When our members know where to go when they need health care, they can usually save themselves time and money. That’s why we have tools and resources to help our members choose the right place for care. Our 24/7 NurseLine, Find A Doctor, Find Urgent Care and Estimate Your Costs tools can help members find the right care close to home or work.

Anthem is working to slow the effects of rising health care costs that have a direct impact on 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 that 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, other 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

We’re notifying you and your group clients about this now, so that you have to time to share this with clients and employees before we implement the ER program on January 1, 2018. We will also use this time to help educate our members about this important topic. We’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. In addition, we will share information with members during fall Open Enrollment meetings.

We encourage you to also take this time to talk to your clients about the ER program and share these helpful resources with them:

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 our members are getting the most from their health care benefits. For questions on the ER program, please contact your Anthem sales representative.