Welcome to the 11th annual agents’ guide to managed care. Each year California Broker surveys health maintenance organizations (HMOs) in the state with direct questions about their plans. We then present the answers to such questions here for you—the professional agent or broker. We hope that this valuable information will help you serve your savvy healthcare clients better. This year, we will print approximately one-third of the completed survey in each of the months remaining in the year 2007.

1. Do you guarantee a time limit on getting referral/treatment routine, urgent, emergency? If not, how many days does it take?
      Aetna:      Our internal policy is five days for routine, three days for urgent pre-certification, one day for urgent concurrent. No referral is required for emergency care.
      Blue Cross: Authorization by the PMG/IPA requires a response time within the following time frames: five days for routine, 72 hours for urgent, and no prior authorization is required for emergency services.
      Blue Shield:      Routine 14 to 30 days, urgent one day, and emergency immediately.
            • A check-up or non-symptomatic preventive care visit with a personal physician should be accessible within 30 days.
            • A routine, symptomatic visit with personal physician should be accessible within seven days.
            • Routine, symptomatic care with a specialist should be available within 14 days. The standard for accessing urgent care with any practitioner is 24 hours.
      CIGNA:      Yes, CIGNA standards are that routine care is accessible within 14 days, urgent care is within 24 to 48 hours depending on the specific circumstances, and emergency care is immediate.
      Health Net of CA:      For urgent requests, a decision must be made on the same calendar day and verbal notification made to the provider and member within 24 hours of the decision. For routine service requests, a decision must be made within 48 hours of receiving all clinical information.
      Kaiser Permanente: No, our members have open access to all primary care services. Pre-authorizations are not required for urgent and emergency care. The maximum wait time is 30 days. However, most routine appointments are scheduled within two to three weeks. It is usually within 24 to 48 hours for urgent care problems that are not emergencies, but require medical attention. Members can call the urgent care number at the facility closest to their home or closest to the office of their physician or nurse practitioner. They can also call the advice nurse. Emergency care is available immediately at plan hospital emergency departments, which are listed in “Your Guidebook to Kaiser Permanente Services.”
      PacifiCare: Optimally the specialist referral process should take less than 30 days from referral to appointment. We monitor this standard annually using the Consumer Assessment of Health Plans Survey (CAHPS) member satisfaction survey. We adjust our goals by market depending upon past performance and national percentile benchmarks.
            Our standards are as follows:
      •     Routine Appointment: 30 days
      •     Specialist Appointment: 30 calendar days
      •     Urgent Care: 24 hours
            A primary care physician (PCP) in a participating Express Referrals provider group may refer a member to a specialist in one of many specialties in their group without prior authorization from the group’s utilization review committee. Members pay their normal office visit co-payment for a referral to a specialist.
2. Do you have any conditions/diagnoses/symptoms that are referred automatically?
      Aetna:      Yes.
      Blue Cross: Automatic referrals for conditions, diagnoses, and symptoms are determined by the PCP, PMG/IPA. Members can self-refer to the Ob/Gyn, ENT, allergists, and dermatologists within our contracted PMGs
      Blue Shield:      Yes, members have access to services through our Access+ Specialist self-referral process and direct access to OB/GYN care and second opinion specialists outside the IPA/medical group. Likewise, they can be referred automatically to mental health and substance abuse services provided by our Managed Behavioral Health Organization. Otherwise, the IPAs/medical groups determine their referral policy for our HMO network.
      CIGNA:      Yes.
      Health Net of CA:      Health Net delegates medical management activities to participating provider groups (PPGs). Each PPG has its pre-certification requirements and systems, which may include direct access to specialty care. Authorization for specialty consultations is not required for or membership that is not delegated to a PPG for management, such as Health Net’s Direct Network HMO membership or other fee-for-service membership.
      Kaiser Permanente: Yes, our plan physicians refer to some conditions, diagnoses, and symptoms automatically. Members have direct access to all primary care services and can easily self-refer to specialty care in the Obstetrics/Gynecology, Optometry, Psychiatry, and Chemical Dependency/Addiction Medicine Departments. At some facilities, members may also self-refer for mammograms and Ophthalmology and Dermatology Department services.
      PacifiCare: Yes.
3. Can a pregnant member go directly to a ­gynecologist without waiting for approval?
      Aetna:      Yes
      Blue Cross: Yes, pregnant members can self-refer to an obstetrician/gynecologist within the PMG/IPA.
      Blue Shield:      Yes, women may self-refer to an obstetrician or OB/GYN or family practice physician in their PCP’s IPA or medical group for OB/GYN services. This is not considered an Access+self referral, so the member would be charged the regular office visit co-pay. Additionally, if a network IPA or medical group contracts with an OB/GYN physician as a network PCP, the OB/GYN may be available to be chosen as a primary care physician.
      CIGNA:      Yes
      Health Net of CA:      Yes.
      Kaiser Permanente: Yes, members can self-refer to some of our specialty and diagnostic services including obstetrics/gynecology.
      PacifiCare: Yes.
4. Do you have self-referral to a gynecologist for an annual well-woman exam?
      Aetna:      Yes
      Blue Cross: Yes, members can self-refer to a gynecologist within the PMG/IPA for an annual well-woman exam.
      Blue Shield:      Yes, women may self-refer to an obstetrician or OB/GYN or family practice physician in their PCP’s IPA or medical group for OB/GYN services including an annual well-woman exam.
      CIGNA:      Yes
      Health Net of CA:      Yes.
      Kaiser Permanente: Yes, members can self-refer to some of our specialty and diagnostic services including obstetrics/gynecology.
      PacifiCare:       Yes.
5. Can a member with severe back pain get an appointment with an orthopedist immediately?
      Aetna:      It is determined by the PCP
      Blue Cross: Requests for orthopedic emergencies, including severe pain, do not require prior authorization. An urgent referral to a specialist is determined by the PCP/PMG/IPA and typically requires a 72-hour response time for authorization of services.
      Blue Shield:      Yes
      CIGNA:      Members in our Open Access Plus and PPO products can go to any specialist directly. Other members should confer with their primary care physician who can contact an orthopedist or other specialist (neurosurgeon, neurologist) to arrange for an immediate appointment. At the direction of the physician, a member can also be enrolled in CIGNA HealthCare’s WellAware disease management program for lower back pain. A registered nurse would help coordinate timely care.
      Health Net of CA:      Yes, as an emergency.
      Blue Cross: Requests for orthopedic emergencies, including severe pain, do not require prior authorization. An urgent referral to a specialist is determined by the PCP/PMG/IPA and typically requires a 72-hour response time for authorization of services.
      Kaiser Permanente: Yes, our primary care physicians can refer to appropriate specialists internally and without prior authorization.
      PacifiCare: Yes, with a PCP referral.
6. How long does it take to get an MRI or equivalent test when a lump is found in a member’s breast or uterus?
      Aetna:      It is determined by the PCP.
      Blue Cross: An urgent referral for diagnostic tests is determined by the PCP/PMG/IPA and typically requires a 72-hour response time for authorization of services. Emergency referrals are determined by the PCP/PMG/IPA.
      Blue Shield:      Seven days or immediately in an emergency.
      CIGNA:      The member’s physician determines the exact time frame. But an appointment can be made immediately if medically necessary.
      Health Net of CA:      Health Net delegates utilization management activities to medical groups. Therefore, if the member belongs to a delegated participating provider group (PPG), the PPG has its own pre-certification requirements, and an MRI may or may not require pre-certification. If the member does not belong to a delegated PPG and Health Net is responsible for conducting utilization management, pre-certification is required for MRIs. Health Net processes urgent pre-certification requests within 72 hours of receipt of all information. Requests for elective MRIs are processed within five business days.
      Kaiser Permanente: Members get MRIs or equivalent tests based on their physician’s clinical decision without the need of heath plan authorization. The wait time for a test is based on clinical urgency and can be shortened at the referring physician’s request.
      PacifiCare: Immediately.
7. Can the member get a second opinion outside of the IPA or the medical group?
      Aetna:      When medically appropriate
      Blue Cross: Yes, members have the right to a second opinion from a qualified healthcare professional within the Blue Cross HMO network.
       Blue Shield:     Yes, all Access+ HMO members have the right to get a referral for a second opinion from their personal physician. Second opinions about care received from a personal physician will generally be provided by a physician within the same medical group/IPA. Second opinions about care received from a specialist may be provided by any specialist of the same or equivalent specialty in Blue Shield’s HMO network. All second opinion consultations require Blue Shield authorization.
      CIGNA:      Yes
      Health Net of CA:      Yes, a member’s authorized representative or provider may request a second opinion for medical, surgical, or behavioral health conditions.
      Kaiser Permanente: Yes, however as a multi-specialty group model health plan, second opinions outside of our medical group are not generally required. Our members can get a second medical opinion from a plan physician upon request. Physicians can refer members to non-plan providers for a second opinion when medical expertise relevant to the member’s condition is not available internally.
      PacifiCare: Members can get a second opinion in accordance with the specifications of the evidence of coverage (EOC) and disclosure form, as summarized below.
