Your HIA is funded when you earn rewards for taking certain steps to improve your health. Check your Plan Summary for more information about earning rewards.
What type of services may I pay for with my HIA funds?
You can use the money in your HIA to pay for health care services covered by the Lumenos plan, such as doctor’s office visits, prescription drugs, and lab tests. Check your Plan Summary for more information on covered services.
What is traditional health coverage?
Similar to a PPO or HMO plan, after you meet your deductible, you pay coinsurance (a percentage of the provider’s charges) when you visit a network provider. You’ll pay more if you visit an out-of-network provider. Check your Plan Summary for more information on coinsurance amounts.
How do I check my health account balance?
It’s easy. First register then log on at anthem.com. You can keep track of your account activity and balance, and get details on your medical claims. You’ll also receive a monthly statement with your account balance, account activity, medical and prescription claim history and important messages about how you may be able to improve your health or save money.
Can I roll over all the money in my HIA at the end of each plan year?
Yes. Whatever you don’t spend on covered services will roll over to the next year, as long as you remain enrolled in the Lumenos HIA plan. You can use roll-over funds to help pay future out-of-pocket expenses.
If I leave this Lumenos plan, what happens to my HIA funds?
You cannot take your HIA funds with you if you leave the plan or your employer. The funds in your HIA stay with the health plan.
Where can I access additional discounts on dental products and services not covered through my plan?
It’s called consumer-driven because it puts you in the driver’s seat of your health and health care spending. With your checkups and preventive care likely covered at 100%, and tools to help you stay healthy and shop around for quality care at more reasonable costs - you might be able to cover all your costs with the money in your account.
It gives you the flexibility of a PPO - you can often go to doctors in and out of your network, though you’ll get better rates with in-network doctors. HSA plans tend to have lower monthly premiums than similar PPOs, and sometimes even HMOs.
It’s sometimes called a consumer-driven health plan (CDHP) because you’re in more control of your care spending at first. With your checkups and preventive care likely covered at 100%, and tools to help you stay healthy and shop around for quality care at more reasonable costs - you might be able to cover all your costs with the money in your account.
If you still have money left in your account, it stays in there for next year and beyond. And you can also take it with you if you change health plans. View IRS rules on paying costs with money in your HSA.
Your employer puts money into your health incentive account (HIA) when you take certain steps to improve your health. You use that money to pay for your share of care costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year as long as you’re still at the same job.
Yes. The three main types of FSAs are:
1. Health care FSA for qualified medical, dental, vision or other health care costs, including insurance deductibles, co-payments and co-insurance.
2. Dependent care FSA for child, elder or other dependent care.
3. Limited purpose FSA for qualified dental and vision care costs only when combined with a Health Savings Account (HSA) or a Health Reimbursement Account (HRA).
To be eligible for an FSA, your employer must offer it. You don’t have to participate in your employer’s health plan. You must elect to participate in the FSA during your employer's open enrollment.
For a Dependent Care Flexible Spending Account (DCA), you must have children under the age of 13 (if divorced, you must be the custodial parent) or you must claim an adult dependent on your tax return who’s physically or mentally unable to care for themselves.
Qualified individuals must meet one of the following criteria: children under the age of 13 or any adult you can claim as a dependent on your tax return who is physically or mentally unable to care for themselves.
For more information, view IRS Publication 503.
To qualify for a DCA, you must be the custodial parent, even if you don’t claim your child as a tax dependent.
For more information, view IRS Publication.
Typically anyone whose employer offers a DCA can participate. As a rule, your DCA can only cover expenses incurred during work hours. Ask your employer’s benefits team to verify eligibility.
For more information, view IRS Publication.
- Before and after school care programs
- Preschool or nursery school
- Extended day programs and summer day camp
- Babysitter (in or out of your home)
- Nanny and au pair services
- Daycare and eldercare facilities
- Educational expenses (summer school and tutoring)
- Tuition for kindergarten and above
- Overnight camp
- Field trip expenses and fees
- Housekeeping services
- Dependent care expenses incurred if your spouse doesn’t work, unless your spouse is a full-time student or is disabled
The work related expense test is the standard the Internal Revenue Service uses to determine if expenses are work related for a DCA. An expense isn’t considered work related just because you had it while you were working. Expenses are considered work related only if both of the following are true:
- They allow you (and your spouse if filing jointly) to work or look for work
- They’re for a qualifying person’s care
For more information, view IRS Publication 503.
