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Beaver, Blue Cross Contract Ends

Posted on: Tuesday, 8 November 2005, 21:00 CST

By Annette Wells, San Bernardino County Sun, Calif.

Nov. 8--If you're a Blue Cross member with Beaver Medical Group as your primary care provider, it's time to look for a new doctor.

Beaver Medical's contract with Blue Cross of California ended in October when the health insurer contacted the state's Office of Managed Health Care to inform it of stalled negotiations and possible termination.

Now, with exceptions of pregnant women, the terminally ill and newborns, the more than 16,000 Blue Cross enrollees most of whom live in Redlands, Yucaipa and San Bernardino must choose another provider or accept new assignment from the HMO.

"In the eyes of the law, the contract is terminated even though it doesn't expire until Jan. 1," said Lynne Randolph, a spokeswoman for the Office of Managed Health Care, which oversees HMO activity in the state. "If the two parties come to an agreement before Jan. 1, the enrollee must request to be sent back (to Beaver). That is state law."

As of Monday, no new contract between Beaver and Blue Cross had been settled, said Robert Alaniz, regional vice president for the HMO.

Last week, John Goodman, chief administrator of Beaver Medical Group and chief executive officer of its management company, Epic Management, said he was disappointed and confused by Blue Cross' decision.

Goodman said negotiations were going well until mid-October, when talks abruptly stopped.

Then, on Oct. 28, Blue Cross sent its Beaver enrollees a letter stating the provider had advised the health plan its contract would end Jan. 1.

The letter tells those members that they will receive a new identification card by mail five days before the termination date and that they should contact a new medical group.

"By law, the health plan has to send a notice to enrollees 60 days prior to the termination date informing them that they will be assigned a new provider group unless the enrollee calls and makes changes themselves," Randolph said.

"They need to do that between now and January. If not, they will be assigned to a provider."

On Nov. 1, Beaver sent its own letter to Blue Cross enrollees saying that the provider anticipates "satisfactory agreement will be reached prior to Dec. 31."

However, Randolph said the state has already approved Blue Cross' plan to transition enrollees to different health-care providers.

According to the Office of Managed Health Care, pregnant women can remain with their Beaver Medical primary care provider for up to 12 months and newborns for up to 36 months under a Continuity of Care clause.

The chronically or terminally ill may also request to keep this provider for up to 12 months.

Enrollees who have upcoming scheduled appointments or surgeries can also make a request for up 180 days after the termination of the contract.

But, they must contact Blue Cross.

Enrollees can go through the HMO's director of providers or seek a referral, but they must call Blue Cross to inform the company of their plans, Randolph said.

When the state approves reassignments, one of the rules is that the primary care provider must be within 15 minutes of an enrollee's residence or place of employment.

"If enrollees are getting assigned primary care providers that are 40 minutes away, that's not right, and we need to be notified," Randolph said.

Randolph said anyone with questions or concerns can call the state's HMO Help Center at (888) 466-2219 or visit www.hmohelp.ca.gov.

It is recommended that enrollees call Blue Cross first.

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Copyright (c) 2005, San Bernardino County Sun, Calif.

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Source: San Bernardino County Sun

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