Choosing The Right Health Plan For You
Anthem Blue Cross offers a broad range of health plans, varying costs, levels of health coverage, and accessibility to health care. These are important considerations for helping you identify which plan is right for you
Your Plan Type and Access to Health Care
IMPORTANT NOTE: When you're on the Anthem Quote page, in order to "APPLY NOW" you are REQUIRED to select a DENTAL PLAN to be able to go forward to show the APPLY NOW button. This is part of the new 2014 ACA compliancy.
The plan type you choose will determine how you select and access health care services. In general, the wider your choice of doctors and hospitals, the higher your costs will be in terms of premiums and/or levels of health care coverage.
Preferred Provider Organization (PPO) Plans
The PPO Plans offer you the most flexibility in your choice of doctors and hospitals (providers). PPO Plans provide coverage (at different levels) for services from both Participating and Non-Participating Providers. Please see he PPO Plan section of this brochure for definitions of these and other terms related to PPO Plan Coverage.
• Price — What are the monthly premiums for each plan? What can you afford?
Common Terms & Definitions
• Features — What health care services does each program cover?
• Cost-sharing — What would be your share of the cost for these services?
• Access — Is it important to you to see any doctor you want or are you willing to trade that flexibility for some other benefit?
• Deductible = the amount you pay each year for covered services before your plan begins paying part of the cost.
• Out-of-Pocket Maximum = The maximum amount for qualifying covered services you would have to spend in any one year, including your deductible, before your plan pays 100% of your covered costs for most services.
PPO and HMO Plan Options
RightPlan PPO 40 Plans
The Anthem Blue Cross RightPlan PPO 40 Plans provide first-dollar coverage (no deductible) for doctor visits, preventive care, hospital stays and other covered medical services. The plans offer a choice of prescription drug coverage: generic only, generic and brand name or no drug coverage.
The Anthem Blue Cross 3500 Deductible PPO Plan provides 100% coverage for most services after the deductible is met, along with affordable monthly premiums.
PPO 3500 (HSA-Compatible) Plan
Like the Anthem Blue Cross 3500 Deductible PPO Plan, the Anthem Blue Cross PPO 3500 (HSA-Compatible) Plan provides 100% coverage for most services after the deductible is met, along with affordable monthly premiums. In addition, it is a qualified high-deductible health plan, which is required when establishing a Health Savings Account (HSA).
PPO Share Plans
The Anthem Blue Cross PPO Share Plans all cover the same comprehensive package of health care services. The difference is in the deductibles, coinsurance amounts and annual out-of-pocket maximums. Blue Cross offers a variety of PPO Share Plans so that you can more precisely choose the best pricing options for you.
Basic PPO and PPO Saver Plans
The Basic PPO and PPO Saver Plans offer in-hospital and surgical coverage with low affordable monthly premiums. These plans are designed to protect against great financial losses due to unexpected illness or injury. Both plans offer limited coverage for professional services; however, for a slightly higher premium, the PPO Saver Plan provides more covered professional services.
The Anthem Blue Cross Individual HMO Plan provides extensive coverage with low out-of-pocket costs for covered health care services you received only from HMO Network doctors and hospitals.
The Anthem Blue Cross Select HMO Plan provides extensive coverage with lower premiums and low out-of-pocket costs for covered health care services you receive from doctors and hospitals in the Select HMO Network. The Select HMO Network is available in 22 California counties.
The Anthem Blue Cross HMO Saver Plan provides the same coverage as the Individual HMO Plan, but has a deductible amount for services you receive from hospitals and other health facilities to keep the premiums lower.
The following information applies to enrollment in plans both on and off the exchange, unless otherwise noted.
Open enrollment period:
The open enrollment period begins October 1, 2013 and ends on March 31, 2014.
Outside open enrollment period:
Individuals who experience a qualifying event will be able to enroll in a plan on or off the exchange outside the open enrollment period. These individuals will have a special enrollment period and, unless stated otherwise, they will have 60 calendar days from the date of a qualifying event to select a plan. Documentation/proof of Qualifying Events is required prior to enrollment. If it is not received, the individual(s) may not be enrolled.
Qualifying events for plans on the exchange:
An individual loses Minimum Essential Coverage*, which includes a loss of eligibility for coverage as a result of:
• Legal separation or divorce
• Cessation of dependent status, such as attaining the maximum age
• Death of an employee
• Termination of employment
• Reduction in the number of hours of employment
• Any loss of eligibility for coverage for any of the following:
o An individual no longer resides, lives or works in the Plan’s Service Area
o Termination of employer contributions
o Exhaustion of COBRA benefits
• An Individual gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption
• An individual, not previously a citizen, national, or lawfully present gains such status
• An Individual’s enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of an error of the Exchange or Health and Human Services
Qualifying events for plans off the exchange:
• Involuntary loss of Minimum Essential Coverage for any reason other than fraud, intentional misrepresentation of a material fact or failure to pay premium
• Loss of Minimum Essential Coverage due to dissolution of a marriage
• Adoption or placement for adoption
*Minimum Essential Coverage refers to plans that must include “essential health benefits” as defined by the Affordable Care Act (ACA). Specifically, the plans must include items and services from at least these 10 categories of care:
1. Ambulatory patient services
2. Emergency services
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness service and chronic disease management
10. Pediatric services, including oral and vision care
Effective Date Assignment
The following information applies to enrollment in plans both on and off the exchange, with effective dates on or after January 1, 2014, unless otherwise noted.