Does the carryover amount limit my future year Health Care Flexible Spending Account (FSA) election?
No.
Reimbursements can be requested when a qualified expense is incurred during the plan year and before the end of the FSA run-out period (or grace period if applicable).
Reminder: If your group benefits end and you’re eligible to enroll in Medicare Part B, do it within 80 days after your group health benefits end - or you could pay more.
- If you are eligible under a federal law known as COBRA, you may have an opportunity to remain covered under your employer's coverage for some period of time, provided you pay the full amount of your premium.
- Your employer may offer retiree coverage.
- You may have the opportunity to convert to an individual policy offered by Anthem.
- You may have the opportunity to continue coverage under your group coverage.
If new coverage is obtained within certain time frames, waiting periods and medical underwriting might not apply. Contact your employer, your Certificate or Customer Care for more information and for any guidelines that apply.
- Here's what it all means and how it works.
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To see if the health care or service your doctor or other health care provider wants to give you is a “medical necessity,” Anthem looks at requests for authorization. Check your Evidence of Coverage or benefit booklet to know what makes something a “medical necessity” and when care requires this review.
A “medical necessity review” may be called utilization review (UR), utilization management (UM), or medical management. It is a review process that helps decide if a certain outpatient care, inpatient hospital stay, technology or procedure is medically needed.
Reviews can happen at different times including:
- When a service, treatment or procedure is asked for or planned ahead. We call this prospective or pre-service review.
- During the course of care. We call this inpatient or outpatient ongoing care review.
- After care or services have been given. We call this retrospective or post-service review.
With so many different things to consider, it may help to get a clear picture of what to expect and how the process works.
- Timing matters.
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We’re committed to deciding cases quickly. Here are types of reviews and time frames you can expect. (The maximum time allowed for a health plan to decide medical necessity once it gets the information needed.)
Non-urgent pre-service (before care):
- 5 business days for fully-insured and HMO/POS plans
- 15 calendar days for self-funded plans (unless otherwise stated in your Evidence of Coverage or benefit booklet)
- 72 hours for non-urgent prescription drug requests for fully-insured and HMO/POS plans
Urgent pre-service (before care):
- 72 hours
- 24 hours for urgent prescription drug requests for fully-insured and HMO/POS plans
Urgent inpatient or outpatient ongoing care (during care):
- 24 hours (in some cases) or no later than within 72 hours of getting a request
Retrospective/post-service (after care):
- 30 calendar days
- What happens if there is a delay?
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If we don’t have the information we need to make a decision, we try to get it from the doctor or other health care provider who requests the service or care.
We’ll write you and the requesting doctor or health care provider if there might be a delay because the information we need is not easy to get. This letter tells you what we need to make a decision. It also explains when to expect the decision once we get the information.
If we don’t get the information we need, we will send a final letter explaining that we are unable to approve access to this benefit because we don’t have enough information.
- Professional reviewers decide
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Qualified licensed health care professionals and doctors from Anthem Blue Cross and the medical group (or their peers) review requests and give an opinion specific to a medical condition, procedure and/or treatment under review. If the reviewer is unable to decide the medical necessity of a request, he or she may call the requesting doctor or other provider to discuss the case. In many cases, medical necessity can be determined after this call.
Decisions are based on what is right for each member for the type of care and service. Medically necessary review decisions made by Anthem Blue Cross are based on:
- Anthem’s medical policy criteria and guidelines (reviewed at least once a year and updated as standards and technology change).
- Nationally recognized clinical guidelines approved by a committee including practicing doctors and health care professionals not employed by Anthem Blue Cross.
- Your health benefits.
Employees, consultants or other providers are not rewarded or offered money or other incentives for denying care or a service, or for supporting decisions that result in using fewer services. Also, Anthem doesn’t make decisions about hiring, promoting or firing these individuals based on the idea or thought that they will deny benefits.
- Medical necessity doesn’t mean payment or coverage
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If we find services are medically necessary, it doesn’t mean the service is paid for or covered. Payment is based on the terms of your coverage at the time of service. There are some exclusions, limitations and other conditions that are part of your benefits. You will find them in your Evidence of Coverage or benefit booklet.
