Anthem is working to slow the effects of rising healthcare costs directly impacting employers and members. Effective January 1, 2018, non-emergency services will not be covered when treated in an emergency room (ER), if more appropriate settings are available. The claim will be reviewed by one of Anthem’s medical directors using the prudent layperson standard and potentially denied. If a member’s claim for emergency services is denied it will be denied as member liability. This means Individual and Group members who choose to receive non-emergency care in the ER could be responsible for the charges.
Members should always call 911 or seek care from the ER for life-threatening situations. However, when seeking care outside of their primary care physician’s hours, options like urgent care centers, retail health clinics, walk-in doctor’s offices, and online services like LiveHealth Online can provide more cost-effective and time-saving options. Members are encouraged to utilize Anthem’s online tools like 24/7 NurseLine to help them determine the right care for non-emergencies.
It’s important to note that non-emergency visits to the ER will be covered if:
- Directed to the emergency room by another medical provider
- Services were provided to a child under the age 14
- There isn’t an urgent care or retail clinic within 15 miles
- Visit occurs on a Sunday or major holiday
Communicating with Your Employees
If you are an Anthem client, it will be important to share this information with employees before the ER program is implemented on January 1, 2018. FirstPerson will share information with members during fall Open Enrollment meetings. Anthem will also use this time to help educate its members about this important topic. They’ll be sending letters to members who have used the ER for minor conditions in the past 12 months. The letter will explain how the ER program works and how minor conditions like the common cold, sore throat, rash, mild fever, suture removal, seasonal allergies and so forth, can be treated safely – and at lower cost – in other settings besides the ER.
We encourage you to also take this time to talk to your employees about the ER program. That’s why we’re sharing these helpful resources with them:
- Employer ER utilization toolkit
- Deciding Where to Get Care article
- Finding the Right Care When It’s Not an Emergency article
Choosing the right site of care can help members get the right care they need while helping them save valuable time and money. We appreciate your partnership as we work to make sure Anthem members are getting the most from their health care benefits.
Please contact your advisor or a member of your account team if you have any questions about this new program.