December 02, 2015
United Healthcare (UHC) recently issued a contract amendment to practices participating in the California health benefit exchange through its UHC Core network. The new contract language amends (or replaces) the prior Appendix 2 of the UHC participating physician agreements.
UHC also advised the California Medical Association (CMA) that the only option for physicians who wish to opt out of the Core product network is to terminate the underlying UHC commercial agreement. There is no option to opt out of just the Core network.
The Core network, introduced earlier this year, is a network being marketed to employer groups seeking lower premiums and used for its 2016 exchange product. This narrowed network will include approximately 45 percent of UHC’s PPO provider network.
In April, UHC notified 19,000 practices included in its commercially contracted provider network, advising of their inclusion in the UHC Core network.
UHC has been approved to offer exchange coverage in the five regions of California where fewer than three exchange health plans offered for 2016 including:
- Region 1: Northern counties (Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne and Yuba counties)
- Region 9: Central Coast (Santa Cruz, San Benito and Monterey counties)
- Region 11: Central Valley (Fresno, Kings and Madera counties)
- Region 12: Central Coast (San Luis Obispo, Santa Barbara and Ventura counties)
- Region 13: Eastern region (Imperial, Inyo and Mono counties)
UHC Core exchange patients from these counties will be allowed to visit any participating Core provider throughout California.
Regarding Section 7 of the amendment, CMA expressed concern to UHC that arranging for services 24/7 for solo or small group practices would not be feasible. In response, UHC clarified that a voicemail message or answering service directing patients with an emergency to the nearest emergency room or to call 911 would satisfy this requirement. For non-emergent situations, the requirement can be met by directing callers to an in-network urgent care center or giving them the ability to speak with a physician or qualified health care professional within a specified time frame.
CMA has also asked UHC to clarify the requirements under Section 19 of the contract amendment, which includes language about conditions under which UHC will pay for services provided when a prior authorization is obtained, and whether it is consistent with Health & Safety Code §1371.8, which prohibits plans from rescinding or modifying authorizations after the provider renders the service in good faith pursuant to the authorization for any reason, including situations where the plan later determines the patient wasn’t eligible.
UHC will be sending a welcome packet to Core participating physicians this month. The payor is also offering a number of one-hour webinars to provide more information about the United Healthcare Core product. Topics included are health plan overview, eligibility and benefits details, how to verify participation status and prior authorization requirements.
To register for one of the webinars, visit www.UnitedHealthcareOnline.com > Tools & Resources > Products & Services > 2016 Health Plans Training.
Physicians who are unsure about their participation in the Core plan network can contact UHC Network Management at (866) 574-6088.