Frequently Asked Questions

Individual and Family health insurance is different from Group (Company) insurance in that they can decline and or change rates based on your health at the time of application.  Below we have some common reasons for difficulties in getting approved but first a few quick tips regarding qualifying for coverage.
 

• Some situations require time away from the condition in order to qualify.  For simple situations, a 6 month period sign, symptom, and treatment free is a good estimate.  This can also pertain to medication.  
• It is not uncommon to be declined by one carrier and accepted by another even though the carriers have very similar underwriting requirements.
• If we are declined by a carrier, we may lose our Short Term option.  If there is an issue, and you have no coverage, we recommend getting Short Term coverage first and then apply for the permanent plan. 
• Brand name medication are heavily scrutinized these days due to the cost associated with their use.  
• If you are currently on Cobra, it typically makes sense to apply for coverage as there is no down side.  You can remain on your Cobra if the coverage is not approved.  Cobra is usually quite expensive.
• The carriers can offer a split approval where one member is not approved but the rest of the family is.
• The carriers are mainly looking at current/recent and ongoing situations.  We all have a medical history but situations that are stable, from which time has passed, typically do not cause problems.
• If you are exhausting or losing Cobra (continuation of group coverage) you may be eligible for HIPAA.  Please check with us if this sounds applicable.

  Some common reasons for declination/deferrals of coverage

  • currently pregnant or an expecting father 
  • multiple medications especially brand name
  • recent (last 6 months including physical therapy) injury
  • recent (last 2-3 years) treatment for heart disease, diabetes, cancer, immune system disorders, or any other serious medical condition
  • height/weight outside guideline range
  • multiple conditions/injuries/illnesses

  More information on Individual and Family California health insurance

  Individual health insurance is insurance you buy on your own, rather than having it provided by your employer.  Please examine your options carefully before declining group coverage or continuation coverage, such as COBRA, that may be available to you.  You should be aware that Anthem Blue Cross requires a review of your medical history that could result in a higher premium or you could be denied coverage entirely.

  If you are in the market for individual health insurance, Anthem Blue Cross has online tools to help you find out how much individual health insurance will cost.  If you have a chronic illness or other health condition, it can be hard to buy individual California health insurance.  If you have applied for individual health insurance and been denied, the information below may help you determine why you may have been denied and if that denial was appropriate.

  Medical Underwriting

  When you apply for individual health insurance, the California health insurance company uses a process called medical underwriting to look at your age, sex, and health history to decide whether it will cover you and how much it will cost to provide you coverage.

No.  Each insurance company has its own underwriting guidelines, which are usually not made public.  However, insurance companies marketing and selling individual health insurance policies in California must file information with the Department of Insurance pertaining to their policies, procedures and underwriting guidelines for offering such insurance (Insurance Code Section 10113.95 which was added by Assembly Bill 356 in 2005).   We have summarized the information that companies have filed in the questions and answers and chart below.

• Health conditions that would automatically not be approved;
• Health conditions that may not be approved;
• Height and weight standards;
• Health history, health care service utilization, and lifestyle or behavior that may cause the insurance company to deny insurance, limit the products they offer, or charge more for the coverage.

Yes, you may go to a non-network provider, but your out-of-pocket costs will be substantially less if you go to a Participating Provider. Please consult your Evidence of Coverage. You can find a network provider here.

1. Go to our Provider Finder and follow the prompts to retrieve your health plan's network providers. If you want directions to a specific provider, simply click on the provider's name and you are linked to an area map that shows various routes to the provider's location.
2. Look in the printed Anthem Blue Cross PPO Directory. You can get a provider directory mailed to you by calling Customer Service at the toll-free number on your ID card.
3. Call the toll-free Customer Service number on your ID Card.

Yes. We recommend that you carry your ID Card at all times. You may need it in case of emergency. You may be required to present your ID Card at your doctor's office or at a hospital.

Please use the Member Services feature to order ID Cards. Or, call the toll free Customer Service number on the back of your ID Card to order new ID Cards. Customer Service is available from 8:30 a.m. to Midnight, Monday through Friday, Pacific time. (800) 333-0912

Your children remain covered if they are unmarried, under 19 years old, or 22 years old or younger as long as they qualify as dependents for income tax purposes and are full-time students (12 or more credits) at an accredited college, university, vocational or technical school. Anthem Blue Cross requires written proof of student status annually. Please see your Evidence of Coverage booklet/policy for more details. The age limit for children to remain on your policy is 23 years old. At that time, they may transfer to their own Individual plan.