Payment of benefits could be limited for a number of reasons, such as:
- Information included with the claim differs from that given at time of review.
- The service performed is not covered.
- You’re not eligible for coverage when the service is given.
- Decisions not to approve are put in writing
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If we find the service is not a medical necessity, you and your doctor or health care provider requesting it will be sent written notice within two business days of the decision. This written notice has:
- A clear and simple explanation of the reason for the decision.
- The name of the criteria and/or guidelines used to make the decision and instructions for how to get a written copy.
- Information on how to appeal the decision and about your rights to an independent medical review.
- Specific parts of the contract that exclude coverage if the denial is based upon benefit coverage.
- To see our guidelines
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Anyone can see our medical necessity guidelines for specific services.
View our guidelines here. Scroll down and select Continue; you will see the Anthem Medical Policies & Clinical UM Guidelines Overview page.
- Select the Medical Policies or UM Guidelines option in the toolbar.
- Select the desired search option: Recent Updates or By Category.
- Select the desired Medical Policy or UM Guideline.
You may also call 1-800-794-0838 to request a free paper copy of the guidelines used to determine your case. These guidelines are used by Anthem Blue Cross to authorize, change or deny benefits for people with similar illnesses or conditions. Specific care and treatment benefits vary based on individual need and covered benefits.
- Questions about utilization management? Call us.
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To learn more about a UM medical decision, pre-authorization requests or the UR process, or if you have questions or issues, call our toll-free number: 1-800-274-7767, Monday through Friday (except holidays) from 8:00 a.m. to 5:00 p.m. Pacific Time.
If you call after hours or don’t reach someone during business hours, leave a confidential voice mail message with your name and phone number. We’ll return your call no later than the next business day, unless you request another time. Calls received after midnight will be returned the same business day.
You also can call Member Services at the number on your ID card to ask for an interpreter in your preferred language. They can read UM information in another language or help explain it in your preferred language free of charge.
If you have a hearing or speech loss, call 711 to use the National Relay Service or the number below for the California Relay Service. A special operator will contact Anthem to help with your needs.
1-800-855-7100 (English TTY/English voice)
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To help ensure continuity/transition of care, we have in place a Transition Assistance Program for newly-covered members that may allow them, if eligible, to continue to see their treating doctor or health professional even though that provider is not part of their new health plan. This Transition Assistance Program is limited to situations where the member was receiving services for certain medical/behavioral conditions at the time their new coverage became effective. It allows in-network benefits for a defined period of time when the treating provider is not part of the Anthem Blue Cross participating provider network and there are clinical reasons preventing immediate transfer of care to another provider who is a participating provider. In addition, the non-participating provider and Anthem would need to agree on payment terms. Members who had the option to continue with their previous health plan or provider and instead chose to change health plans or providers are not eligible for the Transition Assistance Program.
Effective January 1, 2018 we expanded our Transition Assistance Program to include newly-covered members under an Individual health care service plan contract whose prior coverage was terminated when their health benefit plan was withdrawn from the market.
Continuity/transition of care may also be provided for members who experience a network disruption with their Primary Medical Group (PMG), Independent Physician Association (IPA), or hospital as a result of a closure or terminated contract with Anthem Blue Cross. Interested members may complete our Continuity/Transition of Care Request Form which provides valuable information needed by our staff in order to initiate the continuity/transition of care process.
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We understand the importance of maintaining the patient/doctor relationship. You may request continuity/transition of care for completion of covered services by the non-participating provider for the conditions listed below. Please contact us using the toll-free number on your current ID card if you:
- Are pregnant.
- Are currently receiving ongoing medical or behavioral health care.
- Have a newborn child up to 36 months old who is receiving care.
- Have been diagnosed with a maternal mental health condition.
- Have a current authorization for health care services.
- Are otherwise concerned that this change will disrupt your care.
You can request continuity/transition of care or ask for further explanation of your rights to continued care. A Member Services representative can assist you with your request.
Eligibility for continuity/transition of care depends on factors outlined in your Evidence of Coverage or benefit booklet and Anthem Blue Cross’ Continuity of Care, Transition of Care Policy.
