New Anthem PPO

A PPO, or Preferred Provider Organization, is a group of providers (doctors, hospitals, labs and other healthcare facilities) that have contracted with Anthem to charge discounted fees for their services.

“In-network” providers are doctors, hospitals, labs and other healthcare facilities that have contracted with Anthem to charge discounted fees for their services. “Out-of-network” providers have no agreement with Anthem and may charge any amount they want, which may be significantly higher. Services received from an in-network provider will always cost you less. See the example below.

The following example shows the cost of in-network vs. out-of-network hospital care for an outpatient procedure and assumes the annual deductible has been met.

 

In-Network Hospital Out-of-Network Hospital
Hospital expenses for a one-day outpatient hospital procedure $10,000 (reflects PPO in-network discounted fee) $15,000 (no discount)
Plan pays
You pay
$9,000 (90%)
$1,000 (10%)
$7,500 (50%)
$7,500 (50%)

In this example, you save $6,500 by using an in-network hospital.

If you were previously in the Anthem PPO, your out-of-pocket costs decreased under the new Anthem PPO. If you were previously in an EPO or non-Anthem PPO, your deductible and out-of-pocket maximum are higher under the new Anthem PPO; other benefits may have higher or lower costs. If you were previously in an HMO, you may pay more out-of-pocket under the new Anthem PPO. Anthem has online tools you can use to find the best care at the lowest cost.

With the Kaiser HMO, you choose a primary care physician (PCP) and can only see providers who participate in Kaiser’s network. The Anthem PPO is more flexible. It doesn’t require you to choose a PCP. It also offers out-of-network coverage for providers who aren’t in Anthem’s PPO network, although your out-of-pocket costs are greater when you use an out-of-network provider.

Also, the Anthem PPO is different in how it covers medical care. For most covered expenses, you pay a calendar year deductible before the PPO starts paying benefits. Then, you and the PPO share expenses (called “coinsurance”) until you reach the plan’s calendar year out-of-pocket maximum. At that point, the PPO pays 100% of covered expenses for the rest of the calendar year.

IMPORTANT: The PPO pays 100% of the cost of in-network routine preventive care (like your annual physical) and related lab fees and tests with no deductible.

The types of care under the Anthem PPO are the same as what was covered under the Trust Fund’s 2018 medical plans.

This is the amount that Anthem will use to determine benefit payments for care or services received from out-of-network providers who can charge any amount they wish to charge. You are responsible for paying any amounts over Anthem’s allowed amount for a given service or procedure.

Whether you can keep seeing your current provider and receive in-network benefits this year will depend mainly on where you live:          

  • All states except Nevada and Utah: Anthem has a large provider network, so it is likely that your 2018 provider participates in the Anthem PPO network. However, if you are enrolled in the Anthem PPO, confirm your provider is in the Anthem network before your first visit. If you need to choose a new network provider, Anthem offers online tools to help you find one (visit anthem.com/ca). Also, Anthem has a dedicated team to help transition certain care from a non-network provider to a network provider.
  • Nevada and Utah: Although Anthem has a large provider network, if you were in the Health Plan of Nevada HMO or Select Health HMO, your 2018 provider may not participate in the Anthem PPO network. You may need to select a new, in-network provider to receive the higher in-network benefits. Of course, you may continue to see your current provider. However, you will pay more for out-of-network care.

Visit anthem.com/ca to search for providers online, then:

  • If you’re not in the Anthem PPO yet, select the “Individual and Family” tab, then choose “Find a Doctor” under the “Care” column. Scroll down to “Identification Number/Alpha Prefix.” Enter “EFW” then click “Continue.” Next, select the type of doctor, area of specialty and location, plus the name of the doctor or medical professional, if available. Then select “Search.”
  • If you’re a participant and have registered for the website, log in, then, under “Useful Tools” on the right, select “Find a Doctor.” Select the type of doctor, area of specialty and location, plus the name of the doctor or medical professional, if available. Then select “Search.”