You may change your existing benefit plan as often as you like. There are different steps involved in changing your plan depending on if you are upgrading or downgrading your plan. If you have questions on changing your existing benefit plan, please contact a dedicated Customer Service Associate at the number on your ID card or contact your broker.

Anthem Blue Cross and Blue Shield of California are separate, competing companies that offer comprehensive plans at the Individual/Family health insurance and Small Group health insurance. Provider Networks Both companies have extensive doctor and hospital lists with 48,000 doctors and 400 hospitals up and down the state. Typically the lists overlap with doctors/hospitals participating in both. Occasionally there will be a doctor who participates with one company but not the other so it's best to check on your doctor. Financial Strength This really is the main reason to go with the "Blues". Smaller or less efficient carriers are having difficulties, with some filing for Bankruptcy. If you are with a smaller carrier that is offering significantly reduced costs, they almost definitely raise rates, lower benefits, and/or leave the market entirely. If you have developed health conditions, the other carriers will not pick you up at that time. Anthem Blue Cross is owned by Wellpoint, Inc named the most admired health care carrier in the nation three years in a row. Blue Shield is a close second.

To add Family Members

Spouse:

You will be required to submit a completed application for the spouse that references the enrolled Subscriber’s Certificate Number. The spouse is subject to underwriting.

Newborn Child:

For coverage to continue beyond the automatic thirty one (31) days from the date of birth to an already enrolled Subscriber or Spouse, Anthem Blue Cross must receive within 60 days of the Child’s birth, an application to enroll the Child and any additional charges due.

Adopted Child:

Anthem Blue Cross must receive an application to enroll the Child within 60 days of acquiring the Child in order for coverage to continue beyond the first thirty one (31) days from the date of adoption. Any additional charges can apply and are due.

Children under 19 that are not newborns or newly adopted:

You will be required to submit a completed application for that(those) child(ren) that references the enrolled Subscriber’s Certificate Number. Each child is subject to underwriting.

To Delete Family Members

To delete a family member from a policy, Anthem Blue Cross must receive this request in writing. The request will become effective the first of the month following the request.

You may send your request to: Anthem Blue Cross P.O. Box 9051 Oxnard CA 93031-9051 Or you may fax the change to our membership department: 800-327-9255

If you have questions about whether a drug is on the prescription drug formulary or needs to be approved, please click here or call us at (800) 7002533.

Most people already have a strong preference between these two models but in case you a need a quick summary, here it is.

With a PPO, you have more flexibility to choose your doctors; you are not locked into a region or a primary care doctor.

You can self-refer yourself out to specialists.

The trade off is that you will help share the costs when you get sick or hurt in the form of a deductible or co-insurance.

With an HMO, you choose a Primary Care Physician who has more control over referral and/or decisions regarding your care.

You must remain within your medical group and within a geographic region.

The trade off with this more structured approach is that there will be less out of pocket when sick or hurt. For example, for inpatient hospital, you may be looking at nothing out of pocket.

TIP: HMO's have become more expensive so compare the annual premium difference with PPO options to make sure you are not paying too much.

Yes.  Insurance companies may look at smoking and drinking history when they decide whether to offer insurance. 

The following chart summarizes underwriting information that health insurance companies have filed with the Department of Insurance.

Downgrading is easy to do within the same kind of plan such as Share 500 to the Share 1500. Upgrading is possible if you are in good health as it is subject to underwriting.

There are a few options for payment with either carrier.

• Billing - bi-monthly, quarterly
• Credit Card - Blue Cross allows monthly, bi-monthly, quarterly credit card deduction
• Checking account auto-deduction - monthly deduction.

No. Although you can select a California health plan such as a Blue Cross of California plan or buy a policy that should cover most medical, hospital, surgical, and pharmaceutical bills, no single policy covers everything. Moreover, you may want to consider additional single-purpose policies like long-term care or disability income insurance. If you are over 65, you may want a Medicare supplement policy to fill in the gaps in Medicare coverage.

If you work for a company with 20 or more employees, your employer must offer you (through age 69) the same California health insurance coverage offered to younger employees. After you reach age 65, you may choose between Medicare and your company

No. The policy can be canceled or renewed (by payment) month to month.

Blue Cross has an online application which tends to process very quickly. Otherwise, you can fax your completed application and copy of check (or credit card section) to 800-569-1156 to start the process immediately. You would then mail the original if paying by check. The credit card option just requires the faxed copy.

