overall). In addition to claims administration, Health Net of California offers corporate performance standards that span all aspects of our business in the areas of: implementation (i.e., identification card production, timeliness and accuracy), member services, provider network, medical management, member satisfaction, customer reporting, and HEDIS reporting. All products can potentially be covered, with the exception of our Medicare HMO due to strict guidelines already in place by the Centers for Medicare & Medicaid Services (CMS). All performance standards are evaluated on an annual basis for compliance. An annual performance standard report, including the calculation of any applicable penalties, is produced approximately 90 days after the close of the plan year.
Kaiser Permanente: Yes, our performance guarantees are made on a group-by-group basis. Our target is for new members to be in our data base with 24 hours of our receiving their information and to have new or replacement ID cards delivered within 7 to 10 work days 90 percent of the time.
PacifiCare: We may agree to performance guarantees upon approval and if the client meets our standard requirements for enterprise-wide performance standards. However, we typically do not agree to performance guarantees for fully insured groups.
28. When a member moves out of state, is any transition coverage available?
Aetna: We have HMO plans in many states; a member might be eligible for coverage in another Aetna HMO service area. Customers may also offer out-of-area plans which provide PPO coverage if members are outside an HMO service area.
Blue Shield of California: Yes, if a subscriber moves out of state to an area served by another Blue Cross and/or Blue Shield plan, the subscriber’s coverage can be transferred to the plan serving his new address. The new plan must offer the subscriber at least its group conversion policy.
Cigna: Yes, if we offer similar coverage to the account in that state.
Health Net of CA: Yes, through PPO, POS, and indemnity lines of business.
Kaiser Permanente: Yes, transition coverage is available to members moving out of state and staying in-network as well as to those moving out of ne