You may also download Anthem’s mobile app from the App Store or Google Play and use the provider search tool, or call Anthem for help finding an in-network provider, at (833) 224-6930.

Ask your doctor to contact Anthem directly. Anthem will email an application packet to the doctor’s office. If the doctor returns the application to Anthem, they will initiate a credentialing review to ensure that the doctor meets their guidelines. This review takes 60 to 90 days to complete. Anthem does not guarantee the addition of any doctors, since acceptance into the network is dependent on the credentialing review and network needs.

See the Comparison of Medical Plan Benefits 2019 or the Summaries of Benefits and Coverage (SBCs) that contain information on the Anthem PPO. Also, you can call Anthem directly for coverage details or contact Participant Services at the Trust Fund at (213) 386-8590 or (800) 293-1370.

Anthem in-network providers can only charge you for copays or services not covered by the plan at the time of service. They cannot charge you deductible or coinsurance amounts until your claim is processed and Anthem’s Explanation of Benefits (EOB) is sent to you. For example, if you have an office visit with an Anthem PPO doctor, the doctor’s office cannot charge you for the deductible and 10% coinsurance until you receive your EOB. However, if the doctor performs a service not covered by the plan such as a Botox injection, the doctor’s office can charge you for that service at the time you receive it since it is not covered under the plan.

For most covered in-network services, the plan pays 90% of the discounted network charge. For most covered out-of-network services, the plan pays 50% of the allowed amount. This is the amount that the Anthem PPO allows as payment for care or services received from out-of-network providers. Your cost-share is determined using the allowed amount, not the total charge or billed amount. For details, see "What does the term “allowed charge” or “allowed amount” mean?" above.

Yes. Register to use the Anthem website at anthem.com/ca. You can then use the “Estimate Your Cost” tool to compare costs and quality for common procedures before you have those procedures/services performed.

No. You may see a specialist without the need for pre-approval or a referral. However, you receive the highest level of benefits by choosing an in-network specialist.

The Anthem PPO provides:

  • A large, nationwide network of doctors, hospitals, labs, and other healthcare facilities to choose from,
  • The ability to see any doctor and receive plan benefits for covered care (but you’ll get greater benefits if you use an in-network provider),
  • The flexibility to see a specialist without a referral,
  • Coverage available even if you are away from home,
  • Services and tools that help you navigate the healthcare system, pay less and get more, and receive care more conveniently, such as seeing a doctor online through LiveHealth Online, and
  • A mobile app to get benefits information, manage claims, find providers and get a new ID card. Once you’re enrolled, visit the App Store or Google Play to download the app.

In addition, Anthem offers the following special services:

  • Estimate Your Cost Tool: helps determine the cost of medical procedures,
  • Anthem HealthGuide: customer service team trained to help you navigate the healthcare system,
  • Anthem’s Blue Distinction Centers: healthcare facilities that specialize in cardiac care, cancer treatments, transplants and spine surgery, for higher quality care, faster recovery and fewer health complications,
  • LiveHealth Online: see a US-based doctor 24/7/365 on your phone, tablet or computer for things like a sore throat, ear pain, cough, flu, pink eye and more,
  • 24/7 Nurseline: access to trained, Registered Nurses 24/7/365 for advice about common health issues,
  • Future Moms Program: pairs moms-to-be with a nurse-specialist pregnancy coach to manage screenings, discuss nutrition and prepare for delivery,
  • ComplexCare: access to trained nurse care managers who work with higher-risk patients with serious orthopedic, heart, nerve, cancer-related and other major health issues (and their doctors) to make a personal nursing care plan,
  • ConditionCare: 24/7 condition management assistance from nurse coaches and Registered Nurses for certain types of cancer, vascular or musculoskeletal diseases, asthma, diabetes, chronic obstructive pulmonary disease (COPD), heart disease, depression and more,
  • MyHealth Advantage Gold: sends you messages about opportunities to improve your health, spend your healthcare dollars more effectively and avoid critical health issues, and
  • AIM: Program that ensures procedures your doctor requests are appropriate and that you receive the right level of care.