A physical is not required...only the completed application and first months premium. Anthem Blue Cross may require a physical for applicants over the age of 55 who have not had one in the last two years.

There is no fee to apply. Only the initial month's premium is submitted with the application.

The first month's premium must be submitted with the application. This can be done with a check made out to the carrier or via credit card (for Blue Cross of California). If the application is not approved, this initial payment will be fully refunded.

There are two different scenarios. If the applicant is in good health and there isn't much the carrier wants to check into, we usually hear back in one to two weeks. If the volume of applications is running high in underwriting, the time frame can be longer. If the carrier wants further information on something listed in the application, they will request records directly from the doctor and this can delay the processing time. It usually adds another 2-4 weeks depending on how quickly the doctor responds back to the request.

Yes. With either carrier, you have a single child or multiple siblings on one plan if they are under the age of 18.

The rates can change by class (the entire state of California or county) or when you move up to a new age band (typically at 5 year increments such as age 35-39). Since Anthem Blue Cross is the part of the largest insurer in the nation you will experience lower rate increases and less often. Once approved, Anthem Blue Cross cannot change rates based on your medical health or claims.

Getting Approved When applying for coverage, Anthem Blue Cross will make their decision to approve/decline coverage and/or increase rates based on pre-existing conditions. You can find more information on qualifying for health insurance. They are mainly looking for current or ongoing situations. Anthem Blue Cross underwriters will also heavily weigh anything that is open-ended such as a doctor's request for a check up in the future which has not happened yet. Medication now weigh heavily because of the associated cost. You can run your situation by us first to see what the probable outcome might be. The carriers cannot exclude a certain condition from coverage in order to approve a person's coverage. Once Approved If you have not had coverage in the prior 63 days before your effective date, there is a 6 month waiting period for pre-existing conditions. This means they will not pay out for claims relating to pre-existing conditions until you have been on the plan for 6 months. If you have not lapsed coverage more than 62 days up to your new effective date, the carrier will take into account your prior coverage against a 6 month waiting period.

Depending on what your condition is and when it was diagnosed and treated, you can probably buy Anthem Blue Cross California health insurance. However, the Anthem Blue Cross may do one of three things:

• provide full protection but with a higher premium, as might be the case with a chronic disease, such as diabetes;
• modify the benefits to increase the deductible;
• exclude the specific medical problem from coverage, if it is a clearly defined condition, as long as the insurer abides by state and federal laws on exclusions.

There are many medical conditions that may cause an insurance company to automatically deny or not approve your application.  These may include the following:

• Health problems for which you have not seen a doctor;
• Health problems that a doctor cannot explain;
• Health problems for which you have not completed treatment.

An insurance company may also automatically deny your application for the health conditions below.  There may be other health conditions that are not on this list.

• AIDS;
• Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process;
• Cancer, under treatment;
• Sleep Apnea;
• Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities;
• Heart disease;
• Renal failure or Kidney Dialysis;
• Diabetes with complications;
• Cirrhosis;
• Multiple Sclerosis;
• Muscular Dystrophy;
• Systemic Lupus Erythematous;
• History of transplant;
• Lymphedema;
• Current infertility treatment;
• Hepatitis;
• Hemochromatosis

Insurance companies may offer you insurance at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time.  Insurance companies will also do this for minor health problems that you had in the past or may currently have.  Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy.  Each application and insurance company is different.  An insurance company may charge a higher premium or limit the products offered for the health conditions below.  There may be other health conditions and time frames that are not on this list.

• Stroke, after 10 years with no reoccurring problems;
• Allergies, while testing is in process;
• Ear infections, controlled with medications;
• Lyme’s disease, without symptoms after one year;
• Breast Implants (non-silicone);
• Ringworm;
• Joint sprain or strain, recovered and no restrictions;
• Migraine headache, mild and infrequent with no emergency room visits;
• Mild depression.

Yes.  Insurance companies usually look at your height and weight when they decide to offer insurance.  They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese.  Some insurance companies use a measurement called the Body Mass Index (BMI) to decide.  If your BMI is above 39, most insurance companies will not offer you insurance.  If your BMI is 30-39, an insurance company may offer you insurance at a higher premium.  If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.

