2013 Membership Directory
AAAHC Offers Accreditation
Standards Tailored
Specifically for Health Plans
03. PROVIDER NETWORK CREDENTIALING
03. Provider Network Credentialing
3.
This chapter describes the requirements for credentialing network health care professionals to provide
member care in an accreditable organization.
Credentialing is a three-phase process of assessing and validating the qualifications of an individual to
provide services. The objective of credentialing is to establish that the applicant has the specialized
professional background that he or she claims and that the position requires. An accreditable organization:
1) establishes minimum training, experience, and other requirements (i.e., credentials) for physicians and
other health care professionals; 2) establishes a process to review, assess, and validate an individual’s
qualifications, including education, training, experience, certification, licensure, and any other competenceenhancing activities against the organization’s established minimum requirements; and 3) carries out the
review, assessment, and validation as outlined in the organization’s description of the process.
On an application for initial credentialing and privileges, the applicant is required to provide sufficient
evidence of training, experience, and current documented competence in performance of the procedures
for which core privileges are requested. At a minimum, the following credentialing and privileging
information shall be provided for evaluation of the candidate:
a.
Education, training, and experience: Relevant education and training are verified at the time of
appointment in accordance with AAAHC-accepted primary and secondary verification sites and
initial granting of core clinical privileges; the applicant’s experience is reviewed for continuity,
relevance, and documentation of any interruptions in that experience.
b.
Peer evaluation: Current competence by reference is conducted and documented.
c.
Current state license: Current licensure is verified through the state licensing website and
documented at the time of appointment.
d.
Drug Enforcement Administration (DEA) registration, if applicable, is verified through the DEA
website and documented at the time of appointment.
e.
f.
Proof of current medical liability coverage, if applicable, meeting governing body requirements.
Information obtained from the National Practitioner Data Bank (NPDB)1.
2013
Accreditation
Handbook
A.
The provider network must be accountable to the governing body. The governing body establishes and is
responsible for a credentialing and reappointment process, applying criteria in a uniform manner to appoint
individuals to provide patient care for the organization. The governing body approves mechanisms for
credentialing, reappointment, and the granting of core privileges, and suspending or terminating privileges,
including provisions for appeal of such decisions.
B.
The governing body, either directly or by delegation, makes (in a manner consistent with state law) initial
appointment, reappointment, and assignment or curtailment of core privileges of network providers based
on professional peer evaluation. This process shall have the following characteristics:
1.
The governing body has specific criteria for the initial appointment and reappointment of network
providers.
2.
Provisions are made for the expeditious processing of applications.
Review Guidelines
The governing body:
1.
Establishes and is responsible for a credentialing and reappointment process, applying
criteria in a uniform manner to appoint individuals to provide patient care for the organization. Yes
No
2.
Approves mechanisms for credentialing, reappointment, and the granting of core
privileges, and suspending or terminating privileges, including provisions for appeal of
such decisions.
Yes
No
3.
Either directly or by delegation, makes (in a manner consistent with state law) initial
appointment, reappointment, and assignment or curtailment of credentialing based on
professional evaluation.
Yes
No
4.
This process shall have specific criteria for the initial appointment and reappointment of
network health care professionals.
Yes
5.
The process shall have provisions for the expeditious processing of applications.
Yes
Note: The NPDB Proactive Disclosure Services (PDS) is an acceptable service for meeting the requirement
for querying the NPDB (see Resources).
Review Guidelines
The governing body ensures that individual provider initial applications and documentation
include:
1. A history of education, training, and experiences that is verified.
Yes
No
2. A peer evaluation/reference.
Yes
No
3. Current state license with verification through the state licensing board website.
Yes
No
4. DEA registration (if applicable) with verification through the DEA website.
Yes
No
5. Medical liability coverage information.
Yes
No
6. NPDB query.
Yes
No
For Health Plans
Fully Compliant
Substantially
Compliant
All elements of the
review guidelines are
present.
4 of 5 elements are
present.
Partially Compliant
3 of 5 elements are
present.
Minimally Compliant
2 of 5 elements are
present.
for
A M B U L AT O R Y H E A LT H C A R E , I N C .
Substantially
Compliant
5 of 6 elements are
present.
Partially Compliant
4 of 6 elements are
present.
Minimally Compliant
3 of 6 elements are
present.