      A second medical opinion is a reevaluation of your condition or health care treatment by an appropriately qualified provider. This provider must be either a primary care physician or a specialist acting within his or her scope of practice, and must possess the clinical background necessary for examining the illness or condition associated with the request for a second medical opinion. Upon completing the examination, the provider’s opinion is included in a consultation report.
     Either the patient or the treating participating provider may submit a request for a second medical opinion.
8. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?
      Aetna:      For our delegated groups, decisions are made by the PCP with their PMG/IPA. The health plan makes this determination for the non-delegated groups.
      Blue Cross: Decisions are made at the PMG/IPA level with the plan performing periodic audits to ensure timely, accurate, and appropriate medical management.
      Blue Shield:      These decisions are made at the IPA/medical group level. Blue Shield can be involved in the event there is a dispute about appropriateness or if a member is dissatisfied.
      CIGNA:      Primary and specialty care providers make decisions about referrals, testing, and treatment. At times, they may coordinate care with their medical groups or IPAs. Hospitalization can require CIGNA authorization.
      Health Net of CA:      A Health Net member’s PCPs and the member’s participating provider group (PPG) authorize all treatment, including referrals. A Member with a chronic condition or disease that requires continuing specialized medical care is eligible for a standing referral to a specialist. A standing referral allows extended access to a specialist for members who have life-threatening, degenerative, or disabling conditions, such as HIV/AIDS. Health Net refers members to practitioners who have demonstrated expertise in treating a condition or disease involving a complicated treatment regimen that requires ongoing monitoring.
      Kaiser Permanente: The member’s primary care physician makes the decisions about specialist referrals, testing, treatment, surgery, and hospitalization. Our physicians do not need authorization for their medical decisions.
      PacifiCare: Our contracted PCPs serve as gatekeepers, acting as the single point of contact, resource, and consultation for all health services provided to members, including specialty referrals. We believe this approach promotes familiarity with the member’s medical history and permits a single physician to monitor the member through complete episodes of care. These physicians look at the whole medical picture, as opposed to looking just at symptoms from a specialist’s point of view. This method reinforces a strong doctor-patient relationship; provides early detection of medical problems, and ensures that medical referrals are appropriate and necessary.
9. What criteria are used to authorize/deny ­specialist referrals, treatments, or tests?
      Aetna:      There is a variety of reference tools, including Milliman and many that the plan has developed and copyrighted. All denials for medical necessity must be made by a medical director. In addition, the plan has adopted an external review process for all fully insured members.
      Blue Cross: Referral processes are delegated to PMGs/IPAs. Blue Cross requires PMGs/IPAs to have established review mechanisms, such as evidenced-based decision criteria. If Blue Cross has a medical policy on a specific technology or therapy, PMGs/IPAs are required to follow it. 
      Blue Shield:      In addition to their own medical necessity criteria, Blue Shield’s contracted IPA/medical groups are required to refer to the Blue Shield Medical Policy and HMO Benefit Guidelines in authorizing/denying specialist referrals, treatments, or tests. The IPA/medical groups’ criteria must be consistent with Blue Shield’s criteria. Blue Shield of California uses nationally recognized utilization management criteria such as InterQual Criteria to determine medical necessity. Medical literature and patient clinical information are also taken into consideration.
      CIGNA:      CIGNA uses Milliman care guidelines. In addition, CIGNA continually assesses developing technologies using evidence-based medicine and independent expert opinion to develop coverage positions, which are posted on the Internet.
     Health Net of CA:      Health Net utilizes established written guidelines, such as InterQual Clinical criteria, along with the Health Net Medical Policy Manual, clinical practice guidelines, and the Schedule of Benefits.
      Kaiser Permanente: Our physicians are not required to seek authorization for medical services.
      PacifiCare: We require our provider groups to demonstrate the use of appropriate medical management guidelines. We conduct annual reviews of written procedures and consider the following factors for cases that may not meet criteria: age, co-morbidities and complications, response to treatment, the psychosocial situation, and home environment. We use written criteria based on sound clinical evidence and specific procedures for applying the criteria to make utilization decisions. In addition, we apply objective and evidence based criteria and consider individual circumstances and the local delivery system. We require our delegated providers to do the same.
10. Are you monitoring the length of time for referral authori­zations? What are you doing to reduce or eliminate delays?
      Aetna:      Yes, timeliness of decisions is part of monthly case assessment audit. Turn-around time is monitored by annual audits and quarterly report submissions. Audits and training address performance gaps.
      Blue Cross: PMGs/IPAs must have a system to monitor utilization review activities. Blue Cross evaluates compliance with federal, regulatory, and Blue Cross timeliness standards through annual on-site audits. If non-compliance is detected, a corrective action plan is presented and a subsequent audit is conducted in 180 days. Blue Cross also monitors this process through the grievance process.
      Blue Shield:      Blue Shield’s contracted IPA/medical groups are responsible for the timeliness of referral authorization decisions. They must comply with our standard of two working days to receive all the necessary information for a non-urgent referral, one calendar day for urgent referral/treatment, and immediately for emergency care. Blue Shield delegated oversight consultant nurses perform annual audits to ensure timeliness standards are met. An IPA/medical group that does not meet timeliness standards for utilization management must take corrective action.
      CIGNA:      CIGNA works closely with physicians and medical groups to expedite referrals and regularly measures member satisfaction with the referral process.
      Health Net of CA:      Yes, it is done through access audit reports, member satisfaction surveys, HEDIS indicators, physician profiles, medical group comparison reports, and member complaints. Delays are remedied through corrective action.
      Kaiser Permanente: Yes, we review our wait time constantly and develop tools to reduce that wait time that are appropriate to each medical center.
      PacifiCare: Yes, we perform annual utilization management assessments of delegated providers, including re-audits as needed, to ensure provider groups are compliant with our standards. As part of the assessment, we review a random selection of up to 30 pre-service denials, 30 concurrent denials and 30 retrospective denials (primarily emergency room services) to allow for a full review of authorization patterns, including those for authorizations for referrals. Additionally, we require provider groups to submit for our approval all changes to their denial notices prior to issuance. The groups must submit utilization data at least quarterly. Where organized provider groups are the predominate system of care, we monitor quarterly provider information related to under-utilization, appeals and grievances to identify trends in delays or denial of service.
11. What are the criteria and processes for getting a referral to a specialist outside of the MG/IPA or plan?
      Aetna:      Out-of-plan approval is done if one or more of these criteria are met: required services not available within the group or network; required non-emergency service available within the plan option, but is not accessible within reasonable timeframe; or the patient is a new member and was previously receiving services from an out-of-plan provider (reviewed on case-by-case basis).
      Blue Cross: Our criteria are consistent with guidelines enacted by state law, which require second opinions outside of the PMG/IPA if an original opinion is from a specialist within the PMG/IPA. If a needed specialty is not available within an assigned PMG/IPA, the PMG/IPA must arrange for the member to be seen by the appropriate specialty. The Blue Cross Transition Assistance Unit facilitates second opinions outside of the PMG/IPA when requested by the member or provider.
      Blue Shield:      Personal physicians may refer patients out of the network with the agreement of the IPA/medical group and/or authorization from Blue Shield. Blue Shield is only involved in referrals when an IPA/medical group wants to refer out of network and not be financially responsible. The IPA/medical group would then contact Blue Shield for authorization and request that Blue Shield be financially liable.
      CIGNA:      A primary care physician can request referral for service outside the medical group or plan when those services are not otherwise available. Members can also contact CIGNA directly to arrange a second opinion.
      Health Net of CA:      Health Net’s contracted participating provider groups (PPGs) are delegated to provide member care including all specialty referrals. If the PPG does not have a particular kind of specialist with which it contracts, the PPG is still responsible to find a specialist out of its network for the member. The PPG has the financial responsibility for paying the specialist. The PPG may deny the request if it has a particular kind of specialist within its network and a member requests to see a specialist that is outside the PPG’s network. The member has the option to appeal the denial with Health Net.
      Kaiser Permanente: Our physicians handle all referrals within our medical groups. Any Kaiser Permanente physician can request necessary care from an outside provider.
      PacifiCare: Our contracted provider network is comprehensive and provides a qualified specialist for every covered benefit. When a service is not available within a member’s provider group, the member receives a referral to a qualified provider or specialist outside the member’s provider group, but contracted with PacifiCare. Either the provider group or we will assess the medical necessity for these requests and authorize care as necessary
            Referrals to non-contracted providers rarely happen, generally only in emergencies or for specialized services not available through a contracted provider; therefore, we do not track this statistic.
12. What complementary medical disciplines are or will be covered?
      Aetna:      Chiro rider. Acupuncture is covered when administered.
