Important Information Regarding Academic Urology of PA

AmeriHealth and Academic met multiple times and exchanged proposals regarding contract terms that would allow Academic to remain in our network. We offered to enter into a new contract with Academic based on reimbursement rates that are equal to the competitive rates that are paid to other urologists in our network. However, Academic refused this offer and insisted on being paid higher rates than other urologists, which is counter to our overall goal of compensating physicians within a given specialty fairly, competitively, and consistently.

Separately, there were ongoing, fundamental disagreements over acceptable contract terms and billing issues that could not be resolved.

We value our relationship with the network physicians who serve our customers, but at the same time we need to put our customers first. As part of our responsibility to ensure access to high quality, cost-effective care, we carefully balance our efforts to fairly, competitively, and consistently compensate physicians with our responsibility to hold down premiums.

Most health insurance plans compensate the physicians in their network using a consistent schedule of fair and competitive fees for each specialty. These fees are adjusted regularly as needed, but are not typically negotiated with individual practices. We follow this approach, and believe we have been reasonable, fair, and responsive in our interactions with Academic over the last several months, including our recent meetings with Academic last month. However, Academic insisted on being paid higher rates than other urologists, which is counter to our goal of compensating physicians within a given specialty fairly, competitively, and consistently. If we had agreed to Academic’s demands for higher compensation, it would have impacted our ability to moderate premium increases, which is unfair to our customers.

We are very sensitive to any potential disruption our members may experience due to Academic choosing not to accept the terms of our contract proposal, and we will work closely with our members so they may continue to have ready access to the quality medical care they need. That’s why we began notifying members 90 days before the contract ended to help make their transition to an alternative in-network urology specialist as seamless as possible, in the event that the contract expired, like it has. We also informed members who were in an active course of treatment with Academic before the contract expired how they may continue to receive care from Academic during a transition period. We will also help members who have questions about scheduled office appointments with Academic.

Since the contract with Academic expired, how you are affected depends on what kind of coverage you have. If you are unsure of what type of benefits plan you have, you can find out by looking at your member ID card. On the front of your card, you will see your plan and copayment amounts. Look next to the word “Plan” and you will see whether your plan is an HMO, PPO, or POS.

Since the contract with Academic expired on November 30, 2011, Academic physicians and Academic locations, including the following locations below, are considered out-of-network. To find out if your urologist would be considered out-of-network, please also refer to the  list of physicians affiliated with Academic.

• Associates in Urology
• Bryn Mawr Urology
• The Urology Center of Chester County
• Tricounty Urology
• Urologic Associates of Montgomery County
• Urologic Health Associates

You may need to choose a new urologist since the contract with Academic expired and your urologist is part of a practice that is affiliated with Academic. If you want to take advantage of your full health plan benefits, you may wish to find another health care provider among the urology specialists that remain in our network. To help you do this, we’ve enclosed a list of 151 urologists at more than 500 locations who will be in our network after November 30, 2011. You may also locate a participating health care provider, visit www.amerihealth.com and select the Find a Provider tab to access the Provider Finder tool.

• If you have HMO or Medicare Advantage HMO coverage. Since the contract with Academic has expired, please contact your primary care physician (PCP) for a referral to a new in-network urologist so that there will be no interruption in meeting your health care needs. If you do not select a new in-network urologist, you will have to pay the full cost out of your pocket. Emergency care will be fully covered. Urgent care must be coordinated through your primary care physician and/or the health plan. Any reimbursements for emergency or authorized urgent care received after the contract ends will be paid directly to you and you will be responsible for paying Academic. However, if you have Medicare Advantage HMO coverage, payment will go directly to the physician.



• If you have POS coverage. Since the contract with Academic has expired, you will need to select a new in-network urologist in order to continue to be covered at the higher network level of benefits. You cannot be referred on an in-network basis to Academic for covered services (except for emergency care).
  
  POS plans generally offer coverage for out-of-network (self-referred) care but often require significant cost-sharing, such as deductibles, benefit maximums, and coinsurance. This means that if you self-refer to Academic after the contract expires, you may face significant out-of-pocket costs when receiving care from an out-of-network provider. Also, with the exception of Medicare Advantage POS members, please be aware that any reimbursement for emergency services or out-of-network (self-referred) services will be paid directly to you, the member. For self-referred services, you will be responsible for paying Academic after the contract expires, including any charges beyond your reimbursement from the plan. This means that in some cases, Academic may require that you pay the balance of your bill, which is the difference between our payment and Academic’s physicians’ charges. You are also responsible for applicable copayments, coinsurance, and deductibles. This amount may be significant. However, you may take full advantage of your in-network portion of your benefits by selecting another participating urology specialist.



