Blue Cross Removes UC Hospitals From EPO Health Plans

Anthem Blue Cross has sent letters to their members notifying them that UC Davis Medical Center, UC San Francisco Medical Center and Children’s Hospital, along with Benioff Children’s Hospital in Oakland are no longer part of their Pathway EPO network as January 1, 2022. The Pathway EPO health plan’s network is offered in many regions of California and through Covered California.

UC Hospitals Dropped from Anthem Blue Cross EPO Plans

It was Covered California who first alerted insurance agents that the UC hospitals were not in the Anthem Blue Cross EPO network for 2022. Covered California had included the UC hospitals as part of the Blue Cross EPO network in marketing for the 2022 open enrollment period.

Blue Cross significantly expanded the regions in Northern California where their EPO plans were offered. Many consumers switched to the Blue Cross EPO because of the lower cost of the plans compared to competitors such as Blue Shield. For some individuals and families, they purposefully selected the Blue Cross EPO plans offered in the Sacramento and Bay Area regions because UC hospitals were in-network.

Neither Covered California nor the sample Blue Cross letter being sent to members explains why the UC hospitals are no longer in-network. Someone, Blue Cross or UC, pulled the plug retroactively to January 1. Fortunately, Blue Cross expanded their EPO network to include Sutter doctors and hospitals for 2022.

Are UC Doctors Still In-Network?

Another question that I have been not been able to get an answer to is whether the associated UC medical group of doctors are still participating network providers or if they, too, are no longer in-network. Even if the UC medical groups are in-network, they can’t really schedule any services at the UC hospitals for patients with Blue Cross EPO plans. Any services at the UC hospitals will be consider out-of-network, for which there is no coverage under an EPO plan type.

Blue Cross guidance regarding doctors is to refer to the provider search tool on their website: www.anthem.com/ca/find-care/ If the doctor does not appear in the search results, the provider is not in the network. Do not rely upon medical group or hospital websites regarding accepted insurance plans. They are infrequently updated and have incorrect information posted from my experience.

Blue Cross notes that individuals undergoing health care treatment at the UC hospitals can continue the treatment for certain medical conditions. The Blue Cross letter states,

There may be exceptions

You may be able to stay with University of California Health for a designated period of time if you are receiving certain types of care:

Under federal law, this includes care if you are:

• In treatment for a serious and complex condition. This can be a sudden (acute) illness that requires specialized treatment in order to avoid death or permanent harm. It can also be an ongoing (chronic) illness that is life threatening or potentially disabling and requires specialized care over a long period of time.

• In a hospital or other inpatient facility.

• Scheduled for non-elective surgery by your current doctor, including your post-operative care for the surgery.

• Pregnant.

• Terminally ill.

Under California law, this includes care if you:

• are pregnant or just had your baby.

• have a maternal mental health condition that’s been diagnosed by your treating care provider.

• are caring for a child up to 36 months old.

• are getting pre-approved care.

• have an acute condition or serious chronic condition

• have a terminal illness.

Additionally, Blue Cross informs members:

Members with previously scheduled services at University of California Health:

Anthem will allow previously scheduled and actively eligible Pathway members to be seen at University of California Health that have an appointment with a date of services 1/1/22 – 3/31/22 without need for an updated authorization. For members with an appointment on or after 4/1/22 the member will need to submit for Continuity of Care.

Can You Change Health Plans?

Covered California included a vague statement about changing health plans in their communication with agents.

In certain circumstances, some members may be offered a Special Enrollment Period to continue their care. Members can also Report a Change to select a new health plan.

Covered California members do have access to a Special Enrollment Period under the Qualifying Life Event of misrepresentation by virtue of incorrect data on the part of the health plan. Just be aware that when you switch to a new carrier, any dollars you have spent meeting deductibles and maximum out-of-pocket amounts will not be carried over to the new health plan.