Prior authorization is required for:

• All inpatient Hospital and Skilled Nursing Facility stays (except inpatient Hospital stays for the delivery of a Child, Mental or Nervous Disorders and Substance Abuse, or mastectomy surgery, including the length of Hospital stays associated with mastectomy).
• Home health visits.
• All Organ and tissue transplants and peripheral stem replacement and similar procedures and Coronary Artery Bypass Surgery.
• All infusion therapy and related service in any setting
• The following diagnostic procedures wherever performed:
  • Magnetic Resonance Imaging (M.R.I.) of the spine only.
  • Computerized Axial Tomography (CAT Scan) of the spine only.
  • Positron Emission Tomography (PET Scan)
• The following specified surgical procedures wherever performed:
  • Septoplasty
  • Knee arthroscopy

You may be able to nominate him or her. Call our Customer Service number on your ID Card. If you utilize the services of a non-Participating Provider, your out-of-pocket expenses will be considerably higher than when you use a Participating Provider. You will be responsible for all charges in excess of what Anthem Blue Cross allows for that provider.

Receiving services from Anthem Blue Cross PPO Providers can substantially reduce your out-of-pocket costs. These lower costs are due to negotiated rates that Anthem Blue Cross PPO providers agree to accept instead of their typical fees, and generally, benefits paid for non-participating providers are more limited. You do not need to make payment for services, unless your plan has an office visit copay, when you receive care from Anthem Blue Cross PPO providers. Anthem Blue Cross PPO providers file claims to Anthem Blue Cross for our members, then bill you for remaining portion of their charges. You do not have to file a claim form for services rendered by Anthem Blue Cross PPO providers.

Anthem Blue Cross Individual Services issues ID cards with the subscribers name only. Dependents names are not listed.

Yes. Insurance companies usually look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese. Some insurance companies use a measurement called the Body Mass Index (BMI) to decide. If your BMI is above 39, most insurance companies will not offer you insurance. If your BMI is 30-39, an insurance company may offer you insurance at a higher premium. If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.

Anthem Blue Cross may offer you medical coverage at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time.  Insurance companies will also do this for minor health problems that you had in the past or may currently have.  Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy.  Each application and insurance company is different.  An insurance company may charge a higher premium or limit the products offered for the health conditions below.  There may be other health conditions and time frames that are not on this list.

• Stroke, after 10 years with no reoccurring problems;
• Allergies, while testing is in process;
• Ear infections, controlled with medications;
• Lyme’s disease, without symptoms after one year;
• Breast Implants (non-silicone);
• Ringworm;
• Joint sprain or strain, recovered and no restrictions;
• Migraine headache, mild and infrequent with no emergency room visits;
• Mild depression.

This basically lets you know how the plan will treat large bills...so called catastrophic or major medical coverage. Your max-out-of-pocket let's you how much you will pay up to for covered benefits, in-network in a calendar year. Usually, the max is per person up to two people maximum. The Blue Shield Preferred Savings plans have a family deductible for 2 or more people on one plan.

A deductible is an amount that you will pay first before the plan kicks in. Keep in mind that you will still get the discounted rate (usually 30-60% off) on covered benefits, in-network even before you meet your deductible. After the deductible is met, you typically go into a % of the discounted rate. Some benefits such as maternity and brand name descriptions will have their own, separate deductible.

Currently there are a few health plans that stand out as being good values. Interestingly enough, they are also the most popular plans state-wide. All these plans combine solid carrier strength and comprehensive coverage with a high(er) deductible which helps to keep your monthly rates down. With current rate increases (last four years), this this is a smart way to insure. Check out the following plans:

ClearProtection (no maturnity)
SmartSense (no maturnity)
CoraGuard (no maturnity)
Lumenos HIA
Lumenos HSA (no maturnity)
RightPlan40 (no maternity)
PPO 3500 HSA Compatible Plan
HMO Saver

There are a lot of differences between a PPO and an HMO, but the biggest differences are in how you access care, and what providers you can access. For more information and the differences see, Difference between HMO and PPO? and Whats is the difference between HMO, PPO and POS?

Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, carefully review the plans

No. If you choose to use a credit card, your card will only be charged if you qualify for short-term coverage. Please note that credit card billing of premiums is optional and you can obtain coverage without using that method of payment.

In most cases, as soon as you complete your application, we will be able to let you know if you do not qualify for short-term coverage.

Coverage for many short-term health insurance plans can start as soon as 24 hours after the application is submitted. In order for coverage to start promptly, you can make your first premium payment by supplying a valid credit card number with your application. Please note that credit card billing of premiums is optional and you can obtain coverage without using that method of payment. If you would prefer to have your coverage start later, you can select a date up to 30 days in the future.

At the end of your coverage term, most health insurance companies will allow you to re-apply for another short-term plan. These plans do not typically constitute an automatic continuation of your first plan. Many short-term health insurance plans only allow you to re-apply once.