      Blue Cross: Blue Cross offers coverage for medically necessary chiropractic, acupuncture, and biofeedback based on a member’s plan design. We also offer a variety of discounted complementary products and services through our HealthyExtensions program, such as massage therapy and hypnotherapy.
      Blue Shield:      Substance abuse rider; chiropractic care rider; acupuncture services; specialty dental care coverage; discount programs for chiropractic, acupuncture and massage therapy; and vision supplies and services. Resources are available to members on the phone, online (www.blueshieldca.com) and in person, including nurses and counselors and health-management programs for chronic diseases, childbirth, newborns, and recovery from surgery.
      CIGNA:      When medically necessary, some members can access acupuncture and chiropractic services as a component of short-term rehabilitation. Other benefit plans offer homeopathic and naturopathic services as riders. In addition, CIGNA’s Healthy Rewards program offers members alternative/complementary medicine and other health related discount programs for the following services: acupuncture, chiropractic services, fitness club membership, hearing care/instruments, laser vision surgery, massage therapy, vitamins and herbal supplements and non-prescription medications, Mayo Clinic books on health, and smoking cessation programs.
      Health Net of CA:      Health Net of California offers chiropractic and acupuncture benefits as supplemental benefit riders to its traditional medical benefit plans. The riders may be purchased with the HMO and POS medical plans. They are designed to complement the benefits plans, rather than replace them. The rider is only available to groups. A variety of benefit plan designs is available including chiropractic only, acupuncture only, and a combination of chiropractic and acupuncture benefits.
      Kaiser Permanente: We offer a supplemental chiropractic benefit. Kaiser Permanente also covers acupuncture when medically necessary as part of a pain-management program.
      PacifiCare: PacifiCare of California does not offer alternative medicine benefits as part of its design. However, all members have access to discounts on alternative medicine benefits through an affinity program. Employer groups can purchase supplemental plans that cover acupuncture and chiropractic benefits.
13. Do you cover blood tests for prostate cancer for non-symptomatic men? If so, at what age?
      Aetna:      Yes, age 40+.
      Blue Cross: Yes, Blue Cross covers screenings for prostate cancer including, but not limited to, prostate specific antigen (PSA) testing when medically necessary and consistent with good professional practice, regardless of age.
      Blue Shield:      Yes, regardless of age.
      CIGNA:      Yes, for men over 50 annually or more frequently when medically indicated.
      Health Net of CA:      Yes, as determined by the PCP.
      Kaiser Permanente: Yes, we cover blood tests for prostate cancer for non-symptomatic men at any age.
      PacifiCare: Yes, these blood tests are covered benefits. The member’s primary care physician determines the necessity of this and all other blood tests.
14. Do you cover mammograms for women with no history of breast cancer?
      Aetna:      Baseline at age 35, annually 40+.
      Blue Cross: Yes, Blue Cross covers mammograms for women with no history of breast cancer with PCP referral and when determined to be medically necessary.
      Blue Shield:      Yes, with a personal physician referral.
      CIGNA:      Yes, for women over 40 annually or more frequently when medically indicated.
      Health Net of CA:      Yes, typically, every one to two years from ages 40 to 65+, but the PCP may authorize mammograms at their discretion.
      Kaiser Permanente: Yes, we cover mammograms for women with no history of breast cancer.
      PacifiCare: Yes, mammograms for women with no history of breast cancer are covered in accordance with U.S. Preventive Services Task Force Guidelines.
15. Do you have an open drug formulary?
      Aetna:      Yes.
      Blue Cross:       Yes, Blue Cross offers a comprehensive formulary that includes various benefit designs from which a client can choose. Options may include an open formulary, a closed formulary, and a selective or partially closed formulary.
      Blue Shield:      Blue Shield’s Access+ HMO plans include a three-tiered open formulary benefit or a two-tier (generic and brand) closed formulary benefit that requires prior authorization of non-formulary drugs.
      CIGNA:      We use a closed drug formulary. However, employers can choose a three-tier or two-tier pharmacy plan if specified and agreed to in the contract. The three-tier plan offers non-formulary drug coverage without submission of a non-formulary request, but at a higher co-payment.
      Health Net of CA:      Health Net offers a recommended drug list, which can be closed, open, or three-tier (generic, brand, and non-recommended drug list).
      Kaiser Permanente: No, we do not have an open drug formulary.
      PacifiCare: No, we use several managed (closed) formularies at different tier levels, but we do not offer an open formulary.
16. If a closed formulary, what happens if a non-formulary drug is necessary?
      Aetna:      Not applicable.
      Blue Cross: Non-formulary drugs may be approved upon review through a prior authorization process.
      Blue Shield:      For non-formulary drugs that are not covered, prior authorization may be requested by the physician for medical reasons, such as documented treatment failure or adverse drug reactions to formulary drugs. The HMO plan with a three-tier co-payment benefit provides the same coverage as a two-tier benefit, but has coverage for non-formulary brand name drugs. In all plans, select formulary drugs, non-formulary or drug dosages/quantities require prior authorization for medical necessity.
      CIGNA:      The member or their physician can ask for an exception to get a non-formulary drug. CIGNA HealthCare’s clinical staff reviews the request.
      Health Net of CA:      Drugs not listed in our recommended drug list may be covered through our prior approval process when medically necessary, unless specifically excluded or limited in the evidence of coverage. The normal process is to have the prescribing physician call Health Net and provide the medical reasons for the non-formulary medication. While physicians can prescribe non-recommended drug list medications, some drugs may require prior authorization to determine appropriate medical indications. If a medication is denied, members are notified that they are entitled to appeal the decision according to the procedures set forth in the Evidence of Coverage. Every member can appeal a non-formulary, non-covered request. Members with a three-tier benefit can get drugs that are not on the recommended drug list at a higher co-payment.
      Kaiser Permanente: Our physicians manage the drug formulary and have the discretion to prescribe all medically necessary non-formulary drugs. If it is not medically appropriate to change a patient’s prescription from a non-formulary to a formulary drug, the physician can authorize the use of the non-formulary drug. With this authorization, the member gets the non-formulary drug at the regular co-payment. If the member prefers a non-formulary drug that is not medically necessary, the member pays the full member price for the prescription.
      PacifiCare: Medically necessary non-formulary medications can be approved through our preauthorization exceptions process.
17. Do you have an experimental/investigative exclusion? If so, how does it work?
      Blue Shield:      Yes, the plan has adopted BlueCross/BlueShield Association technology assessment criteria to evaluate whether technology improves health outcomes. Drugs that are considered experimental or investigational, or that are not recognized in accordance with generally accepted medical standards, are not covered in Blue Shield’s formulary.
      Blue Cross: Yes, however, all treatment decisions are based on medical necessity as it applies to a member’s condition. A request would be denied for a procedure that is considered experimental or investigative for a member whose condition has no unique or discerning characteristics. If we determine that a requested procedure does not meet our medical necessity criteria, the member can request an independent medical review. Our corporate Medical Policy and Technology Committee evaluates new procedures for incorporation into benefit plans.
      CIGNA:      Yes, a CIGNA medical director makes evidence-based decisions about an experimental/investigational request based on the available medical literature, expert opinion, and the facts of the case. Coverage positions are developed on a regular basis assessing emerging technologies; they are posted on the Internet. Providers can access CIGNA HealthCare’s Web-based provider portal to request reviews of technologies for which coverage positions have not yet been developed. CIGNA HealthCare also uses a formal independent expert review process when appropriate.
      Health Net of CA:      Health Net does not cover experimental or  investigational drugs, devices, procedures, or therapies. The member can request an independent medical review of Health Net’s decision from the California Department of Managed Healthcare if Health Net denies or delays coverage for a requested treatment on the basis that it is experimental or investigational. The member can request the review if the following criteria are met:
            • The member has a life-threatening or seriously debilitating condition.
            • The member’s physician certifies to Health Net that the member has a life-threatening or seriously debilitating condition for which standard therapies have not been effective or are otherwise medically inappropriate.
            • There is no more beneficial therapy covered by Health Net.
            • The member’s physician certifies that the proposed experimental or investigational therapy is likely to be more beneficial than available standard therapies. As an alternative, the member can submit a request for a therapy that is likely to be more beneficial than available standard therapies based on documentation presented from the medical and scientific evidence.
      Kaiser Permanente: Yes, services or supplies are considered experimental if generally accepted medical standards do not recognize them as safe and effective for treating the condition or if government approval has not been obtained when the services or supplies are to be provided. Some members are eligible for independent external review of plan denials.
      PacifiCare: Yes. We have an experimental/investigative exclusion.
            Experimental and/or Investigational Procedures, Items and Treatments are not covered unless required by an external, independent review panel as described in Section Eight of this Combined Evidence of Coverage and Disclosure Form. Unless otherwise required by federal or state law, decisions as to whether a particular treatment is Experimental or Investigational and therefore not a covered benefit are determined by a PacifiCare Medical Director, or his or her designee. A Member with a Life Threatening or Seriously Debilitating condition may be entitled to an expedited external, independent review of PacifiCare’s coverage determination about Experimental or Investigational therapies as described in Section Eight: Overseeing Your Health Care, Experimental or Investigational Treatment.