Non-Compliant
2 or fewer elements
are present.
No
No
Non-Compliant
1 or no element is
present.
1
© 2013 A C C R E D I TAT I O N A S S O C I AT I O N
Fully Compliant
All elements of the
review guidelines are
present.
N/A
50
For information on the National Practitioner Data Bank, see www.npdb_hipdb.hrsa.gov.
© 2013 A C C R E D I TAT I O N A S S O C I AT I O N
for
A M B U L AT O R Y H E A LT H C A R E , I N C .
51
The 2013 AAAHC Accreditation Handbook for Health Plans was developed with health plans and
managed care organizations in mind, with new chapters to help you comply with the Affordable
Care Act and be more relevant in today’s changing health care environment.
You’ll find more focus on care management and care coordination and a new process for the
collection of outcomes data for your members. Plus, the 2013 Standards include special chapters
for behavioral and dental health organizations.
If you’d like more information on AAAHC Health Plan Standards, call us at 847-853-6060 or
email [email protected].
TA B L E o f c o n te n t s
Letter from the President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
About CAHP
O u r m i s s i o n — Advocating for Health Plans
The mission of CAHP is to serve our member health plans
by creating and sustaining an environment that permits
them to maintain viability and grow as organizations
dedicated to coordinating or providing high quality,
affordable and accessible health care to their members.
■■
2012 Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
■■
2012 Seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
■■
CAHP Board of Directors. . . . . . . . . . . . . . . . . . . . . . . . . . 6
■■
CAHP Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CAHP Associate, Partner
and Health Group Members. . . . . . . . . . . . . . . . . . . . . . . . . 1 3
CAHP Health Plan Members. . . . . . . . . . . . . . . . . . . . . . . . . 31
Service Area Data Spreadsheet. . . . . . . . . . . . . . . . . . . 34
Health Plan Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
We do this by:
»» Advocating for the interests of health plans and
their members on legislative and regulatory issues
»» Educating policy makers, opinion leaders and
regulators on the implications of policy concepts,
issues and proposals
»» Promoting collaborative efforts among health plans,
providers, purchasers, brokers, other health care
associations and other stakeholders to assert policy
toward the provision of high quality, affordable and
accessible health care
»» Informing the media and the public about our
philosophy and the benefits health plans provide
»» Engaging the state’s political leaders
»» Promoting opportunities and forums for plan
members to meet, exchange ideas and discuss critical
issues affecting the industry and industry effectiveness
California Association of Health Plans
1415 L Street, Suite 850
Sacramento, CA 95814
916.552.2910
www.calhealthplans.org
Letter from the President
W
e are pleased to provide you with the
first edition of the California Association
of Health Plans’ membership directory. This
directory was created to spotlight our growing
family of health plan, health group, partner
and associate members — all of whom share
CAHP is proud to represent
California’s health plans,
which ensure access to
quality health care for
21 million Californians.
Aetna Health of California, Inc.
Alameda Alliance for Health
Anthem Blue Cross
a commitment to ensure Californians have
Blue Shield of California
access to affordable quality health care.
CalOptima
CalViva Health
Much of the information traditionally provided
through our annual report — our detailed
surveys of each of our member health plans,
information on all of our members, and highlights of CAHP
events and sponsors — can be found on the pages of our new
Membership Directory. In addition, it features expanded information on our health group, partner and associate members,
who are an important part of CAHP.
Care1st Health Plan
CenCal Health
Central California Alliance for Health
Central Health Medicare Plan
Chinese Community Health Plan
CIGNA HealthCare of California, Inc.
Community Health Group
Contra Costa Health Plan
We are appreciative of the support and contribution of each of
Easy Choice Health Plan
our members, all of whom help to make us a strong organization
GEMCare Health Plan, Inc.
and voice on health care in California. During this important
Health Net of California
transition of our health care system, their input is invaluable.
Health Plan of San Joaquin
We hope you enjoy our new directory.
Sincerely,
Health Plan of San Mateo
Heritage Provider Network
Inland Empire Health Plan
Inter Valley Health Plan
Kaiser Permanente
Kern Family Health Care
L.A. Care Health Plan
Molina Healthcare of California
Monarch Health Plan, Inc.
Patrick Johnston
On Lok Lifeways
President & CEO, California Association of Health Plans
Partnership HealthPlan of California
PrimeCare Medical Network, Inc.
