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California Individual DMHC Rate/Benefit Action
Effective May 1, 2011
Rate and benefit filings have been closed by the DMHC
with no objection
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Rate Changes
Effective 5/1/11 -- for DMHC Plans Sold Prior to 9/23/10 (grandfathered and non-grandfathered)
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• Rate and benefit filings with the DMHC
• Notification mailing 2/23/11 to DMHC members
• California law, SB 1163 requires 60-day notification
What other mailings coincide with the rate action?• March open enrollment – (Not all DMHC members get open
enrollment notice – closed PPO share plans do not, which is a majority of membership).
Each mailing offers clients plan options• Remember, clients can only take advantage of one “open enrollment” or
move without medical underwriting.
Background and Overview
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Plan Name GF Contract Code
PPO Share 7500 00Y4
PPO Share 5000 01LC
PPO Share 3500 00Y3
PPO Share 3500-R 01LA
PPO Share 2500 7891, 1871
PPO Share 1500 7889, 7890
PPO Share 1000 1393, 1503, 7878
PPO Share 500 7895, 1501, 1575, 1920,7888, 7904
HMO Saver 7896, 7879, 7894, 7905, NM03
100% HMO 7898, 7906, 7897, NM02, 1913
Select HMO PE43
The following DMHC GF plans will be subject to a rate increase on 05/01/11:
Grandfathered (GF) Plans (Sold On Or Before 3/23/10)
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Plan Name NGF Contract Code
PPO Share 7500 06AW
PPO Share 5000 06AX
PPO Share 3500 06AV
PPO Share 3500-R 06AH
PPO Share 2500 07TU
PPO Share 1500 07TU
PPO Share 1000 0ADZ
PPO Share 500 0ADY
HMO Saver 06AY
100% HMO 07TQ
Select HMO 06AZ
The following DMHC NGF plans will be subject to a rate increase on 05/01/11:
Non-Grandfathered (NGF) Plans Sold Between 3/24/10 & 9/22/10
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•DMHC NGF standard rates are 3-4% higher than GF rates on average
•NGF base rates are higher than GF base rates because they reflect the Federal Health Care Reform benefit levels
•NGF plans must cover Preventive Care benefits at 100%. Member has no cost share.
•No annual dollar limits on essential health benefits.
•Children are expected to be guaranteed issue for the NGF plans under Health Care Reform.
Grandfathered Vs. Non-Grandfathered Rates
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When Do DMHC Members Rates/Benefits Change?
Rate Changes apply to DMHC Members who are:
•Not in an initial 12-month rate guarantee
•Have not received a rate increase in the last 6 months
The majority of members (nearly 95%) will receive the rate adjustment on 5/1/11.
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Dental Rate Increase
Dental rate increase effective 05/01/11 on following plans (contract codes):
• Dental Prudent Buyer (7874*)
• Dental Net (QI4V**)
• Dental Blue (ZE6N**, ZE7N**, ZE8N**, DZ09*, DZ10*,DZ11*,DZ12*, 01PU*, 01PW*)
Note: SmileNet (Y437, 7438, 7439) rates do not change. Tonik Enhanced Dental changed 1/1/11.
*CDI **DMHC
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Benefit Reductions
Benefit changes, to help moderate the rate increase, effective 05/01/11 will:
•Increase Medical Deductibles•Increase Brand/Specialty Co-pays•Increase Brand/Specialty Deductibles•Increase Coinsurance Maximum•Increase Office Visit Co-Pays
Please note:
•All members on impacted DMHC plans will receive their benefit changes effective 5/1 regardless of their renewal month.
•Member ID cards and endorsements will go out in a separate, future mailing.
•Plan names will stay the same, even though deductible levels may change.
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DMHC Benefit Changes-5/1
Plan/Contract CodeCurrent Benefit New Benefit
Individual PPO Share 5007895, 1501, 1575, 1920, 7888, 7904, 0ADY
Participating and Non-Participating Provider Deductible:
$500
Participating and Non-Participating Provider Deductible:
$550
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$5000
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$5850
Prescription Drug Deductible:$250
Prescription Drug Deductible:$275
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
Individual PPO Share 10001393, 1503, 7878, 0ADZ
Participating and Non-Participating Provider Deductible:
$1000
Participating and Non-Participating Provider Deductible:
$1150
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$5000
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$5850
Prescription Drug Deductible:$250
Prescription Drug Deductible:$275
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
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Plan/Contract Code
Current Benefit New Benefit
Individual PPO Share 15007889, 7890, 07TV
Participating and Non-Participating Provider Deductible:
$1500
Participating and Non-Participating Provider Deductible:
$1750
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$6000
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$7050
Prescription Drug Deductible:$250
Prescription Drug Deductible:$275
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
Individual PPO Share 25007891, 1871, 07TU
Participating and Non-Participating Provider Deductible:
$2500
Participating and Non-Participating Provider Deductible:
$2950
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$7500
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$8850
Office Visit Copay$35
Office Visit Copay$40
Prescription Drug Deductible:$500
Prescription Drug Deductible:$575
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
DMHC Benefit Changes-5/1
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DMHC Benefit Changes-5/1
Plan/Contract Code Current Benefit New Benefit