If you're between jobs, waiting for coverage from another health insurance plan to start, laid off, on strike, a recent college graduate or seasonal employee and know that you only need coverage for a specific period of time, short-term health insurance may be a great option for you.

Short-term health insurance plans provide you with coverage for a limited period of time, and may be an ideal solution for those between jobs or those waiting for other health insurance to start. Typically, short-term plans offer coverage up to six months, although some plans may offer coverage up to 12 months. If you think you'll need coverage for a longer period of time, you may want to look at a standard, longer-term health insurance option like our individual and family health insurance plans. The application process for short-term health insurance is usually simpler than standard, longer-term health insurance. Short-term health insurance plans are designed to protect against unforeseen accidents or illnesses, rather than to provide comprehensive coverage, and, as such, typically do not include coverage for preventive care, physicals, immunizations, dental or vision care. Purchasing a short-term medical insurance plan will make you ineligible for any guaranteed issue individual health plans commonly referred to as HIPAA Plans. HIPAA plans are usually very expensive and are generally intended for people with pre-existing medical conditions who would have trouble getting health insurance otherwise. If you wish to maintain your eligibility for HIPAA plans, you should not purchase a short-term plan. Please consult your benefits advisory to discuss your rights under the Health Insurance Portability and Accountability Act (HIPAA) and other rights under state law. Short-term health insurance plans typically do not cover pre-existing medical conditions. The definition of a pre-existing condition varies by state, but, in general, short-term health insurance policies exclude coverage for conditions that have been diagnosed or treated within the previous 3 to 5 years. If you have an existing medical condition, you may want to research whether you can extend your current insurance. Employer-sponsored insurance can be extended under a government-regulated option commonly referred to as COBRA, which you should seriously consider if you have an existing medical condition.

Group health insurance plans are categorized as either indemnity plans (also known as "traditional indemnity," "fee-for-service," or "FFS" plans) or managed care plans. Indemnity and managed care plans differ in their basic approach. Put broadly, the major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid. You will typically have a broader choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers with an indemnity plan while you will typically have less out-of-pocket costs and paperwork with a managed care plan.

Indemnity plans once dominated the American health insurance market, but are no longer as popular as they used to be. They are most common on the east coast. Managed care plans now take up a much larger share of the general health insurance market and are especially dominant in the western parts of the country. There are three basic types of managed care plans: PPOs, HMOs, and POS plans.

Your company will probably be eligible for a small business plan if it meets the following criteria:

1. Your company consists of at least two full-time owners, officers, partners and/or employees, as verified by officially-filed state quarterly wage and tax statements (DE-6 in California) or annual federal tax return documents;

 

2. Your company is a legitimate business entity (i.e., your company was formed for a purpose other than to obtain insurance), as verified by one of the following documents:

 

•    A business license or fictitious name filing (proprietorships and partnerships);
•   Articles of incorporation (corporations); or
•   Articles of organization (limited liability company). 

 

3. Your company meets the minimum employer contribution percentage set by the insurance company.

 

Please note that eligibility criteria may vary among insurance companies and by state. If you have any questions about your company's eligibility for a particular small business plan, please call one of our licensed representatives Mon - Fri, 6AM-5PM PT at 800-569-1156.

Significant tax advantages may be available to employers who offer group health insurance coverage to their employees. Employers can generally deduct 100% of the health insurance premiums they pay on qualifying group health plans. Providing health insurance coverage to employees as part of a total compensation package may also result in reduced payroll taxes for employers. Additionally, when the employer offers group health coverage, it's possible for an employee's share of the premium to be paid with pre-tax dollars, resulting in tax savings for the employee. Check with your accountant or tax advisor for specific tax benefits for your business and employees.

Typically, an employer is required to cover 50% of the employee's monthly premium. In these cases, the employee covers the remainder of his or her own premium and then covers the full premium for any of his or her dependants. Minimum employer contribution levels may differ from state to state and from one insurance company to the next. Also, some employers opt to cover a higher percentage of the employee's monthly premium and sometimes a portion of the premium costs for an employee's dependants.

During the application process, you'll be able to indicate how much of your employees' (and their dependents') monthly premiums you would like to cover.

It's no secret that employees value health insurance benefits. Surveys have shown that workers value health insurance coverage second only to monetary compensation. By offering group health insurance benefits to your employees, you may find it easier to hire and retain the best workers for your company.