San Francisco Health Plan
Santa Clara Family Health Plan
SCAN Health Plan
Sharp Health Plan
SIMNSA Health Plan
UnitedHealthcare of California
Valley Health Plan
Ventura County Health Care Plan
2
Western Health Advantage
C AH P an n ual co n ference
October 21–23, 2013 | huntington beach
CAHP Conference 2012
T r a n s f o r m i n g t h e Healt h Ca r e L a n d s c a p e
October 15 –17, 2012
•
Hyatt Regency Huntington Beach
Over the past 30 years, California has been at
new service
the forefront of health care innovation. Leaders
sectors. We
at the state and federal level are taking lessons
heard from Peter
from managed care to transform the health
Lee, Executive
care system so more Californians have access
Director of the
to high quality, affordable care.
Exchange, as
This year’s conference focused on how the
principles of managed care are taking root
across the spectrum of health care from
the Health Benefits Exchange to the Duals
Demonstration project and similarly into
Seven hundred health care leaders
came together to explore how we
can collectively improve health care
for all Californians.
well as Director,
Brent Barnhart
and key staff
from the Department of Managed
Health Care on their perspectives on the
changing health care environment.
Attendees had the opportunity to delve into a range
of topics including the legal and political developments impacting the California landscape as well as
policy shifts changing the way health plans provide
services. We examined how
to best collaborate on the
transformation of our health
care system with insight from
political leaders and policy
wonks alike.
Seven hundred health care
leaders joined us for the
only gathering of California’s
managed care plans, which
was focused on our shared
commitment to improve
health care for all Californians
in a constantly changing
environment.
4
CAHP Seminar Series 2012
February 22 • Burbank Marriott
The Changing Face
of Medi-Cal Managed Care
299 Attendees
April 25 • Hilton Bayfront
San Francisco Airport
Claims: Looking Beyond Payment
to Reduce Costs and Improve Care
57 Attendees
Supported by:
• Nurse Response
• APS Healthcare
• LogistiCare Solutions
• GTESS Corporation
• Advanced Diabetes Supply
• Genzyme, a sanofi Company
• CareCall, Inc
• ClearStone Solutions
• Casenet LLC
• Purdue Pharma LP
March 21 • Embassy Suites
Sacramento
SB 946–Autism Coverage
Mandate: What Does it Mean
to Your Health Plan
121 Attendees
Supported by:
Supported by:
• VARIS, LLC
• GTESS Corportation
• Moss Adams LLP
• Plexis Healthcare Systems
• HTMS
• Pegasystems
May 30 • Burbank Marriott
California Health Benefit Exchange:
Looking to Success in 2014
147 Attendees
Supported by:
• Softheon, Inc
• ACES
• HTMS
• CoramRx
• Dell, Inc
• OptumHealth
• Magellan Health Services
• California Psychcare Inc
• NationsHealth
August 1 • Hilton Bayfront
San Francisco Airport
Behavioral Health:
Care Across the Continuum
62 Attendees
Supported by:
• APS Healthcare
• GenerationOne
• NationsHealth
• Sante Well Being
5
CAHP Board of Directors
Paul Markovich | CHAIRMAN OF THE BOARD
Howard Kahn
Blue Shield of California
President & CEO
L.A. Care Health Plan
CEO
Garry Maisel | VICE CHAIR
Richard Chambers
Western Health Advantage
President & CEO
Molina Healthcare of California
President
Peter Welch | SECRETARY/TREASURER
Jack Horn
CIGNA HealthCare of California, Inc.
President and General Manager
Partnership HealthPlan of California
CEO
Chris Wing
SCAN Health Plan
President & CEO
Beth Andersen
Aetna Health of California, Inc.
President, West Region
Melissa Hayden Cook
Sharp Health Plan
President & CEO
Pam Kehaly
Anthem Blue Cross
President and General Manager
Alex Uhm
UnitedHealthcare of California
Chief Operating Officer — California
Steven Sell
Health Net of California
President
PA S T C H A I R P E R S O N S
Jerry Fleming . . . . . . . . . . . . . . . . . . . . . . . . . 20 1 1 – 201 2
Maya Altman
Howard Kahn. . . . . . . . . . . . . . . . . . . . . . . . . 2009 – 2010
Health Plan of San Mateo
Executive Director
Curtis Terry. . . . . . . . . . . . . . . . . . . . . . . . . . . 2007 – 2008
David Helwig . . . . . . . . . . . . . . . . . . . . . . . . 2005 – 2006
Ken Wood . . . . . . . . . . . . . . . . . . . . . . . . . . . 2002 – 2005
Mark G. Hyde. . . . . . . . . . . . . . . . . . . . . . . . . 2001 – 2002
Bradley Gilbert, M.D.