18. What are the most frequently requested procedures presently being denied on the basis of experimental/investigative or not medically necessary exclusions?
      Aetna:      This information is not readily available.
      Blue Cross: It includes the artificial disc for degenerative disc disease, since this new device does not yet have sufficient long-term studies to show efficacy. The most frequently denied requested service under not medically necessary is the referral to a non-contracted provider when a qualified contracted provider is available.
      Blue Shield:      The most frequently denied procedures due to the absence of medical necessity or because they are considered experimental/investigational are the following:
      •     Bariatric surgery – Morbid obesity surgery
      •     Reduction mammoplasty
      •     Varicose Veins
      •     MRI of the Breast
      •     Pet Scan for Breasts
      CIGNA:      This data is not available.
      Health Net of CA:      The most frequently denied requested procedures are those that are not FDA approved/accepted in the medical community as standard, safe, and effective.
      Kaiser Permanente: If a plan physician determines that a procedure or service is medically appropriate for a member and its omission would adversely affect the member’s health, it is considered medically necessary. As a result, we do not consider a medically necessary service or procedure to be exclusion. Additionally, we do not deny experimental or investigative procedures if they are considered medically necessary and appropriate for the member’s care. All procedures and treatments are reviewed on a case-by-case basis with the determination for care made by the physician.
      PacifiCare: This information is not available. We do not track the number most frequently denied investigational/experimental or not medically necessary procedures. We do track appeals and grievances. If a member appealed a denial, and it was due to one of the above reasons, we may be able to provide that procedure; however, it would not apply to our book of business.
19. What is the standard hospitalization for normal and a Caesarean birth?
      Aetna:      It is determined by the physician.
      Blue Shield:      Two days for a normal birth and four days for a Caesarean. Blue Shield’s actual hospitalization was 1.99 days for vaginal deliveries and 3.52 days for caesarian deliveries as reported to HEDIS for the 2006 measurement year.
      CIGNA:      Typical hospitalization is not less than 48 hours for normal vaginal delivery and not less than 96 hours for a caesarian section. But this can be modified based on the physician’s recommendations.
      Health Net of CA:      Standard hospitalization for normal birth is two days. For Caesarean birth, it’s four days.
      Kaiser Permanente: In Northern California, it is 1.89 for a normal birth and 3.43 for a Caesarean. In Southern California, it is 1.86 for a normal and 3.36 for a Caesarean. (Data source: YE2005 HEDIS)
      PacifiCare: The average length of stay is two days for a normal birth and four days for a Caesarean.
20. What is the number of hospital days utilized in a year for every thousand members?
      Blue Shield:      175.55 for general hospital and acute care.
      CIGNA:      171
      Health Net of CA:      203.78
      Kaiser Permanente: In Northern California, it is 3.34. In Southern California, it is 3.17 (Data source: YE2005 HEDIS)
      PacifiCare: Our total in-patient utilization in 2006 was 160.92 per 1,000 members.
21. What are your loss ratios, administration/medical?
      Aetna:      We do not report locally.
      Blue Shield:      We do not report individual HMO loss ratios. Instead, we produce a consolidated report for all of our products.
      Health Net of CA:      Medical: 85.8%/administrative: 9.8%
      Kaiser Permanente: Operating expense as a percentage of revenue is not available. Administrative expense as a percentage of revenue is 4.13%. Medical and hospital expense as a percentage of revenue is 99.88%. (Data source: 2005 DMHC Report.) (Please note that the full Department of Managed Healthcare filing includes the regions of Northern and Southern California and Hawaii combined.)
      PacifiCare: As of December 31, 2006, our commercial medical loss ratio for PacifiCare of California is 85.1%. The administrative ratio is 7.8%.
22. Is your plan NCQA accredited?
      Aetna:      Yes, Aetna Health of CA, Inc is accredited and has received Quality Plus distinction in Care Management, Physician, and Hospital Quality.
      Blue Cross: NCQA has awarded Blue Cross of California’s  Commercial HMO/POS products its highest accreditation status of Excellent for service and clinical quality.
      Blue Shield:      Yes, in 2005, the NCQA granted Blue Shield’s HMO and point-of-service plans an Excellent accreditation, the highest possible rating.
      CIGNA:      Yes, CIGNA HealthCare has an Excellent accreditation designation.
      Health Net of CA:      Yes. Commercial HMO and POS and Medicare lines of business have received the excellent accreditation status from the National Committee for Quality Assurance (NCQA).
      Kaiser Permanente: Kaiser Permanente in Northern and Southern California earned ratings of Excellent in the most recent surveys by the NCQA in the commercial HMO and Medicare-contracted product lines.
      PacifiCare: Yes. PacifiCare of California maintains an Excellent accreditation rating.
23. What is your ratio of PCPs vs. specialists?
      Aetna:      1/3.7
      CIGNA:      1/2.72
      Health Net of CA:      1:2.2
      Kaiser Permanente: Not available.
      PacifiCare: As of June 30, 2007, our ratio of PCPs to specialists is 1  to 3.1.
24. What is your ratio of members to PCPs? (members: PCP)
      Aetna:      31.1/1
      Blue Shield:      1:1.77
      CIGNA:      35/1
      Health Net of CA:      90:1
      PacifiCare: As of June 30, 2007, our ratio of members to PCPs is 131 to 1.
25. Does your contract include binding arbitration?
      Aetna:      Yes
      Blue Cross: Yes
      Blue Shield:      Yes, the majority of our contracts with providers do require binding arbitration to resolve disputes.
      Health Net of CA:      Yes.
      Kaiser Permanente: Yes
      PacifiCare: Yes, our contract includes binding arbitration.
26. How often can members change their PCP at will?
      Aetna:      There is no limit.
      Blue Cross: Monthly.
      Blue Shield:      Our Access+ HMO members may change their personal physician without cause once a month. This change is effective the first day of the month following notice of change.
      CIGNA:      There are no specific limits; however, we encourage our members to stay with one primary care physician to ensure more effective care management. We also recommend that our members do not change their doctor while in the middle of care, to the extent possible. Otherwise, a member can change their primary care physician effective the first of the month following the request.
      Health Net of CA:      Members may change PCPs within a physician group or from one physician group to another once per month.
      Kaiser Permanente: There is no limit. Members can change their physician at any time.
      PacifiCare: Members may request a change of individual provider or provider group at any time, for any reason. Requests received between the first and the 15th of a month take effect on the first day of the next month. Requests received between the 16th and the end of the month take effect on the first day of the second month. Members must select participating providers accepting new patients within 30 miles of their home or work and can identify which providers are accepting new patients by calling our Customer Service department, looking in our provider directory, or visiting our Web site.
27. Do you offer a performance guaranty (i.e. employees will be on the computer by a certain date or have ID cards by a certain date)?
      Blue Cross: Yes, Blue Cross can offer standard performance  guarantees to our clients; guarantees may also be customized on a case-by-case basis. Blue Shield: Yes, we offer performance guarantees for groups with a qualifying minimum subscribership.
      CIGNA:      Yes, in most instances, we can work with a company to develop appropriate performance guarantees.
      Health Net of CA:      Yes, We are willing to place an appropriate amount at risk for compliance with performance standards that Health Net and the employer group have established and agreed upon. The standards, methodology, and breakdown of amounts at risk can be negotiated once all performance guarantees are finalized and the group meets the eligibility requirements for performance standard consideration. An employer group must maintain a minimum of 1,000 subscribers in a Health Net plan to be eligible to participate in performance guarantees. All standards and guarantees need to be finalized at least three months before the group’s effective date and are in force for one plan year. Due to the evolving nature of our industry, Health Net reserves the right to re-negotiate performance guarantees at the end of each plan year.
      Kaiser Permanente: Yes, we offer a performance guaranty on a group-by-group basis.
      PacifiCare: We may agree to performance guarantees upon approval and if the client meets our standard requirements for enterprise-wide performance standards. However, we typically do not agree to performance guarantees for fully insured groups.
28. When a member moves out of state, is any transition coverage available?
      Blue Cross: Blue Cross’ HMO product is only available in California. Therefore, a member who moves move out of state would no longer be eligible for a Blue Cross HMO plan. Transition assistance is provided for members who have a POS/PPO plan, for relocations involving a new employer, merger, or acquisition.
      Blue Shield:      Yes, if a subscriber moves out of state to an area served by another Blue Cross and/or Blue Shield plan, the subscriber’s coverage may be transferred to the plan serving his new address. The new plan must offer the subscriber at least its group conversion policy.
      CIGNA:      Yes, if we offer similar coverage to the account in that state.
      Health Net of CA:      Yes, through PPO, POS, and indemnity lines of business.
      Kaiser Permanente: Yes, transition coverage is available to members.
      PacifiCare: If a member moves out of the state permanently, they are no longer in our service area and would be terminated from the plan. Members must live within our service area to be eligible for continued enrollment in our health plan. Members traveling outside their PacifiCare service area for a limited time are covered for emergency services. This also applies to out-of-area student dependents who must also maintain a permanent residence within the service area in order to enroll in the health the plan.