Access our Continuity/Transition of Care Request Form and Termination of Provider: Enrollee Notification Policy
- Inpatient Admissions:
- Elective Admissions
- Emergency Admissions
- Inpatient Skilled Nursing Facility
- Newborn Stays beyond Mother (NICU)
- OB Related Medical Stay (OB complications, excludes childbirth)
- Rehabilitation Facility Admissions
- Durable Medical Equipment
- (AAC) Devices/Speech Generating Devices (SGD) Augmentative and Alternative Communication
- Automatic External Defibrillator
- Bone Growth Stimulators
- Electric Tumor Treatment Field (TTF)
- Lower Limb Prosthesis
- Myoelectric Upper Extremity Prosthetic Devices
- Pneumatic Compression Devices for the Prevention of Deep Vein Thrombosis in the Home Setting
- Pulse Generator System for Tympanic Treatment of Inner Ear Endolymphatic Fluid
- Standing Frames
- Transtympanic Micropressure
- Outpatient treatments, including certain ambulatory surgical procedures
- Ablation of Solid Tumors Outside the Liver
- Ablative Techniques as a Treatment for Barrett's Esophagus
- Ablative Techniques Treating Primary and Metastatic Liver Malignancies
- Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
- Ambulance Services: Ground, Air and Water Ambulance Services (non-emergency)
- Anesthesia Services for Gastrointestinal Endoscopic Procedures
- Bariatric Surgical Procedures
- Biofeedback and Neurofeedback
- Blepharoplasty Procedures
- Hearing Aids/Cochlear Implants
- Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- Canaloplasty
- Capsule Endoscopy
- Cardiac Resynchronization Therapy (CRT)
- Cardioverter-Defibrillators
- CAR-T Therapy
- Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement
- Chemodenervation of extraocular muscle (for diagnosis of strabismus)
- Chemodenervation of extremity and/or trunk muscles (e.g. for dystonia, cerebral palsy, multiple sclerosis)
- Chemodenervation of internal anal sphincter (for diagnosis of anal fissure)
- Chemodenervation of muscles innervated by facial nerve, unilateral (e.g. for blepharospasm, hemifacial spasm)
- Chemodenervation of neck muscles (e.g. for spasmodic torticollis, spasmodic dysphonia)
- Chin Implants
- Contact Laser Vaporization of Prostate
- Cosmetic and Reconstructive Procedures of the Head and Neck, Trunk and Groin; and Skin Related
- Cranial Remodeling Bands and Helmets (Cranial Orthotics)
- Deep Brain Stimulation
- Destruction by Neurolytic Agent
- Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
- Endoscopic Treatment of GERD, Dysphagia and Gastroparesis
- Extracorporeal Shock Wave Therapy for Orthopedic Condition
- Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- Facial Dermabrasion/Scar revision
- Fetal Surgery for Prenatally Diagnosed Malformations
- Focused Ultrasound Ablation of Uterine Leiomyomata
- Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
- Gender Reassignment Surgery
- Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- Gene Therapy for Ocular Conditions and Spinal Muscular Atrophy
- Gynecomastia Repair
- Hairplasty
- High Intensity Focused Ultrasound for Oncologic Indications
- Home Health, Home Infusion Therapy, Wound Care in the Home Setting
- Hyperbaric Oxygen Therapy
- Hysterectomy
- Implantable Cardioverter-Defibrillator (ICD)
- Implantable Infusion Pumps
- Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
- Implanted Artificial Iris Devices
- Inhaled Nitric Oxide
- Insertion/Injection of Prosthetic Material Collagen Implants
- Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
- Intracardiac Ischemia Monitoring
- Intraocular Anterior Segment Aqueous Drainage Devices
- Intraocular Telescope
- Kyphoplasty Procedures
- Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies
- Lysis of Epidural Adhesions
- Magnetic Source Imaging and Magnetoencephalography
- Mandibular/Maxillary (Orthognathic) Surgery
- Manipulation Under Anesthesia
- Maze Procedure
- Meniscal Transplantation
- Myomectomy
- Nasal Implants
- Nasal Surgery for the Treatment of Obstructive Sleep Apnea and/or Migraine Headaches (includes: Excision of Polyp(s), Turbinate(s), Ablation of Turbinate(s), Septoplasty, Repair of Vestibular Stenosis)
- Neuroplasty
- Neurostimulator Implantation
- Occipital Nerve Stimulation
- Open Sacroiliac Joint Fusion
- Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
- Panniculectomy/Abdominoplasty/Lipectomy/Diatasis Recti Repair