Inland Empire Health Plan
CEO
Ron Williams . . . . . . . . . . . . . . . . . . . . . . . . . 2000 – 2001
Bruce Bodaken. . . . . . . . . . . . . . . . . . . . . . . 1998 – 2000
Arthur M. Southam, M.D.. . . . . . . . . . . . . 1995 – 1998
Kathleen Swenson. . . . . . . . . . . . . . . . . . . . 1994 – 1995
Jerry Fleming
Kaiser Foundation Health Plan
Senior VP, Health Reform
Implementation and Policy
6
R. Judd Jessup. . . . . . . . . . . . . . . . . . . . . . . . 1992 – 1994
Stuart Byer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1987 – 1992
Anthony Pescetti . . . . . . . . . . . . . . . . . . . . . 1985 – 1987
Maree Church . . . . . . . . . . . . . . . . . . . . . . . . . 1983 – 1985
CAHP Staff
Patrick Johnston
Sunshine Moore
President & CEO
Policy Analyst/Writer
Charles Bacchi
Geri O’Neil
Executive Vice President
Business Development Manager
Nicole Kasabian Evans
Marjorie Purscell
Vice President, Communications
Meeting and Events Manager
Nick Louizos
Connie Flores
Director, Legislative Affairs
Administrative Services Manager
Abbie Totten
Selena Coppi Hornback
Director, State Programs
Legislative Assistant
Athena Chapman
Director, Regulatory Affairs
7
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When change moves you
in a new direction, choose
the right navigator.
In health care, success requires diligence and
foresight—two qualities that will prove even
more important in the days to come. As reforms
take effect, will you be ready?
We’ve helped health plan organizations
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Ever feel as if the costs of diabetes
management just keep coming around?
S:14”
Diabetes care is complex and requires that many issues,
beyond glycemic control, be addressed.1 One issue is
medication adherence.2 Medication adherence may
prevent hospitalizations for diabetes complications.2
Another major issue is hypoglycemia. Not only is it a
barrier to successful diabetes management,1 but it can
also be very costly3:
• ER-to-inpatient costs: $10,3623
• ER plus outpatient costs: $9863
• Hospital admission costs: $7,3173
However, you may not be informed of all your
members’ hypoglycemic events. In a multicenter,
retrospective medical record review of 3 academic
emergency departments, 83% of hypoglycemia
visits, often excluded in prior hypoglycemia
analyses, were coded as “diabetes with other
specified manifestations,” while others may not
be reported at all.4
For these reasons, diabetes management costs may be
even greater than you know.
That’s why Novo Nordisk is committed to providing your organization with a broad range of
solutions in glycemic management.
For more information about Novo Nordisk, please visit novonordisk-us.com.
References: 1. American Diabetes Association®. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.
2. Healthcare Cost and Utilization Project. Economic and Health Costs of Diabetes. Rockville, MD: Agency for Healthcare Research and Quality;
2005. 3. Curkendall SM, Zhang B, Oh KS, Williams SA, Pollack MF, Graham J. Incidence and cost of hypoglycemia among patients with type 2
diabetes in the United States: analysis of a health insurance database. JCOM. 2011;18(10):455-462. 4. Ginde AA, Blanc PG, Lieberman RM,
Camargo CA Jr. Validation of ICD-9-CM coding algorithm for improved identification of hypoglycemia visits. BMC Endocr Disord [series online].
April 1, 2008;doc 8:4.
© 2012 Novo Nordisk
Printed in the U.S.A.