Part II of the HMO Survey

29. Describe the utilization process.

Aetna: Information is gathered from the physician and patient. The nurse consultant or physician reviewer and the attending physician discuss whether a test or treatment is appropriate. The physician reviewer can recommend alternative treatment and further testing. Protocol is reviewed annually; the consulting specialists, who are most familiar with procedure, review and approve any changes.

Blue Cross: The utilization management process is delegated to the PMGs/IPAs for our HMO product. They must have established review mechanisms, such as evidenced-based decision criteria and guidelines, which align with accepted medical practice. PMGs/IPAs maintain structured processes for referral management, pre-service, con, and post-service review. Routine and active oversight is conducted to ensure compliance with regulatory and accrediting agency standards.

Blue Shield: We delegate our utilization management services to our contracted IPAs/medical groups. We conduct annual audits of their utilization management process to ensure compliance with our medical policy guidelines.

CIGNA: CIGNA physicians and nurses perform utilization management for inpatients in coordination with medical groups. To help ensure appropriate care and facilitate discharge planning, CIGNA reviews medical records for hospitalized members and consults with physicians via nurses located on-site at hospitals or by phone. Utilization review for most outpatient services is delegated to IPAs/Medical Groups. Inpatient procedures and hospitalizations, outpatient surgical procedures performed in a facility, transplants, and investigational therapies are reviewed directly by CIGNA HealthCare using Milliman Care Guidelines and CIGNA Coverage Positions. CIGNA utilization nurses (RNs), also conduct case management. Most outpatient referrals for specialists and procedures do not require prior authorization as long as they are requested by the primary care physician, but CIGNA performs utilization review of select outpatient services when there is demonstrated value.

Health Net of CA: Health Net operates a multi-dimensional utilization/case management (UM/CM) program to direct and monitor healthcare services. It involves pre-service, con, and post-service evaluation of the utilization of services provided to members. The UM/CM program is structured to ensure that qualified health professionals make medical decisions using written criteria based on sound clinical evidence without undue influence of Health Net management or concerns for the plan’s fiscal performance.

Kaiser Permanente: Kaiser Permanente physicians plan our patient’s care and work collaboratively with their peers to ensure appropriate treatment plans and use of resources. Utilization Management staff are available to support physicians in the management of member’s healthcare needs throughout the continuum of care and provide a variety of services such as discharge planning, utilization review, care management, and ensure compliance with internal and external regulatory requirements related to utilization management.

The majority of utilization management, including reviews, is conducted internally as part of our integrated system of healthcare delivery. Kaiser Foundation Health Plan Inc., Kaiser Foundation Hospitals, and the Permanente Medical Groups work in partnership to provide and coordinate medical management and review for our Health Plan members. Please note that department chiefs at the regional and facility levels handle utilization reviews. Members from Palm Springs, Ventura, and the Coachella Valley area receive utilization review via contracted physicians within our affiliated medical groups.

PacifiCare: We use industry-leading medical management programs to ensure that each enrollee receives the appropriate care necessary and that we control unnecessary healthcare costs for our clients. Our medical management programs focus on reducing variation, improving the quality of care provided and ensuring cost effectiveness. We base medical decisions on scientific evidence and all of our medical management services include physician guidance and input. We developed online, science-based and objective utilization management criteria as well as technology-based clinical decision support systems related to case, utilization, and disease management.

30. Describe the case management (CM) process.

Aetna: The following are some ways in which cases are identified: through the PCP or pharmacy, during certification reviews, during PMG/UM case reviews, and through other internal reporting and sources including member services, claims, and specialty programs. The case manager coordinates services for members with multiple and complex needs with the PCP and the member to develop a care plan identifying services, frequency, duration, and goals. We use a team approach. The team includes the PCP, the specialist, member, family, caregiver, and healthcare provider community. There are also internal programs to coordinate care. The focus is on educating members and maximizing quality outcomes.

Blue Cross: The participating medical groups/IPAs perform in-area case management functions. Blue Cross case managers support participating medical groups/IPAs for members with exceptional needs or complex medical conditions. When appropriate, they manage out-of-area emergency admissions and help with transfers to in-area care. They also facilitate communication between healthcare providers and ensure that appropriate follow-up care is arranged with the PMG/IPA.

Blue Shield: Case management is a voluntary program that focuses on early identifying and managing patients with potentially long-term and catastrophic healthcare needs. Candidates are identified during the pre-service, pre-admission, or con review process. Claims, authorization, and pharmacy data is used to identify potential candidates. The case manager helps identify appropriate cost-effective treatment options. Case management may follow members who are receiving alternative levels of care, such as inpatient rehabilitation, skilled nursing facility care, long-term home health services, and hospice services. Members utilizing an acute facility three or more times in a six-month period may also be identified for case management. Utilization management, claims, and other medical operations team members can request case management for specific situations. Family members and providers can also request case management.

CIGNA: Members are identified via real-time and claims-based predictive modeling tools, along with referrals from physicians and medical groups, CIGNA clinical staff, and employers. Case managers collaborate with physicians, medical group case managers, members, and employers to facilitate ongoing treatment plans and support the primary care physician. Case managers monitor short-term and long-term goals for inpatient and outpatient care. They document and evaluate the effectiveness of the services provided. Besides traditional complex and catastrophic case management, CIGNA has a number of specialty case management units. They are staffed with RNs who are dedicated to areas, such as high-risk maternity, neonatal intensive care, oncology, obesity, and transplant. CIGNA has an extensive suite of disease management programs, including those for obesity complications and depression. CIGNA also offers online access to wellness information, care management services, and health coaching programs.

Health Net of CA: Health Net and its delegates provide case management/disease management programs to deliver individualized assistance to members in all lines of business who are experiencing complex, acute, or catastrophic illnesses or have exceptional needs. Health Net’s approach to utilization management extends far beyond traditional oversight. Health Net provides outreach to members with sensitive conditions; uses population-based risk stratification and predictive modeling; and partners with physician groups to improve performance.

Kaiser Permanente: Case management is high-intensity, focused care for our sickest members, including those with high-risk pregnancies, cystic fibrosis, HIV/AIDS, end-stage renal disease, organ transplants, and complications from chronic conditions, as well as the frail elderly and the terminally ill. Members in need of case management are identified through clinical and utilization data from our disease registries, pharmacy records, hospital and outpatient visits, and laboratory results. Members can also self-refer to case management or be referred by a physician or family member. Our case managers are master’s-level clinicians or registered nurse

PacifiCare: We designed our case management program to identify, intervene, coordinate, and monitor care plans that provide high quality and cost-effective care for covered persons with catastrophic and complex healthcare needs. Our case managers facilitate communication and coordination of care among all parties on the healthcare team. This program involves the patient and family in the decision making process to minimize fragmentation in the delivery of healthcare. The case manager assesses the patient’s needs and educates them and the healthcare delivery team about case management, community resources, insurance benefits, cost factors, and all related topics so that informed decisions can be made. The case manager is the link among the patient, the providers, the payer, and community. Our case management unit is primarily staffed by registered nurses with certification in case management. A Licensed Clinical Social Worker (LCSW) augments the internal staff.

31. Can the PCP participate in profits or losses in any way at the plan level or the participating medical group/IPA level?

Aetna: In California, Aetna participates in the IHA/7 health plan program of Pay for Performance. PCPs can participate in that IPA P4P bonus.
Blue Cross: 
The participating medical groups/IPAs perform in-area case management functions. Blue Cross case managers support participating medical groups/IPAs for members who have exceptional needs or complex medical conditions. When appropriate, they manage out-of-area emergency admissions and help with transfers to in-area care. They also facilitate communication among healthcare providers and ensure that appropriate follow-up care is arranged with the PMG/IPA.