Individual PPO Share 350000Y3, 06AV
Participating and Non-Participating Provider Deductible:
$3500
Participating and Non-Participating Provider Deductible:
$4100
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$7500
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$8800
Office Visit Copay$40
Office Visit Copay$45
Prescription Drug Deductible:$750
Prescription Drug Deductible:$875
Brand Prescription Drug Copay:$15 (or 40%, whichever is greater)
Brand Prescription Drug Copay:$20 (or 40%, whichever is greater)
Individual PPO Share 3500-R01LA, 06AH
Participating and Non-Participating Provider Deductible:
$3500
Participating and Non-Participating Provider Deductible:
$4100
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$7500
Participating and Non-Participating Provider Copayment/Coinsurance
Maximum:$8800
Office Visit Copay$40
Office Visit Copay$45
Prescription Drug Deductible:$750
Prescription Drug Deductible:$875
Brand Prescription Drug Copay:$15 (or 40%, whichever is greater)
Brand Prescription Drug Copay:$20 (or 40%, whichever is greater)
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DMHC Benefit Changes-5/1
Plan/Contract Code Current Benefit New Benefit
Individual PPO Share 500001LC, 06AX
Participating and Non-Participating Provider Deductible:
$5000
Participating and Non-Participating Provider Deductible:
$5900
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$7500
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$8850
Office Visit Copay$40
Office Visit Copay$45
Prescription Drug Deductible:$750
Prescription Drug Deductible:$875
Brand Prescription Drug Copay:$15 (or 40%, whichever is greater)
Brand Prescription Drug Copay:$20 (or 40%, whichever is greater)
Individual PPO Share 750000Y4, 06AW
Participating and Non-Participating Provider Deductible:
$7500
Participating and Non-Participating Provider Deductible:
$8850
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$7500
Participating and Non-Participating Provider Copayment/Coinsurance Maximum:
$8850
Office Visit Copay$40
Office Visit Copay$45
Prescription Drug Deductible:$750
Prescription Drug Deductible:$875
Brand Prescription Drug Copay:$15 (or 40%, whichever is greater)
Brand Prescription Drug Copay:$20 (or 40%, whichever is greater)
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DMHC Benefit Changes-5/1
Plan/Contract Code Current Benefit New Benefit
Individual HMO7898, 7906, 7897, NM02, 1913, 07TQ
Copayment/Coinsurance Maximum:$3000
Copayment/Coinsurance Maximum:$3500
Office Visit Copay$10
Office Visit Copay$15
Prescription Drug Deductible:$250
Prescription Drug Deductible:$275
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
Individual Select HMOPE43, 06AZ
Copayment/Coinsurance Maximum:$3000
Copayment/Coinsurance Maximum:$3500
Office Visit Copay$25
Office Visit Copay$30
Prescription Drug Deductible:$250
Prescription Drug Deductible:$275
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
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DMHC Benefit Changes-5/1
Plan/Contract CodeCurrent Benefit New Benefit
Individual HMO Saver7896, 7879, 7894, 7905, NM03, 06AY
Deductible:$1500
Deductible:$1750
Copayment/Coinsurance Maximum:$3000
Copayment/Coinsurance Maximum:$3500
Office Visit Copay$10
Office Visit Copay$15
Prescription Drug Deductible:$250
Prescription Drug Deductible:$275
Brand Prescription Drug Copay:$30
Brand Prescription Drug Copay:$35
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Upgrades-Member Plan Change Option
Plan Movement Options For Members Who Receive Benefit Changes
Members can upgrade to an open plan available for sale:•within their plan family, if available•without medical underwriting •through April 30. •their current plan must be paid to May 1, 2011•change form must be received on or before April 30, 2011*•new plan effective May 1, 2011
If a member takes advantage of another opportunity to change plans (see Open Enrollment March 1-March 30 slide deck), this upgrade option will no longer be available. (This open enrollment option does not apply to the majority of DMHC membership) Members will also have the opportunity to move to other open plans as is normally the case, per Plan Option tables.
*Change form will include a grid of their options. To assist them with rates on plan options, use PlanFinder or your quoting site, keeping in mind their rate may be higher if they have an underwriting tier other than Level 1.
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Upgrades-Member Plan Change Option
Current Plan and Contract Codes New Plan Option
Individual HMO- 7898, 7906, 7897, NM02, 1913, 07TQ Individual HMO – 06C0
HMO Saver- 7896, 7879, 7894, 7905, NM03, 06AY Individual HMO – 06C0Select HMO – 06C2HMO Saver – 06C1
Select HMO- PE43, 06AZ Individual HMO – 06C0Select HMO – 06C2
PPO Share 7500- 00Y4, 06AW *PPO Share 1000 – 06BLPPO Share 3500 – 06BXPPO Share 5000 – 06BZPPO Share 7500 – 06BY
PPO Share 5000- 01LC, 06AX *PPO Share 1000 – 06BLPPO Share 3500 – 06BXPPO Share 5000 – 06BZ
PPO Share 3500-R- 01LA, 06AH *PPO Share 1000 – 06BLPPO Share 3500 – 06BX
PPO Share 3500- 00Y3, 06AV *PPO Share 1000 – 06BLPPO Share 3500 – 06BX
PPO Share 2500- 7891, 1871, 07TU *PPO Share 1000 – 06BL
PPO Share 1500- 7889, 7890, 07TV *PPO Share 1000 – 06BL
PPO Share 1000- 1393, 1503, 7878, Z828, 0ADZ *PPO Share 1000 – 06BL
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Agent Tools
On the “5/1/2011 Rate and Benefit” page on the agent site:
•Rate Sheets
•Sample member materials.
Rate action client reports on Agent Services that show which clients are affected and their new medical and/or dental rates.
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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.