- Partial Left Ventriculectomy
- Patent Foramen Ovale and Left Atrial Appendage Closure for Stroke Prevention
- Photocoagulation of Macular Drusen
- Preimplantation Genetic Diagnosis Testing
- Presbyopia and Astigmatism-Correcting Intraocular Lenses
- Private Duty Nursing in the Home Setting
- Real-Time Remote Heart Monitors
- Removal of Lung
- Rhinoplasty
- Rosacea Treatment
- Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
- Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
- Sclerotherapy/Ablation of Varicose Veins
- Somnoplasty
- Specialty Pharmacy Medications – non-oncologic
- Stereotactic Radiofrequency Pallidotomy
- Subtalar Arthroereisis
- Surgical Treatment of Migraine Headaches
- Surgical Treatment of Migraine Headaches
- Total Hip Arthroplasty (Elective)
- Total Knee Arthroplasty (Elective)
- Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
- Transcatheter Heart Valve Procedures
- Transtympanic Micropressure
- Treatment of Hyperhidrosis
- UPPP (Uvulopalatopharyngoplasty)
- Uterine Fibroid Ablation - Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
- Uterine Fibroid Embolization
- UPPP (Uvulopalatopharyngoplasty)
- Vagus Nerve Stimulation
- Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- Virtual Colonoscopy
- Viscocanalostomy
- Human Organ and Bone Marrow/Stem Cell Transplants
- Donor Leukocyte Infusion
- Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
- Heart Transplant
- Kidney Transplant
- Liver Transplant
- Lung or Double Lung Transplant
- Multi-visceral Transplant
- Pancreas Transplant
- Simultaneous Pancreas/Kidney
- Small Bowel Transplant
- Stem Cell/Bone Marrow Transplant (with or without myeloablative therapy)
- Uterine Transplant
- Laboratory
- Advanced Lipoprotein Testing
- Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
- Lab Testing to Aid in Diagnosis of Heart Transplant Rejection
- Multi-biomarker Disease Activity (MBDA) blood tests
- Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
- Rupture of Membranes Testing in Pregnancy
- Serological Antibody Testing for Helicobacter Pylori
- Vitamin-D deficiency in average risk individuals
- Mental Health/Substance Abuse (MHSA):
- Applied Behavioral Analysis (ABA) - Not all plans include benefits for ABA/Adaptive Behavioral Treatment; contact Customer Service to determine if this is included as a benefit under the member’s plan and to confirm precertification requirements
- Facility Based Care – Acute Inpatient Admissions, Partial Hospitalization, Intensive Outpatient Therapy (This includes Residential Treatment Centers, however, not all plans include Residential Treatment Center benefits; contact Customer service to determine if this is included as a benefit under your plan and to confirm precertification requirements
- AIM Specialty Health Programs (applies only to groups with the AIM Specialty Health Program) (https://aimspecialtyhealth.com/guidelines/185/index.html)
- Cardiology
- Genetic Testing
- Musculoskeletal
- Radiation Oncology
- Radiology
- Sleep Disorder Management
- Specialty Pharmacy Medications - oncologic
- Surgical GI
- Surgical Site of Care
A Consumer-Driven Health Plan (CDHP) is a high-deductible plan that also includes a tax-free Health Savings Account (HSA) or Health Reimbursement Account (HRA). Depending on your plan, you may put tax-free money into your account, or your employer might put money in, for example, as a reward for steps you’ve taken toward better health. Then, you use that money for your share of care costs, such as your deductible or coinsurance.
It’s called “consumer-driven” because it puts you in the driver’s seat of your health and health care spending. With your check-ups and preventive care likely covered at 100 percent by your plan, as well as tools to help you stay healthy and the ability to shop around for quality care at more reasonable costs, you might be able to use your CDHP to cover most if not all your health care costs.
Qualified medical expenses include medical, dental, vision and prescription expenses. Visit this website for more information:
qme.anthem.com/ca
Yes, FSA funds can be used for over-the-counter medicines without a prescription. Visit this website for more information:
qme.anthem.com/ca
Not sure if a medication is covered? Search your plan’s drug list or call the customer service number on your member ID card.