Blue Shield: No, the PCP does not participate in profits or losses.

CIGNA: The primary care physician does not participate in plan profits or losses in any way. The relationship between the PMG/IPA and the PCP is based on the contract between the two parties.

Health Net of CA: In 1993, Health Net of California introduced the Quality Care Improvement Program (QCIP). At the time, it based medical group compensation on member satisfaction scores. This program was enhanced in 1998 by incorporating quality of care outcomes into the compensation formula. In addition to contracted compensation, QCIP evaluates medical groups based on member satisfaction rates, quality of care outcomes, and collaboration. Health Net evaluates medical groups’ cost performance measures. Like most health plans in the country, we do this by utilizing shared-risk pools when determining compensation. This is where budgets are established for medical services and hospital care. If the services do not consume the budget, the group shares in the savings. Conversely, the group shares in paying for additional costs if the cost of care exceeds the budgeted amount. However, at no time do we favor cost performance over quality. Recently, other California health plans have added programs similar to QCIP.

Kaiser Permanente: All of our physicians are eligible for an incentive payment based on the performance of our organization. Performance is measured by the collective results of each medical center. Each individual at the medical center can enhance the performance of the entire group. Incentive payments are based on several criteria including quality of care and member/patient satisfaction.

PacifiCare: Medical groups and IPAs can earn additional revenue through a quality incentive program by improving and maintaining patient safety, patient satisfaction, and quality of care. The quality incentive program measures key indicators of quality in hospitals and medical groups based on the groups’ service and clinical quality. The quality incentive program rewards medical groups and IPAs for attaining the required performance. The better a provider group performs in these categories the more quality incentive program dollars they can earn. In 2004, our quality incentive program expanded to include 20 measures, 17of which improved an average of 20%. The incentive pool was $18 million in 2004 and $65 million in 2005. In 2006, we paid out more than $96 million.

32. How are the premium and risk shared among the plan, MG/IPA and PCP?

Aetna: Premium is not shared with providers. In California, we have some IPA risk share arrangements and an IPA or Medical Group share in savings if a target budget is not exceeded.

Blue Cross: For professional services, Blue Cross has a capitulated arrangement with the PMG/IPAs, which are responsible for payment of professional services. Clinical efficiency is promoted through a program of shared savings between the PMG/IPA and Blue Cross for expenditures related to inpatient care and generic pharmacy prescription.

Blue Shield: When no capitated hospital is associated with the medical group, we establish shared risk arrangements for medical groups, but not individual physicians. The shared risk arrangement does not affect payments to the group for professional services covered in the group’s capitation. The shared risk fund is set up to pay for services related to institutional fees. A fund is established for the group. Funding is made monthly and is tied to membership. Blue Shield makes payments from this fund for institutional services for group members. The group and Blue Shield share any money that’s left in the fund at the end of the year. A negative balance would carry over to the following year.

CIGNA: Most medical group and IPA arrangements are capitated.
Capitation does not contain provisions for withhold payments (For example, a lump sum that is withheld and distributed later if certain utilization targets are met by the provider). The standard contract is shared risk, with CIGNA retaining risk for inpatient facility charges.

Health Net of CA: The majority of HMO physician services are paid under a pre-paid capitation payment to the contracted Participating Physician Group (PPG). The PPG, in turn, reimburses the physician directly for services.

Kaiser Permanente: Kaiser Foundation Health Plan (KFHP) contracts with the Permanente Medical Group (TPMG) in Northern California, and the Southern California Permanente Medical Group (SCPMG) to provide comprehensive medical services to KFHP members. The contractual arrangements are reimbursed at negotiated capitation rates as set forth in itemized budgets. The medical groups are reimbursed at negotiated capitation rates. A small portion is paid on an actual cost basis for specific items. Subject to limits on risk sharing, the medical groups are fully at risk for the capitated portion. They share the risk equally with the health plan for the actual cost portion.

PacifiCare: All of our contracted medical groups and independent physician associations (IPA) participate in a risk-sharing arrangement. In addition, we contract with several networks of individual physicians in rural areas that do not participate in risk-sharing. We contract with multi-specialty medical groups and independent physician associations (IPA) primarily through split or professional capitation contracts. Both contracts provide a monthly age, gender and benefit adjusted capitation. The risk-sharing arrangements are:

33. What happens when a member provider bills a participant for services? How do you deal with the fact that the participant is at financial or credit risk in a dispute between the provider and the plan?

Aetna: Participating providers are required to accept payment (plus member’s co-payment) as payment in full. Balance billing is not permitted.

Blue Cross: Our first priority is to protect our membership from inappropriate billing. Our HMO providers are contractually required to refrain from billing members except for co-payments. If a participating provider bills a member, it is brought to the attention of the PMG/IPA liaison and the PMG is directed to pay the claim. If the PMG does not pay the clean, authorized claim in 45 days from receipt, the plan pays the bill and debits the PMGOs capitation payment for the ensuing period.

Blue Shield: Typically, our customer service representatives can resolve this type of case by contacting the provider’s office to clarify the correct patient liability. Providers are contractually prohibited from holding members responsible for any charges other than deductibles, co-payments, or non-covered services. Contracted in-network physicians should bill members directly for services, so we ask that our members call member services for assistance in handling this situation.

Health Net of CA: Health Net’s HMO contracts have a hold-harmless clause that prohibits medical groups from billing or collecting from members, except for standard co-payments and non-covered services. In the event of a balance bill, Health Net removes the member from the situation and resolves the matter directly with the provider.

Kaiser Permanente: Kaiser Permanente is a prepaid, group practice HMO. Kaiser Foundation Health Plan (KFHP) contracts with The Permanente Medical Group (TPMG) in Northern California, and the Southern California Permanente Medical Group (SCPMG) to provide comprehensive medical services exclusively to KFHP members. Providers do not bill members for services. Our providers are reimbursed at negotiated capitation rates; therefore, no disputes between the providers and the health plan would put members at financial or credit risk.

34. Do you have a nurse on call 24 hours for questions at the plan level? At the PMG/IPA level?

Aetna: Yes, the Informed Health nurse-line is available to members. Network doctors are required to be available 24 hours a day.
Blue Cross: 
At the plan level, no. PMG/IPAs are required to provide 24-hour phone access.

Blue Shield: Yes, as part of our NurseHelp 24/7 program, members may receive around-the clock online and telephone access to a registered nurse. They get confidential advice and information about minor illnesses and injuries, chronic conditions, fitness, nutrition, and health related topics.

CIGNA: Yes, CIGNA offers a 24-hour health information line staffed with licensed nurses.

Health Net of CA: Health Net has Decision Power, which focuses on coaching for chronic disease, significant medical conditions, and medical questions asked by the member. The coaching is available 24 hours a day, seven days a week from experienced clinicians who are ready to give individualized support through any medical situation.

Kaiser Permanente: Yes, every Kaiser Foundation Hospital has an emergency department, which is staffed 24 hours a day, seven days a week, and which members can call for clinical advice at any time.

PacifiCare: Yes, at the plan level there is a 24-hour nurse line and medical audio library. Members can listen to pre-recorded health topics or speak with a licensed registered nurse. The nurse line staff can provide general counseling and triage recommendations. At the PMG/IPA level, PCPs are contractually required to provide after hours call coverage.

35. Do you include treatment by a physician’s assistant (PA) or nurse practitioner (NP), rather than by a physician? Do you guarantee a physician exam for adults when requested by the patient?

Aetna: Yes, but physicians using PAs or NPs are required to oversee services. Members have a right to request a PCP.

Blue Cross: Treatment by a physician’s assistant or nurse practitioner is included in our coverage, if available at the PMG/IPA level. Members always have the right to see a physician, rather than a PA or NP, if desired.

Blue Shield: Yes, we include treatment by a physician’s assistant on nurse practitioner, but the physician partners are responsible for managing the treatment decision. We also guarantee a physician exam for adults.

CIGNA: Yes, when appropriate, PAs or NPs can work together with a physician. Yes, members can request an annual physical examination.

Health Net of CA: As long as a physician’s assistant or nurse practitioner is under the physician’s guidance and providing treatments under the scope of his or her license, treatment is covered. Members have the right to have exams conducted by physicians instead of PAs or NPs.

Kaiser Permanente: Yes, members can request a physician, physician’s assistant, or nurse practitioner. Members will be seen by a PCP if requested.

PacifiCare: Yes, treatments by the physician’s assistant and nurse practitioner are included. However, the member has the right to request a physician examination.