As a business owner, you may not have health insurance coverage yourself. Perhaps you've considered shopping for an individual health insurance plan for yourself and your family, but did you know that by obtaining insurance through a company, you may get better rates than through the individual market?

Additionally, there are various tax incentives available to you and your employees when you participate in a group health insurance plan. For example, businesses can generally deduct 100% of the premiums they pay on qualifying group health plans and, by offering group health insurance as part of a total compensation package, you may be able to reduce payroll taxes. Plus, your employees can pay their portion of the monthly insurance premium with pre-tax dollars. Make sure that you take these incentives into consideration when determining the affordability of a health insurance plan for you and your employees.

HSAs make it easy to save on your taxes:

• At the end of each year, you will be sent a statement showing the amount you contributed to your HSA that year. You can deduct this amount provided it is less than or equal to the maximum allowable contribution.
• Much like an IRA, HSA deductions are "above-the-line" and thus can be taken even if you do not itemize.
• If you are self-employed, in addition to deducting your HSA contributions, you may be able to deduct 100% of your health insurance premiums, provided that:
  • You are not eligible to participate in a subsidized health plan offered by an employer or your spouse's employer.
  • The deduction does NOT exceed the amount of net income from your business.

Note: Check with your accountant or tax advisor for the specific federal and state tax benefits that apply to you.

Using funds in your Health Savings Account is easy:

• Typically an HSA will provide you with a checkbook or debit card. When you pay for a qualified medical expenses, use the debit card or check to make the payment.
• You do not need to get approval from the HSA administrator when you use funds in your account.
• You do not need to submit receipts to the HSA administrator, although you should save them just as you keep receipts for other items that are deducted from your taxes.

NOTE: You must establish the HSA before you incur medical expenses otherwise the expenses will not qualify.

You can make a one-time distribution from an IRA to fund your HSA, provided it doesn't exceed HSA contribution limits. Employees have the opportunity for a one-time, tax-free transfer of funds from their flexible spending account (FSA) or health reimbursement arrangement (HSA) to their HSA.

• The Business HSA allows employees the freedom to apply for the health insurance plan that best suits their needs and budget.
• Through employer contributions to an employee's Health Savings Account, a Business HSA empowers employees to manage their own healthcare dollars.
• While an HSA-compatible health insurance plan will require the employee to fulfill an annual deductible before coverage kicks in, expenses paid toward the deductible may be paid out of the employee's Health Savings Account, and leftover funds may be saved and grow from year to year. In case of a serious injury or accident, the HSA-compatible health plan will be there to cover medical bills beyond the deductible.
• By participating in a BusinessHSA program, employees can find affordable HSA-compatible health insurance plans and have the option to save money for the future through a tax-advantaged savings account.

• Deducting 100% of your HSA contributions from your taxable income
• Having the money in your HSA accrue interest and/or gains on a tax-free basis
• Paying no penalties or taxes when you use your HSA to pay for qualified medical expenses
• Having a high-deductible HSA-compatible health insurance plan, which typically has a lower premium than a plan with a lower deductible

• Pre-tax money is deposited each year into an HSA and can be easily withdrawn at any time with no penalty or taxes to pay for qualified medical expenses. Withdrawals can also be made for non-medical purposes, but will be taxed as normal income and are subject to a 10 percent penalty if done prior to age 65.
• Any HSA funds not used each year remain in the account, and earn interest tax-free to supplement medical expenses at any time in the future.
• Like an IRA, the account belongs to you, not your employer. But unlike an IRA, your employer CAN contribute to your HSA.

Claims payment usually occurs within 30 days of the Home plan approval to pay their member’s claim. 

When a member belongs to an account that is exempt from the BlueCard Program, Anthem Blue Cross and Blue Shield will electronically forward your claims to the member’s Blue Plan. That means you will no longer need to send paper claims directly to the member’s Blue Plan. Instead, you will submit these claims to Anthem Blue Cross and Blue Shield. However, you will continue to submit Medicare supplemental (Medigap) and other COB claims under your current process.

Occasionally, exceptions may arise in which Anthem Blue Cross and Blue Shield will require you to file the claim directly with the member’s Blue Plan. Here are some of those exceptions:

• You contract with the member’s Blue Plan (for example, in contiguous county or overlapping service area situations).
• The ID card does not include an alpha prefix.

Occasionally, Anthem may request that you file the claim directly with the member’s plan. For instance, there may be a temporary processing issue at Anthem, the member’s plan, or both that prevents completion of the claim through the BlueCard Program. When in doubt, please send the claim to Anthem and we will handle the claim for you.