Call Anthem Member Services at (833) 224-6930 for more information or to register for these special services.

Telemedicine is a service that lets you see a US-based, board-certified doctor 24/7 via video chat on your phone, tablet or computer, through Anthem’s LiveHealth Online service. Use this service to diagnose common conditions—like a sore throat, headache, or the flu—or get answers to medical questions. Visit livehealthonline.com for more information and to enroll. You only need to pay a $5 copay for each LiveHealth Online visit.

Under the Anthem PPO, most common preventive services and tests are covered at 100% with no copay or deductible when received from an in-network provider. These include:

  • Annual wellness exams, including doctor’s office visits and any required diagnostic or laboratory testing,
  • Immunizations,
  • Colorectal cancer screenings,
  • Well-woman exams, including screenings for cervical and breast cancer,
  • Child and adolescent preventive care, including well-baby and well-child exams,
  • Alcohol and drug abuse screenings, and
  • Certain preventive medications.

Visit anthem.com/ca for more information and a complete list of covered preventive care services.

The annual deductible under the Anthem PPO depends on whether you receive services in-network or out-of-network. The in-network deductible is $300 per person, with a maximum of $900 per family. For out-of-network services, the annual deductible is $500 per person, with a maximum of $1,500 per family.

Generally yes, but it depends on the service or care you are receiving. Eligible preventive care services received in-network are covered at 100% with no deductible. In addition, you do not have to pay the annual deductible before the plan starts paying outpatient prescription drug benefits or if you need ambulance services. However, for most other types of services and care, including doctor and specialist visits, you must meet the annual deductible before the plan starts paying benefits.

If you or your dependents are covered under a Trust Fund plan and another group medical plan, benefits will be coordinated between the plans on a “non-duplication” basis. It is not intended that you receive greater benefits than the actual allowable charges you incur. For details and rules for coordination of benefits, see the Health and Welfare Trust Summary Plan Description.

The annual out-of-pocket maximum under the Anthem PPO depends on whether you receive services in-network or out-of-network. Once you’ve met the annual individual out-of-pocket maximum, the plan will begin paying 100% of eligible charges for that individual. The annual medical in-network out-of-pocket maximum is $2,500 per person with a maximum of $5,000 per family. The annual outpatient prescription in-network out-of-pocket maximum is $1,000 per person with a maximum of $2,000 per family. There is no out-of-pocket maximum for out-of-network services, except for emergency care in an emergency room.

Yes. Emergency services are covered whether you use an in-network or out-of-network provider. However, out-of-network providers may charge for expenses that are not covered or charge more than the plan’s allowed charge and the charges will be paid at the out-of-network level if it’s deemed not to be a true emergency (see "What does the term “allowed charge” or “allowed amount” mean?" above). So it’s a good idea to receive in-network care whenever possible.

Yes. You’re covered through the BlueCard® program to get care anywhere in the United States and worldwide, as described in your Summary of Benefits and Coverage, but claims are processed at the out-of-network level. For more information, visit anthem.com/ca.

After you receive care from an in-network or out-of-network provider, you will receive an EOB statement from Anthem. This is not a bill. It’s a document showing the amount the provider charged, how much of that amount is allowable under the plan, how much the plan paid to the provider and the amount you owe the provider, if applicable. Your EOB statement will also show how much you’ve paid toward your annual deductible. EOBs are sent to you automatically when your provider files a claim for service. You can also see your EOBs online by registering at anthem.com/ca.

HealthGuide is Anthem’s new, enhanced customer service model. It provides tools to help you get the care that’s right for you and get more value from your benefits. Anthem offers specially trained health guides who can:

  • Connect you with healthcare programs and support,
  • Spot gaps in your medical care, such as routine exams and screenings,
  • Help you save money on prescription drugs, and
  • Compare costs and find in-network providers.

Call Anthem’s HealthGuide, at (833) 224-6930.

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