36. Can doctors be terminated for over utilizing services?

Aetna: When inappropriate use of services, under/over utilization or quality issues are identified, the provider is counseled; an action plan for improvement is developed; and service activity is monitored. The provider could be terminated if performance does not improve.

Blue Cross: Blue Cross contracts with the PMGs/IPAs, which contract with the individual providers. If the PMG/IPA does not take appropriate action against a physician who is not complying with appropriate use of medical services, Blue Cross can stop a physician from providing services to our members.

Blue Shield: Yes, provider practices are reviewed for quality of care and utilization issues. Problems may be discovered from individual or patterns of claims submission, a subscriber complaint, or at the time of credentialing/re-credentialing. Often, further information is requested from a provider for a complete review of the problem. If the provider does not submit the requested information after several contacts, the provider is terminated for non-compliance with their contract, rather than the quality or utilization issue that prompted the review. Because the review cannot be completed, the termination is for administrative reasons, rather than for quality or utilization reasons.

CIGNA: CIGNA has never terminated a physician’s contract for over utilizing services unless there was evidence that it was hurting the quality of care or was fraudulent.

Health Net of CA: A peer review team measures and rates adverse action material submitted by the providers and various primary source agencies including the Medical Board of California, the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, Medicare/Medicaid Sanctions, Office of Inspector General, opt-out Medicare reporting, and the claims history for credentialing and re-credentialing. Health Net also investigates allegations made in the community and by the media. The provider has a right to appeal the decision through a fair hearing. Health Net uses quality data in physician management and evaluation to help identify potential provider issues.
Kaiser Permanente: No, providers cannot be terminated for over utilizing services.

PacifiCare: Yes, we have terminated a small number of contracts with participating practitioners and delegated providers for failing to adhere to quality standards, typically less than one percent annually. The precipitating events included behavior presenting a potential risk of imminent harm to PacifiCare members and behavior contrary to the requirements of state and federal law. Our termination procedures adhere to contractual and regulatory requirements, and include informing the provider with required appeal rights and description of the appeal process.

37. How do you determine with which providers to contract? Do providers get incentives for refusing to contract with other plans (for example, to maintain a semi-exclusive relationship with a managed care plan)?

Aetna: It is monitored based on geographic access with the necessary mix of physician specialties and hospital services. An annual study determines the availability of PCPs relative to residence of member population. Providers don’t get incentives for refusing to contract with other plans.

Blue Cross: We consider geographic factors, experience of PCPs and specialists, board certification, and quality/reputation factors. We do not provide incentives for refusing to contract with other health plans.

Blue Shield: We have national criteria in selecting providers, which addresses credentialing, licensure, accreditation, affiliations, disciplinary actions, access, cost effectiveness, and quality of care. Blue Shield does not give providers incentives to limit contracting with other managed care plans.

CIGNA: Provider contracting is based on geographic, business, and member needs. Providers must meet credentialing criteria including verification of education and license status. There are no exclusive or semi-exclusive relationships.

Health Net of CA: To ensure the quality of the Health Net network, all potential PPGs are subjected to intensive reviews to ensure that they meet or exceed Health Net’s guidelines in the areas of medical management, financial viability and stability, and network accessibility. No incentives are given for refusing to contract with other plans.

Kaiser Permanente: We contract exclusively with the Permanente Medical Groups in Northern and Southern California to provide comprehensive medical services to members including primary care, specialty care, laboratory, and imaging services. Our physicians do not contract with other plans.

PacifiCare: Once we determine that network expansion is necessary, we research available providers in that area. We contact prospective providers for detailed assessments on their credentialing, quality assurance, and administrative capabilities. Before contracting, we assess area needs and hold initial discussions to gauge mutual interest. If this initial assessment is satisfactory, a provider delivery systems team begins contract negotiations. The length of the process varies depending on the urgency of need for additional providers and the availability of these providers during the auditing and contracting process. The process usually takes from two to six months. We do not offer anti-competitive incentives to any physician.

38. How can a member get information about a doctor’s schooling and malpractice suits?

Aetna: Plan service professionals have access to plan’s national provider database, which generally includes the medical school of graduation. Malpractice information is not available.

Blue Cross: Blue Cross does not provide information about a provider’s schooling or malpractice suits. Members can request information from the Medical Board of California via the Website, the phone, or in writing. Members can also contact the PMG/IPA directly.

Blue Shield: Members can access www.blueshieldca.com for information about a provider’s education. To get information about malpractice suits, members can contact the National Practitioner Databank in Washington, D.C. for a fee.

CIGNA: Members can call our Member Services department or look up the information on myCIGNA.com. Malpractice information is available to the public through the state medical board Web site. A peer review committee, which is staffed by CIGNA doctors and non-CIGNA doctors, reviews individual physicians’ histories before credentialing and re-credentialing the physician into the CIGNA network.

Health Net of CA: Members can contact Health Net’s customer call center to get information about a participating physician’s schooling. Members can also access Doc Search at our Website, www.healthnet.com, for physician languages, board certification information, provider-specific information, and weekly and daily provider updates. Members can contact the Medical Board of California, the American Medical Association, or the applicable specialty board for information about a doctor’s malpractice suits.

Kaiser Permanente: Each medical center maintains physician information, which members can access to verify licensure, medical school graduation, residency, and fellowship training, and board certification. Members can contact the California Medical Association for malpractice information.

PacifiCare: The member can call customer service for educational history, licensing information, and board certification. The member can call the Medical Board of California for malpractice information.

39. What are your grievance procedures?

Aetna: Our customer service professionals can respond to most issues by phone. If the issue cannot be resolved during the call, the customer service professional researches the inquiry and then responds to the member. Our goal is to respond to all inquiries within 15 business days. Members who are not satisfied with the response can file an oral or written grievance. We will forward a written notice stating the result of the review to the member within 30 business days of receiving the grievance. The decision is final and binding unless the member submits a written request within 30 days of the notice of the grievance decision, for a hearing by the hearing panel/grievance committee. The member’s next course of action is to request an external review. The external reviewer decides within 30 days of the request. Expedited reviews are available when a member’s physician certifies that a delay in service would jeopardize the member’s health. Once the review is complete, we abide by the decision of the external reviewer. The Complaints and Appeals Tracking System was developed to support our national grievances and appeals process.

Blue Cross: Blue Cross is responsible for registering, investigating, and responding to member grievances and appeals. The appeal process is not delegated to PMGs/IPAs. To file a grievance and appeal, the member should call the toll-free Blue Cross customer service number listed on their ID card or file an appeal or grievance online at www.bluecrossca.com. After Blue Cross reviews the member’s grievance and appeal, the member receives a written statement of the resolution or pending status within 30 calendar days. The member has the right to request an expedited appeal if their condition is acute or urgent. Expedited appeals are resolved within three calendar days.

Blue Shield: Once a member files an appeal, Blue Shield assigns a grievance coordinator to contact the member by telephone to get a clear understanding of their concern. The coordinator then researches and forwards the grievance to all appropriate parties. Once a resolution has been made, the coordinator contacts the member via telephone to inform them of the decision and the options available if they are dissatisfied with the resolution.

Members who are dissatisfied with the resolution can request a second-level “Initial Appeal” review. During this review, members can appoint a representative or a provider to act on their behalf. If the member succeeds in their appeal and reimbursement is required, the coordinator will complete a payment request and submit it to the Grievance Resolution Department manager or supervisor for approval. All appeals are to be resolved within 30 calendar days.

CIGNA: Members can call Member Services or file a written complaint/appeal. The complaint is investigated and reviewed within 30 days (when appropriate) and the member is notified of the decision. An expedited appeal may be filed when the member or provider is concerned with potential loss of life or health or the ability to gain maximum function. When necessary, procedures are modified to meet or exceed applicable regulatory and accreditation guidelines.

Health Net of CA: When members complain about the quality of service provided by the plan or its participating practitioner, the grievance is documented and researched and an acknowledgement letter to the member is sent within five days. The hospital/ PPG/practitioner has seven days to respond to the grievance.

The final resolution letter is sent to the hospital/PPG/practitioner. If it takes longer than 30 days to resolve, a letter of explanation is to the member. The grievance is documented when members complain about the direct provision of care or the quality of care by a participating provider. If the matter is urgent, it will be forwarded to a clinical specialist for immediate attention and resolution (If required, care will be provided to the member). An acknowledgement letter and medical records release form will be sent to the member within five days. The hospital/PPG/practitioner has seven days to respond to the grievance. Health Net will determine if the grievance can be resolved with the records at hand if the member does not provide out-of-plan records or if the medical record release form is not signed. If it can’t, the case is closed until all necessary information is provided. After review, a letter to the member will communicate the disposition. The final resolution letter will be sent to the hospital/PPG/practitioner. If the matter takes longer than 30 days to resolve, a letter will be sent to the member to explain the delay and provide an estimated resolution date.