Open enrollment period:
During the open enrollment period of October 1, 2013 through March 31, 2014, there will be two phases:
Phase 1: If an application and full initial premium payment are received during the period of October 1, 2013 through December 15, 2013, coverage will be effective on January 1, 2014.
Phase 2: If an application and full initial premium payment are received during the period of December 16, 2013 through March 31, 2014:
• Between the 1st and 15th of the month, coverage will be effective date on the first day of the following month.
• Between the 16th and the last day of the month, coverage will be on the first day of the second following month
Exception: Newborns and adopted children can be added to their parent’s existing coverage or enrolled in a separate plan as of the date of birth or placement.
Outside open enrollment period with a qualifying event:
If an applicant applies outside the annual open enrollment period due to a qualifying event and their application is approved and full initial month’s premium is received, their effective date will be as follows:
• In the case of birth, adoption or placement for adoption, coverage is effective on the date of the birth, adoption, or placement for adoption; or
• In the case of all other qualifying events, coverage is effective on the first day of the following month after the application is received
For a complete list of qualifying events for both on and off the exchange, refer to the qualifying events section under Enrollment Periods.
Buying Health Coverage OFF the Exchange
Helpful tools used to assess the best plan options OFF the exchange for NEW and existing clients:
This online store is available for you to shop for ACA compliant plans and submit applications. This tool is available in English and Spanish and allows shoppers to compare plans side-by-side.
• Find a Doctor
This valuable tool is easily accessible on both the Plan Comparison and the Plan Details pages so your clients can view and search for doctors in each plan’s network.
This convenient tool lets you and your Individual clients view their current coverage, compare it with other ACA compliant plans and easily make changes if needed. This tool is available for reviewing options and submitting Change of Coverage Applications.
New Eligibility Guidelines
To be eligible to enroll for coverage all applicants must:
1. Be a United States citizen or national or be a lawfully present non-citizen for the entire period for which coverage is sought; and
2. Be a legal resident of the state in which they are applying;
3. Be under age 65;
4. Submit proof satisfactory to Anthem to confirm dependent eligibility, if requested;
5. Agree to pay for the cost of Premium that Anthem requires;
6. Reveal any coordination of benefits arrangements or other health benefit arrangements for the applicant or Dependents as they become effective;
7. Not be incarcerated (except pending disposition of charges);
8. Not be entitled to or enrolled in Medicare Parts A/B and or D;
9. Not be covered by any other group or individual health benefit plan.
Applicants are eligible for enrollment if they live, work or reside in our designated service area.
Eligible dependents of the policyholder or spouse/domestic partner include married or unmarried children up to the end of the calendar month in which they turn 26 years of age, regardless of student or tax status.
Please refer to the domestic partner language under the section for “Servicing your clients on ACA compliant plans”.
An applicant or dependent is not eligible to apply for an Individual health care plan/policy if they are on active duty with any branch of the Armed Services.
You can send your clients a “Quotes and Comparisons” email for up to five plans. Once your client selects a plan and is ready to apply, he or she can click the “Apply Now” button to start the application process.
Ongoing Premium Payment Options
Payment options for ongoing premium payment
Current members can select any of the following methods for paying their ongoing monthly premiums
Monthly Automatic Premium Payment
• Members can choose debit dates of the 1st to 6th of the month
• Premiums can be deducted from the member’s checking or savings account
• The “Automatic Premium Payment for Individual Plans” form must be completed by the member
• This form is available at the online Producer Toolbox and member website and can also be requested from Member Services.
Check or Money Order
• Paper payments should be sent with the identification number written on the check or money order and accompanied with the monthly bill
• Payments must be submitted to the address provided on the bill
• Members can register at our member website and make their payments online
• Payments can be made by electronic check
• Members can opt to “turn off” their paper bills and receive electronic email reminders
Payments over the phone
• Payments can be made through our Automated IVR Payment system
• Payments can be made through one of our Member Services representatives
• We can accept check or credit card payments via phone
Plan Materials and Member Services
ID Cards and Certificate of Coverage or Evidence of Coverage (EOC) booklet
Once approved, your client will receive their ID cards with the toll-free phone number for Member Services. Under separate cover they will receive their Welcome letter and plan booklet.
Members have the ability to manage their health benefits any time, day or night, through our website at www.anthem.com/ca
. Members under the age of 18 cannot be viewed or registered in Member Self Serve. Members should select the member tab, and enter their home state. Members who log in will be able to:
• Find a doctor or hospital
• Order a new ID card
• View their benefits
• View status of their claims
• View their plan’s prescription formulary
• Pay their premiums online
Members enrolled in off exchange plans can make address changes by contacting Member Services. Members can also change their address by submitting a written request to Member Services or by contacting their producer.
If you submit the address change on your client’s behalf, please submit the change in writing, by fax or email to Agent Services.
Members enrolled in plans on the exchange need to contact the exchange directly for address changes.
Note: For both on and off exchange plans, if your client moves from one geographical rating region to another, their rates may be subject to change and the plan they are on may not be offered in the new rating region.
Important Anthem Phone Numbers and Addresses
Member Technical Support
Medical claims fax: 877-287-1262
Medical claims mailing address:
P.O. Box 60007, Los Angeles, CA 90060-0007
Pharmacy pre-authorization: 888-831-2242
Pharmacy pre-authorization fax: 888-831-2243
Mailing address: P.O. Box 9051, Oxnard, CA 93031-9051