• If you have a contract with the member’s Plan, file with that Plan.
• If you normally send claims to the direct provider of care, follow normal procedures.
• If you do not normally send claims to the direct provider of care and you do not have a contract with the member’s Plan, file with Anthem Blue Cross and Blue Shield.

The claim submission process for international BCBS Plan members is the same as for domestic BCBS Plan members. You should submit the claim directly to Anthem Blue Cross and Blue Shield.

If you are a non-PPO (traditional) provider and are presented with an identification card with the “PPO in a suitcase” logo on it, you should still accept the card and file your claim to Anthem. You will still be given the appropriate traditional pricing per your contract with Anthem.

You should always submit BlueCard claims to Anthem Blue Cross and Blue Shield. Be sure to include the member’s complete identification number when you submit the claim. The complete identification number includes the three-character alpha prefix. Do not make up alpha prefixes. Incorrect or missing alpha prefixes and member identification numbers delay claims processing.

Once Anthem Blue Cross and Blue Shield receives a claim, it will electronically route the claim to the member’s BCBS Plan. The member’s Plan then processes the claim and approves payment, and Anthem Blue Cross and Blue Shield will pay you.

The BlueCard Managed Care/POS program is for members who reside outside their Blue Plan’s service area. However, unlike other BlueCard programs, BlueCard Managed Care/POS members are enrolled in Anthem Blue Cross and Blue Shield ‘s network and primary care physician (PCP) panels. BlueCard Managed Care/POS members will have a blank suitcase log on their card. Their eligibility can be verified by Anthem Blue Cross and Blue Shield as well a 1-800-676-BLUE (2583)

You can verify the member’s network benefits when you verify their eligibility. Call 1-800-676-BLUE (2583). You can also determine a member’s participation status by the logo on their ID card. A blank suitcase logo on a member’s ID card means that the patient has BCBS traditional, POS, or HMO benefits delivered through the BlueCard Program.

You’ll immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their membership card. BlueCard PPO members are BCBS members whose PPO benefits are delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard PPO members, only those whose membership cards carry this logo. BlueCard PPO members traveling or living outside of their Blue Plan’s area receive the PPO level of benefits when they obtain services from designated BlueCard PPO providers.

Some identification cards may not have an alpha prefix. This may indicate that the claims are handled outside the BlueCard Program. Please look for instructions or a telephone number on the back of the member’s ID card for how to file these claims. If that information is not available, call Anthem Blue Cross and Blue Shield’s BlueCard Customer Service Department. It is very important to capture all ID card data at the time of service. This is critical for verifying membership and coverage. We suggest that you make copies of the front and back of the ID card and pass this key information on to your billing staff. Do not make up alpha prefixes.

There are two types of alpha prefixes: Plan-specific and account-specific. 

The three-character alpha prefix at the beginning of the member’s identification number is the key element used to identify and correctly route out-of-area claims. The alpha prefix identifies the BCBS Plan or national account to which the member belongs. It is critical for confirming a patient’s membership and coverage. The prefix is part of the member’s identification number.

When members from other BCBS Plans arrive at your office or facility, be sure to ask them for their current Blue Plan membership identification card. The main identifiers for BlueCard members are the alpha prefix, a blank suitcase logo, and, for eligible PPO members, the “PPO in a suitcase” logo. (Members from other Blue Cross and Blue Shield plan’s, other than Anthem, are generally considered BlueCard members)

Occasionally, BCBS HMO members affiliated with other BCBS Plans will seek care at your office or facility. You should handle claims for these members the same way as you do Anthem Blue Cross and Blue Shield members and BCBS traditional, PPO and POS patients from other Blue Plans¾by submitting them to Anthem through the BlueCard Program.

Similar to BlueCard Traditional and BlueCard PPO, the BlueCard Managed Care/POS program is for members who reside outside their Blue Cross Blue Shield Plan’s service area. However, unlike other BlueCard programs, BlueCard Managed Care/POS members are actually enrolled in the (name of local Plan) network and primary care physician (PCP) panels. Therefore, you should treat these members as you treat any other Anthem Blue Cross and Blue Shield POS member, applying the same referral practices and network protocols.

A national program that offers members traveling or living outside of their Blue Plan’s area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider.

A national program that offers members traveling or living outside of their Blue Plan’s area the traditional, or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Plan’s service area.

Medicare+Choice is excluded from the BlueCard Program. You must file Medicare+Choice claims with the member’s BCBS Plan. In addition, claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program. Please follow your FEP billing guidelines

Currently four types of products are administered through the BlueCard Program: BlueCard Traditional, BlueCard PPO, BlueCard Managed Care/POS, and HMO. The following products are optional under the BlueCard Program.