Kaiser Permanente: Members can submit complaints to the member service rep at the facility through the call center. The complaint is acknowledged within seven calendar days. A response is made within 30 days after it has been submitted. A complaint or grievance will be resolved within 60 days from the date it was received by plan. An external, independent, third party review process is available to non-Medicare members who have completed the internal grievance/appeals process.

PacifiCare: If a problem occurs, we encourage members to contact our Customer Service department as their first source for resolution. This team will make every effort to find a solution to the member’s situation. If the situation requires additional action, the member may submit a formal complaint requesting an appeal or quality review. Additionally, members in California may file an appeal using the online grievance form available at www.pacificare.com. This request initiates the appropriate appeal or quality of care review process. A medical reviewer, a healthcare professional with the education and training related to the complaint, makes the determination if the complaint involves the medical necessity of a treatment.

40. What systems are in place for assessing participant satisfaction?

Aetna: Member satisfaction is measured yearly at the network level using CAHPS 2.0H survey. The plan administers the most recent survey required by HEDIS to assess satisfaction. We also participate in the Consumer Assessment Survey to evaluate member satisfaction with IPA and Medical Groups.

Blue Cross: Blue Cross conducts a variety of surveys each year to measure our members’ health and satisfaction and improve the quality of care and customer service. We conduct a semi-annual customer satisfaction service survey, an annual consumer assessment of health plans, and an annual consumer assessment survey to assess the quality of care at the PMG/IPA level.

Blue Shield: Our Quality Management and Improvement Program is designed to comply with recognized industry requirements and standards established by the National Committee on Quality Assurance, Knox-Keene regulation, Department of Managed Healthcare, and the Center for Medicare & Medicaid Services. Our Quality Management Committee and the Board Quality Improvement Committee review and amend the program annually. We use HEDIS measures to monitor member satisfaction surveys, member inquiry analysis, disenrollment, member appeals, access to care and quality of service, and medical record audits and office site reviews.

CIGNA: CIGNA uses the HEDIS CAHPS member satisfaction survey. The health plan participates in the Consumer Assessment Survey, which analyzes member satisfaction with medical groups and addresses utilization management, appointment wait times, office staff, etc. We continually monitor and improve member satisfaction.

Health Net of CA: Three online customer satisfaction surveys are being conducted among members, employer groups, and brokers.

Kaiser Permanente: The plan conducts ongoing surveys to evaluate member and patient satisfaction with physicians, access to services, and quality of care. Survey feedback is disseminated throughout the organization to target areas for improvement.

PacifiCare: PacifiCare uses the NCQA CAHPS annually to assess patient satisfaction with their care. Our satisfaction results are reported in our annual HEDIS results. CAHPS is a mail survey, which fulfills a component of the NCQA accreditation process. A telephone follow-up and interview occurs among non-responders per NCQA specifications.

41. Do you participate in outcomes research? Do you provide physician performance review data to the public?

Aetna: Yes, HEDIS is available for public review through the California Cooperative HEDIS Reporting Initiative.

Blue Cross: Yes, we have tools that support predictive modeling, provider profiling, hospital profiling, disease management, network analysis, quality assessment, regulatory reporting, and HEDIS submission. Additionally, Blue Cross has acquired HealthCore Inc., a leading outcomes research company. Performance review data for our PMGs/IPAs is available publicly on our Website and in provider directories.

Blue Shield: Yes, Blue Shield of California conducts outcomes research for disease management programs and participates in broader research efforts. Collaborative studies may be published. For example, the results of a controlled study of complex case management outcomes are being prepared for publication. Blue Shield is a sponsor/participant in IHAs Pay for Performance project. The California Cooperative Healthcare Reporting Initiative and California’s Office of the Patient Advocate provides public reports of medical group performance and information technology measures. Efficiency measures are being developed and tested to be added to the report.

CIGNA: CIGNA is accredited by the NCQA and participates in reporting HEDIS clinical outcome data, which is available for public review. CIGNA HealthCare participates in the Integrated HealthCare Association’s Pay for Performance program. It provides data at the medical group level, which is reported to the public annually through the state’s Office of Patient Advocate. CIGNA also participates in the California HealthCare Foundation’s CHART hospital quality initiative. Through myCIGNA.com, the company offers an array of information about provider and hospital quality for its members.

Health Net of CA: Medical groups are rated on wide-ranging quality-of-service and quality-of-care measurements. Results are available at www.healthnet.com.

Kaiser Permanente: The most recent developments in medical outcomes research are incorporated into our evidence-based Clinical Practice Guideline program, assessed by our New Technologies Committee, and incorporated into our extensive library system with online capabilities. In addition, our clinicians are involved in a broad scope of clinical, epidemiological, and health services research projects. Kaiser Permanente has earned ratings of excellent in the latest review by the National Committee for Quality Assurance. We also routinely get high scores in many outcomes based surveys, such as HEDIS, Leapfrog, and METEOR, which measures our member satisfaction. Physician performance reviews are not available to the public.

PacifiCare: Yes, outcome results are incorporated into our provider group profile, which compares each provider group with network averages. We release these performance results to the public through our quality index profiles. The reports look at clinical, service and administrative quality measures. PacifiCare motivates provider compliance by intervening aggressively when deficiencies are found and by sharing best practices when excellence is identified.

42. Do you notify members when their PCP is no longer a member of the plan? How?

Aetna: Yes, members are notified by letter. They are apprised of transition of care issues and instructed on how to select a new PCP.

Blue Cross: Yes, PMGs/IPAs are required to provide 90 days notice to the plan when a physician within the PMG/IPA leaves the group or is terminated from our network. The PMG/IPA must offer the services of another PCP within the group. The plan provides at least 60 days’ notice in writing to all members enrolled with the terminating PCP. This letter includes the name of their new PCP or medical group.

Blue Shield: Yes, we are regulated by the Department of Managed Healthcare, which requires written member communication of network changes 60 days before the effective date of the change. For IPA or medical group terminations, we use a standardized communication and transition process. First, we analyze network access using GeoAccess software to determine how provider termination affects the member. Second, we determine which primary care physicians in the terminating IPA or medical groups are affiliated with other Blue Shield contracted IPAs and medical groups. We then transition affected members, as necessary. If their personal physician is affiliated with another contracted IPA/medical group, the member goes to the new group and maintains their physician. If their personal physician is not affiliated with another contracted IPA/medical group, the member goes to a new personal physician in a new medical group. Letters relating this to the members are mailed at least 60 days before the effective date of the transition. Employers also get written notification along with copies of the member letters.

CIGNA: If a PCP is no longer a member of our health plan, members are notified by mail about 60 days before the effective date and are encouraged to choose a new PCP.

Health Net of CA: Health Net participating physician groups and individually contracted physicians are required, by contract, to notify us of any changes to the provider network including new physicians joining the PPG, address and telephone number changes, and physician terminations. We notify our members when their PCP leaves the network or becomes affiliated with a different contracting PPG. Members can follow their PCP to a new contracting PPG. Members can choose a new PCP within our network or remain at their PPG if their PCP is no longer available in our network. When possible, members get written notice within 30 to 60 days of the provider’s decision to leave the network. Provider listings are available at www.healthnet.com and are updated monthly.

Kaiser Permanente: Yes, each medical center has developed general protocols to facilitate the transition of care to another physician. All patients who are scheduled to see the physician for outpatient care are contacted to reschedule with another plan physician.

PacifiCare: Yes, PacifiCare sends a notification letter to all affected members 30 days prior to the termination date of a physician or medical group. The member selects a new PCP or medical group. If the member does not select a PCP or medical group within 30 days, we automatically assign a PCP or medical group that is geographically closest to their residence. If the member is unhappy with the assigned provider, he or she may request a change at any time by calling customer service.

43. What action is the plan or the IPA/MG taking to have online eligibility, administrative changes, referrals, etc?

Aetna: We participate in the Work Group for Electronic Data Inter-change, the Computerized Patient Record Institute, and the American National Standards Institute. A monthly eligibility file is provided to IPAs and Medical Groups.

Blue Cross: Through our Internet application, mybcclink.com group, administrators can process eligibility transactions including additions, changes, and cancellations. (Changes are processed in real-time, assuming a confirmation response is received.) The administrator can also order ID cards; perform quick inquiries on employees; and locate providers via our provider finder. The mybcclink.com application features confidential and secure data through user ID and personal identification numbers, drop-down menus for easy point-and-click operation, and easy to follow hyper-link steps to guide the administrator through electronic enrollment, benefit changes, and maintenance processes.

Blue Shield: We are fully HIPAA compliant, ensuring secure electronic and online transactions. We offer electronic enrollment and eligibil