Extension of benefits for Anthem members who access benefits through Pathway NetworksFebruary 04, 2019
ATTENTION: Anthem members with individual policies and members of small groups who access benefits through Pathway Networks only (together “Pathway Members”)
Helping to ensure members have access to health plans that offer greater affordability and access to quality health care remains our focus at Anthem Blue Cross and Blue Shield. It’s come to our attention some members may have enrolled based on the incorrect assumption WellStar would be in the Pathway network throughout 2019. We have worked closely with Commissioner Beck and the Department of Insurance to find a solution that allows impacted Pathway Members to receive care from WellStar primary care providers beyond February 4, 2019.
We are pleased to extend benefits for 90 days to Pathway Members who, during open enrollment, selected or were assigned a WellStar affiliated Primary Care Physician (PCP) or those who attempted to choose a WellStar PCP. “Extension of benefits” means the impacted Anthem Pathway Member can receive treatment from WellStar PCPs until May 4, 2019, and Anthem will allow the previously contracted reimbursement rate.
We cannot guarantee that WellStar will permit Pathway Members to schedule appointments, nor can we guarantee WellStar will not bill members for the difference between the Anthem allowed reimbursement and WellStar’s billed charges (“balance bill”). However, we understand that WellStar committed to the Department of Insurance not to balance bill Pathway Members during this time, collecting only member cost shares that may apply.
This extension of benefits will allow Pathway Members extra time to transition to in-network PCPs. Please note, the extension of benefits does not apply to outpatient services or hospital inpatient admissions at WellStar Hospitals occurring after February 4, 2019. Pathway Members who qualify for the sixty (60) day continuation of care period, may have other options.
Members can call the Member Services number on their Anthem ID card for more information.
To help answer our member’s questions and give guidance on how to access care from in-network providers, Anthem is mailing letters to members. This notification explains the impact on their coverage with Anthem.
Additionally, Northside Health Systems which is in-network, has agreed to establish a hotline number (404) 303-4291 to provide concierge services to assist Pathway Members who need help scheduling appointments during this period of transition. We look forward to ensuring our members receive high quality, affordable care through our network of participating providers and hospitals.
Frequently Asked Questions
- Atlanta Medical Center
- Atlanta Medical Center South
- WellStar Cobb Hospital
- WellStar Douglas Hospital
- WellStar Kennestone Hospital
- WellStar North Fulton
- WellStar Paulding Hospital
- WellStar Spaulding Regional Hospital
- WellStar Sylvan Grove Hospital
- WellStar West Georgia Medical Center
- WellStar Windy Hill Hospital
Wellstar Medical Groups
WellStar Medical Group
WELLSTAR HEALTH SYSTEM – PROF PROVIDERS
How are Pathway Members affected
1. What does the termination of WellStar from the Pathway Network mean for Pathway Members assigned to the medical groups?
The WellStar Health and Anthem agreement for the Pathway Network terminated February 4, 2019. We are pleased to grant an extension of benefits for 90 days to Pathway Members who, during open enrollment, selected or were assigned a WellStar affiliated Primary Care Physician (PCP) or those who attempted to choose a WellStar PCP. Pathway Members also have the ability to apply for continuity of care. Form and materials can be found on anthem.com/wellstar.
We cannot guarantee that WellStar will permit Pathway Members to schedule appointments nor can we guarantee Wellstar will not bill members for the difference between the Anthem allowed reimbursement and WellStar’s billed charges (“balance bill”).
2. What about Pathway Members who need emergency medical care from a hospital that is not affiliated with the new receiving medical group?
Emergency medical services do not require pre-authorization, regardless of where they are delivered. Hospitals must still provide services for Pathway Members requiring emergency care. Coverage will be provided according to the member’s benefit plan.
3. Will Pathway Members be informed that they will be transferred to another medical group?
If Pathway Members chose to reassign their PCP during this special period, they will receive a new card in the mail after the selection has been made. If they elect to maintain their WellStar PCP, they will be autoassigned a new PCP towards the end of the special period.
4. Will affected Pathway Members receive a new membership ID card?
Yes, Pathway Members affected by this contract termination will be sent a new ID cards.
5. What if Pathway Members would rather self –select a PCP and medical group rather than transfer to the medical group to which they are reassigned?
When possible, Pathway Members will be assigned to alternate medical groups with which their PCPs are affiliated. However, Pathway Members can choose another in-network Anthem primary care physician and/or medical group (when available) within their service area. Please see the Find a Doctor feature available on www.anthem.com. Members who need assistance in selecting a different PCP and/or medical group can call the Anthem Customer Service department using the toll-free telephone number listed on their ID card.
Alternate Medical Groups
6. What Anthem products are affected by this termination?
This termination affects Anthem members enrolled in Commercial Pathway, Pathway X, Pathway Enhanced, Pathway X Enhanced, & Pathway X Guided Access individual or small group health plans and are assigned to or are being treated by WellStar providers or at a WellStar facility.
7. Do Anthem network PCPs have capacity to accept Anthem’s Pathway enrollees from WellStar Health?
In preparation for WellStar’s termination from the Pathway Network, Anthem carefully considered physician panels and the capacity of the in-network PCPs to accept additional patients. The PCPs to which the Pathway Members have been assigned are willing and capable of serving the health care needs of the Anthem enrollees being transitioned from WellStar.
In addition, Northside Health Systems which is in the Pathway Network, has agreed to establish a hotline number (404) 303-4291 to provide concierge services to assist Pathway Members who need help scheduling appointments during this period of transition.