• Stand-alone dental and prescription drugs
• Stand-alone vision and hearing

The BlueCard Program is a national program that enables members obtaining healthcare services while traveling or living in another Blue Cross Blue Shield (BCBS) Plan’s area to receive all the same benefits of their contracting BCBS Plan and access to providers and savings. The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing and reimbursement.

Yes. You have several choices, including HIPAA and Conversion Plans, buying Individual Health Insurance, or MRMIP.

You cannot enroll in Federal COBRA or Cal-COBRA if you:

• Are enrolled in Medicare.
• Are fired for gross misconduct.
• Did not enroll in the time limit.
• Do not pay your premiums on time.
• Are covered or become covered by another health plan.

They end when:

• The time period ends (up to 18 months of Federal COBRA followed by up to 18 months of Cal-COBRA, or up to 36 months total if you only have Cal-COBRA).
• You do not pay your premiums on time.
• The employer no longer offers any health insurance.
• You move outside the health plan's service area.
• You enroll in Medicare.
• You enroll in another health plan.

• You have the same benefits as other employees in the same plan.
• If other employees have open enrollment periods when they can change from one plan to another, you can too.
• If the employer changes the employees from one plan to another, you change too.
• You have no restrictions because of pre-existing conditions.
• If the group plan offers specialized plans, such as dental or vision plans, they must be offered to you also. However, if you change to Cal-COBRA from Federal COBRA, these specialized plans do not have to be offered to you.

Yes. Federal COBRA lasts 18 months. Then you can keep your health insurance for 18 more months under Cal-COBRA.

• You may be able to get Federal COBRA if you have health insurance through an employer who has 20 or more employees and there is a qualifying event described below.
• You may be able to get Cal-COBRA if you have health insurance through an employer who has 2 to 19 employees and there is a qualifying event described below.

  A qualifying event means that you lose your health insurance because:

  • The employee's job ends.
  • The employee's hours are cut.
  • You divorce or legally separate from the employee.
  • You are no longer a dependent of the employee.
  • The employee enrolls in Medicare.
  • The employee dies.

The HR department of your previous company is a good place to start. If you can

If you previous employer cancels their group health insurance, you will lose your COBRA option. If your employer decides to switch health insurance to a different insurance company, you will be provided with the opportunity to elect coverage with this new insurance carrier.

This will depend on your eligibility for other options based on your health status at that time. This will be better explained in the

In general, you can remain on COBRA for a period of 18 months. Disabled persons and other qualified beneficiaries may be eligible to remain on the COBRA plan for an additional 11 months, but at an increased premium. This may vary under some state mini-COBRA laws.

Your COBRA coverage will begin on the day following the termination date of your coverage under your previous health plan. This will likely be the first day of the month following the date that you were terminated. If you do not enroll in COBRA prior to this date, you are responsible for making up the premium payment back to this date.

Yes, your coverage will not change. You will be on the exact same plan that you had when you were employed. During an open enrollment period, you may have the option to switch to other available plans offered under the existing group health insurance policy.

If there is no continuing group health insurance plan through your previous employer, there is no COBRA option available to you. In order to maintain a group health plan, a company must have employees currently on payroll. If a company goes out of business, they are no longer qualified to maintain group health insurance, which in turn affects the COBRA rights of all individuals previously insured under that plan.

No. Any, or all, qualified COBRA beneficiaries may enroll in COBRA. You can select which family members to enroll in COBRA after reviewing other available options.

This will depend on how much your employer was paying for your insurance. Under federal COBRA, your maximum premium will be 102% of the amount that was charged to your employer by the insurance company. Under the American Recovery and Reinvestment Act of 2009, you may be entitled to a 65% reduction of this premium.

You have 60 days from the date that your coverage under the group plan is terminated or from the date that the COBRA election notice has been provided. This is referred to as the

In general, your employer must notify the health plan administrator within 30 days from the date of the termination of employment. Notice must be sent to you within 14 days of the plan administrator being notified. Since not all employers are as familiar with COBRA laws as they should be, we highly recommend that you contact your previous employer or insurance carrier within the first 10 days following termination notice to ask for your COBRA election papers. This will also insure that your notice is sent to the proper address, which you should also verify during this phone call. This may vary under some state mini-COBRA laws.

Under federal COBRA, which applies to groups of 20 or more employees, you must be a