• If you have PPO coverage. Since the contract with Academic has expired, you will need to select a new in-network urologist in order to continue to be covered at the higher, in-network level of benefits. If you choose to obtain covered services from Academic after November 30, 2011, these services will be subject to deductible, coinsurance, benefit maximums, and preauthorization requirements for the out-of-network portion of your benefits plan. (NOTE: If you have Medicare Advantage PPO coverage, you are not subject to preauthorization requirements since prior authorization is not permitted.)
  
  NOTE: As long as Academic physicians remain participating in the Highmark Blue Shield’s Traditional network, physician claims for AmeriHealth/PPO members will be covered at the out-of-network benefits level. Members cannot be billed the difference between Academic’s physicians’ charges and the allowed amount.
  
  If Academic physicians no longer participate in the AmeriHealth PPO or Highmark Blue Shield networks and you seek care from them, the claim will be paid at the out-of-network benefits level and you may be balanced billed you for charges that are above the amounts paid by AmeriHealth. This means that in some cases, Academic may require that you pay the balance of your bill, which is the difference between your payment and Academic’s physicians’ charges. You are also responsible for copayments, coinsurance, and deductibles. These amounts are your responsibility and could be significant. All AmeriHealth reimbursements will be made directly to you, the member, and you will be responsible for paying the non-participating provider. However, you may take full advantage of your benefits by selecting another participating urology specialist. (NOTE: If you are a Medicare Advantage member, the payment will go directly to the physician, and you will be responsible for applicable copayments and coinsurance. You may not be balanced billed above the amounts paid by AmeriHealth.)
  
  If you have commercial coverage, before any nonemergent procedure by an Academic physician is scheduled after November 30, 2011, you may wish to ask the physician’s business office for an estimate of your bill, or you may access your account by logging on to amerihealthexpress.com to determine what portion of the bill for which you will be responsible. If you are not a current user of amerihealthexpress.com, register now.

If you are in an active course of treatment with an Academic physician for a chronic or acute medical condition and prudent medical practice requires continued care from the same physician after November 30, 2011, you, your Academic urologist, or your primary care physician may request consideration for an exception to allow coverage for “continuity of care.” All continuity of care situations require preauthorization, and the temporary coverage for treatment at Academic will begin on November 30 (the date the contract ends.) The temporary coverage will be in place for a period specifically outlined in your benefits plan. (NOTE: If you have Medicare Advantage coverage, continuity of care will continue for a transitional period for up to 90 days from the date you are notified of Academic’s termination from our health plan.)

To request consideration for an exception to allow coverage for continuity of care, please use the  Continuation of Care Form our website. You, your Academic urologist, or primary care physician, must complete this form and sent it to CMC Precertification Department at the address on the bottom of the form.

Note: All approvals for continuity-of-care exceptions are contingent upon Academic continuing to honor the terms of its agreements with AmeriHealth, including payment provisions, even after the contract expires.

A referral that expires after November 30, 2011, will no longer be valid.

• If you have HMO or Medicare Advantage HMO coverage. Since the contract expired, we will not honor preauthorizations issued for procedures to be performed after November 30, 2011, by an Academic physician. Please note, there may be exceptions to this. To find out if your preauthorization will be honored, please call Customer Service at 1-800-275-2583.



• If you have POS, PPO, Medicare POS, or Medicare PPO coverage. Since the contract expired on November 30, 2011, procedures are considered out-of-network after this date, and may be covered at the out-of- network benefits level. If you choose to obtain covered services from an Academic physician after November 30, 2011, these services will be subject to the deductible, coinsurance, benefit maximums, and preauthorization requirements of the out-of-network portion of your benefits plan. (Note: If you have Medicare Advantage PPO coverage, you are not subject to preauthorization requirements since prior authorization is not permitted.)
  
  Out-of-network providers may also balance bill you for charges that are above the amounts paid by AmeriHealth. These balance-bill amounts are your responsibility and could be significant. Therefore, you may decide to have your physician arrange for covered services to be delivered in-network. (NOTE: If you have Medicare Advantage coverage, you may not be balanced billed above the amounts paid by AmeriHealth and any payment will go directly to the physician.)
  
  However, to the extent applicable, you, your Academic urologist, or your primary care physician may request an exception to allow for continuity of care as noted in the above section.