Local News

What Physicians Need to Know About the Anthem Exchange Addendum

By the California Medical Association (CMA): April 8, 2014

Anthem Blue Cross recently notified over 11,000 practices who are currently participating in its individual / exchange network of a contract addendum that will become effective July 1, 2014. The amendment only applies to physicians who are currently participating in the Anthem Blue Cross individual / exchange network.

According to the notice, which was mailed on March 31, the addendum contains new regulatory requirements. While many provisions are requirements of Covered California, the California Medical Association (CMA) has concerns with certain provisions that appear to be beyond the scope of regulatory requirements.

The new language in section 7 contains a broad requirement that physicians participate in any existing or future quality initiatives of Anthem or Covered California. While Covered California does require qualified health plans (QHPs) to report on a number of quality measures, CMA is concerned that this broad provision could require physicians to comply with overly burdensome and / or costly requirements in order to meet current or future quality program criteria.

Additionally, there are no exceptions if a physician is unable to comply with or report various quality or other performance measures. Additionally, and of significant concern, the language in section 12 removes a participating physician’s ability to opt out of just the individual / exchange product without affecting the underlying Prudent Buyer contract, as is allowed currently. Effective July 1, 2014, the only option for physicians who wish to opt out of the individual / exchange product is to terminate the underlying Prudent Buyer PPO agreement.

CMA has expressed our concerns to Blue Cross on these issues and is awaiting a response.

One other provision of note is section 10, which allows Anthem to share providers’ contracted rates with Covered California. While Covered California does require QHPs to provide access to provider rates as of July 2014, CMA has expressed concern with Covered California about the intended uses of this data.

Physicians do have the right to opt out of the exchange product without affecting the underlying Prudent Buyer PPO contract if Anthem receives notice before the effective date of the addendum, July 1, 2014. If you do not wish to participate in the individual / exchange product, you can opt out by providing 90 days written notice, which should be sent via certified mail with return receipt, to Anthem Blue Cross Prudent Buyer Plan Contract Processing, Attn.: Individual / Exchange Contract Processing, Mail Station 8A, PO Box 4330, Woodland Hills, CA, 91365-4330. The notice must be received by Anthem by June 30.

In addition to the addendum, the notice included an invitation to attend a webinar on Anthem’s exchange products. The webinars will be offered in late April and will cover how to confirm participation status, provider networks, plan names, enrollment periods, covered benefits, sample ID cards, risk adjustment and provider resources — click here for more information. Physicians are as always urged to carefully review and assess the impact any contract changes or addendums will have on their practices. Questions and concerns about the Anthem exchange addendum should be directed to the Anthem Blue Cross Network Relations at (855) 238-0095 or at networkrelations@wellpoint.com.

To help physicians understand their rights when it comes to health plan contract amendments, CMA has published "Contract Amendments: An Action Guide for Physicians." Additional guidance on negotiating and managing complex third-party payor agreements is also available in CMA’s contracting toolkit, "Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors.”

Comments are closed.