8. Will Anthem provide continuity of care/transition assistance services to Pathway Members?
Pathway Members who, during open enrollment, selected, were assigned or tried to select a WellStar PCP do not need to file for continuity of care at this time. Other Anthem Pathway Members who wish to continue care with their current WellStar specialty care physician should submit a Continuity of Care form to Anthem. If the Pathway Member meets certain criteria, they will be permitted to continue receiving treatment from WellStar providers for up to sixty (60) days after February 4, 2019. Some conditions that may warrant a continuation of care follow:
The member is receiving active treatment for an acute medical condition, behavioral health condition, or serious chronic condition.
Some conditions that don’t qualify for Continuation of Care include but are not limited to:
- The member is pregnant and has begun care with a WellStar OB-GYN.
- The member has a terminal illness.
- The member is a child between the ages of birth and 36 months.
- The member has a surgery or other procedure that was authorized and is scheduled within 180 days after the contract’s termination date.
- Routine exams, vaccinations and health assessments
- Ongoing conditions you may have but are able to manage well, like diabetes, arthritis, allergies, depression, asthma, hypertension (high blood pressure) and glaucoma
- Elective (non-urgent) inpatient and/or outpatient surgery
If you think you might be eligible, call us right away. We’ll confirm whether you’re eligible. And then you can work with your doctor to fill out the Continuity of Care form. You can download the Continuity of Care form or you can call the Member Services number on your Anthem ID card to get a copy mailed or emailed to you. When you fill out the form: 1. Please answer all questions completely. To help us review your form quickly, return it as soon as possible. 2. Section 1 and 2 need to be completed by the patient. If the patient is a minor, a guardian’s signature is required. 3. Section 3 is completed by the treating health care provider or doctor. 4. The treating health care provider should fax the completed form to Medical Management at 1-877-254-4971.
If continuity of care is approved through Anthem’s Transition Assistance Unit, the claim is processed at in-network benefit levels so that the member is only financially responsible for applicable deductibles, coinsurance and/or co-payments.
If an Pathway Member does not meet the requirements for transition assistance, then continuity of care will not be provided. In this case, the provider will be considered out-of-network and the member will incur significant out-of-pocket expense if he or she chooses to receive care from the provider.
9. If a Pathway member does not qualify for continuity of care or have a current WellStar PCP, can he or she choose to go to a WellStar Health affiliated provider anyway?
For Pathway HMO & Pathway Guided Access HMO members, most specialty and hospital services must first be approved by Utilization Management (UM). If approved, Anthem will cover the claim at the member’s in-network benefit levels; however, the member will be responsible for considerable out-of-pocket costs. If not approved, the claim will be denied due to lack of authorization as stated in the member’s Evidence of Coverage (“EOC”) and the member will be responsible for the entire cost of the care.
Members who are enrolled in a Pathway Enhanced point-of-service (POS) plan and continue to access WellStar Health providers after the termination date, will have significantly higher out-of-pocket costs. Members should be advised to check their EOC , which outlines coverage for seeking care from a provider who does not participate in Anthem’s network.
WELLSTAR HEALTH SYSTEM - HOSPITALS
How Members are affected
10. What Anthem products are affected by this contract termination?
This termination affects Anthem Members enrolled in Commercial Pathway, Pathway X, Pathway Enhanced, Pathway X Enhanced, and Pathway X Guided Access individual or small group health plans and are assigned to or seek care from a WellStar provider.
11. How do Pathway Members know if their doctor will be affected by this contract termination?
Pathway Members can contact the Anthem Customer Service number listed on their ID card if they are not sure if their doctor is affected by this termination.
Physicians, Medical Groups, and Alternate Hospitals
12. What other participating Anthem Pathway Network hospitals are available in the vicinity of the WellStar Hospitals?
Anthem has a statewide hospital network including numerous acute care facilities. The Find a Doctor feature available on www.anthem.com can be used to locate a Pathway participating hospital in a specific area.
For a complete list of contracted hospitals, as well as ambulatory surgical centers and other ancillary facilities, please see the Anthem website at www.anthem.com. Customer Service representatives can check the provider database for a physician’s admitting privileges at nearby Pathway Network facilities. Pathway Members should confirm the information they receive with their treating physician. Every effort will be made to assist members in understanding their choices and the potential financial consequences of seeking care with a provider that is not in the Anthem provider network.
Post-Termination Care – WellStar Health System
13. What if a Pathway Member is in-patient at a WellStar hospital on the day the contract expires?
If a Pathway Member was in-patient at 11:59 PM on February 3, 2019, then the Pathway Member will continue to receive care at WellStar until he or she is discharged or transferred to an in-network facility. In addition, the Pathway Member’s in-network benefit levels will apply for the entire in-patient stay.
14. If a Pathway Member does not have access to an alternate participating facility or a particular service is not available elsewhere, can he/she go to a WellStar hospital?
Anthem will ensure Pathway Members have timely access to care. If a service is not available at a participating provider, Pathway Members may request an out-of-network referral by contacting Customer Service. Requests will be reviewed on a case by case based on Anthem’s Out-Of-Network Referral Policy. When an out-of-network referral is approved by Anthem, the Pathway Member’s in-network benefit levels will apply. However, because WellStar will no longer be in Anthem’s Pathway provider network, PathwayMembers may be responsible for higher out of pocket expenses up to the providers full billed charges depending on their benefit plan. Pathway Members can call the Customer Service number on their ID card with with questions regarding the potential financial impact of choosing care from a non-participating provider.
14. What if a Pathway member wants a different product that contracts with Wellstar Health?
Pathway Members who wish to change products outside of Open Enrollment may be able to. If a Pathway Member experiences a qualifying event, they can take advantage of a special enrollment period to make changes to their individual health plan or buy a new one. In most cases, they will have 60 days from the date of the qualifying event to make the change. To find out more, please visit healthcare.gov.