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Extension of Benefits for Anthem Members Who Access Benefits Through Pathway Networks

June 12, 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 Pathway Members may have enrolled based on the incorrect assumption that WellStar would be in the Pathway network throughout 2019. We have worked closely with the Department of Insurance and the Insurance Commissioner 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 through the end of the year to impacted Pathway Members who, during open enrollment, selected or were assigned a WellStar affiliated Primary Care Physician (PCP). “Extension of benefits” means the impacted Anthem Pathway Member can receive treatment from WellStar PCPs and specialists until December 31, 2019, and Anthem will allow the previously contracted reimbursement rate.  As usual, Pathway Members will be financially responsible for applicable deductibles, coinsurance and/or co-payments.
 
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”).
 
Please note, the extension of benefits does not apply to outpatient services or hospital inpatient admissions at WellStar Hospitals occurring after February 4, 2019. 
 
In addition, some Pathway plans require members to obtain a referral from their PCP before seeing certain specialists.  This referral requirement will continue and is not changed by the extension of benefits.  If you have questions about whether a PCP referral is required under your plan, please contact the Anthem Member Service number on the back of your ID card.
 
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 who are eligible for the further extension of benefits. This notification explains the impact on their coverage with Anthem. 
 
Pathway Members also can call the Member Service number on their Anthem ID card for more information. 
 
Additionally, Northside Health Systems which is in-network, has established a hotline number  (404) 303-4291  to provide concierge services to assist Pathway Members who need help scheduling appointments during this plan year. We look forward to ensuring our members receive high quality, affordable care through our network of participating providers and hospitals.
 
 

Frequently Asked Questions
 

WellStar Hospitals
 
  • 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
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 through the end of the year to Pathway Members who, during open enrollment, selected or were assigned a WellStar affiliated Primary Care Physician (PCP) a WellStar PCP.  Impacted Pathway Members will receive a letter in the coming days.  If you have any questions, please call the Member Service number on the back of your ID Card.
 
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”).
 
Pathway Members also may be able to apply for benefits under Anthem’s Out-Of-Network Referral policy. (Please see FAQs #5 and #9 below.)
 
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. What Anthem products are affected by the termination of WellStar from the Pathway Network?
 
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 who were assigned to or are being treated by WellStar providers or at a WellStar facility prior to February 4, 2019.
 
4Do in-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. PCPs participating in the Pathway Network are willing and capable of serving the health care needs of Anthem enrollees in Pathway Guided Access plans who selected or were assigned a WellStar PCP during open enrollment and who wish to select a new PCP during this plan year.  For more information or assistance selecting or changing your PCP, please contact the Member Service number on the back of your ID card.
 
In addition, Northside Health Systems which is in the Pathway Network, has established a hotline number (404) 303-4291 to provide concierge services to assist Pathway Members who need help scheduling appointments.  We look forward to ensuring our members receive high quality, affordable care through our network of participating providers and hospitals.
 
5. If a Pathway member does not qualify for the extension of benefits, can he or she choose to go to a WellStar Health affiliated specialty provider or WellStar Hospital or outpatient facility anyway?
 
For Pathway Members who do not qualify for the extension of benefits, WellStar hospitals, WellStar outpatient facilities and WellStar doctors are out-of-network for your plan.  If you choose to continue to access WellStar hospitals, outpatient facilities, or doctors after the February 4, 2019 termination date, you will have significantly higher out-of-pocket costs.  If a particular healthcare service is not available from a participating provider, you may be eligible for additional benefits under Anthem’s Out-of-Network Referral Policy.  See FAQ #9.    
 
6. 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 seek care from a WellStar provider.
 
7. How do Pathway Members know if their doctor will be affected by this contract termination?
 
Pathway Members can contact the Anthem Member 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

 
8. 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. Member 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

 
9. 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?
 
For all Pathway Members, if a service is not available at a participating provider, Pathway Members may request an out-of-network referral by contacting Member 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 is no longer in Anthem’s Pathway provider network, Pathway Members may be responsible for higher out of pocket expenses up to the provider's full billed charges depending on their benefit plan. Pathway Members can call the Member Service number on their ID card with questions regarding the potential financial impact of choosing care from a non-participating provider.
 
For Pathway Members who are eligible for the extension of benefits, you do not need to request an “out-of-network referral” from Anthem to see the WellStar Primary Care Provider listed on your ID card, but your Pathway plan may require that you obtain a standard referral from your PCP before seeing other WellStar doctors.  In addition, the extension of benefits does not apply to outpatient services or hospital inpatient admissions at WellStar Hospitals or facilities occurring after February 4, 2019.  Pathway Members who are eligible for the extension of benefits and who wish to receive a service at a WellStar hospital or outpatient facility can request an “out-of-network referral” from Anthem, which will be reviewed on a case-by-case basis based on Anthem’s Out-Of-Network Referral Policy.  Please contact the Member Service number on the back of your ID card for more information about whether a PCP referral is required under your Plan or about Anthem’s Out-of-Network Referral Policy.  
 
Please note, for all Pathway Members, if you choose to obtain services at a WellStar hospital or outpatient facility after February 4, 2019 and do not have an approved out-of-network referral, you will have significantly higher out-of-pocket costs. 
 
10. 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 under certain circumstances. 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.