0312-00007951-1
March 2012
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Associate Members
AAAHC
Ambry Genetics Corporation
Accreditation
Clinical Diagnostics
Carolyn Kurtz
Jacqueline Threadgill
Vice President and General Counsel
5250 Old Orchard Road, Suite 200
Skokie, IL 60077
P (847) 853-6060
F (847) 853-9028
info @ aaahc.org
www.aaahc.org
Vice President of Managed Care
15 Argonaut
Aliso Viego, CA 90505
P (949) 900-5500
[email protected]
www.ambrygen.com
ACES
Amgen
Biotechnology
ABA treatment (Autism)
Joe Gelinas
Tim Crilly
Corporate Account Manager
1822 Calle Borrego
Thousand Oaks, CA 91360
P (805) 313-8135
F (805) 435-8174
[email protected]
www.amgen.com
Director of Business Development
16782 Von Karman Ave #11
Irvine Ca 92606
P (714) 873-8558
F (949) 833-2230
[email protected]
www.acesaba.com
Acorda Therapeutics, Inc.
Amylin Pharmaceuticals
Biopharmaceutical
Biotech Manufacturer
Mike Little
Stephanie Roberts
Director, National Accounts
516 Elm Avenue
San Bruno, CA 94066-4226
P (650) 952-1570
F (650) 952-1576
[email protected]
www.amylin.com
Account Director, West Region
420 Saw Mill River Road
Ardsley, New York 10502
P (520) 241-8559
[email protected]
www.acorda.com
AIDS Healthcare Foundation/
Positive Healthcare
APS Healthcare
Managed Health Care
Alycia Sepe
Michael O’Malley
Plan Administrator
1001 N. Martel Ave.
Los Angeles, CA 90046
P (323) 436-5000
[email protected]
www.positivehealthcare.org
Vice President, Development
44 S Broadway, Suite 1200
White Plains, NY 10601
P (804) 378-5002
F (914) 288-4605
[email protected]
www.apshealthcare.com
Amber Pharmacy
ATG Rehab
Specialty Pharmacy
Complex Rehab Medical Equipment
Terri Dill
Steve Rich
Regional Vice President, Managed Care
10004 South 152nd Street
Omaha, NE 68138
P (888) 370-1724
F (877) 645-7514
[email protected]
www.amberpharmacy.com
Region Vice President
610 N. Pastoria Ave.
Sunnyvale, CA 94085
P (888) 736-8745
F (408) 736-0203
[email protected]
www.atgrehab.com
Care Management
15
Associate Members
Availity, LLC
Catamaran
Health Information Network
Pharmacy Benefit Management
David Fularczyk
Mark SantaCroce
Health Plan Strategic
10752 Deerwood Park Blvd South, Suite 110
Jacksonville, FL 32256
P (414) 897-7598
C (414) 344-8113
[email protected]
www.availity.com
Area Vice President of Sales, Western Region
2441 Warrenville Rd, Suite 610
Lisle, IL 60532
P (630) 577-3100
F (630) 577-3101
[email protected]
www.catamaranrx.com
Avanir Pharmaceuticals Inc.
Celgene Corporation
Pharmaceutical Manufacturer
Biopharmaceutical
Julie Brown
George Malouly
Account Manager
20 Enterprise, Suite 200
Aliso Viejo, CA 92656
P (425) 876-4760
F (949) 362-6265
[email protected]
www.avanir.com
National Accounts
86 Morris Avenue
Summit, NJ 07901
P (310) 995-0175
[email protected]
www.celgene.com
Beacon Health Strategies
Managed Behavioral Healthcare
Organization (MBHO)
Brian Wheelan
Executive Vice President,
Corporate Strategy and Development
200 State St.
Boston, MA 02109
P (781) 994-7500
F (781) 994-7600
[email protected]
www.beaconhealthstrategies.com
Calibrated Healthcare Network LLC
Business Process Outsourcing
Yvonne Daugherty
Sr Vice President of Marketing
13621 NW 12th St., Suite 100
Sunrise, FL 33323
P (954) 903-5065
F (954) 903-5940
[email protected]
www.conveyhealthsolutions.com
Coram LLC dba
Coram Specialty Infusion Services
and CoramRx
Home Infusion & Specialty Pharmacy Provider
Business Process Outsourcing
Jim Sepeda
Jovita Montes De Oca
Regional Director, Managed Care
3160 Corporate Place
Hayward, CA 94545
P (510) 732-8800
F (510) 732-8801
[email protected]
www.coramhc.com
CEO
1601 Monte Vista Ave., Suite 250
Claremont, CA 91711
P (866) 955-0044
F (909) 256-8903
[email protected]
www.calibratedgroup.com
California Association of
Physician Groups (CAPG)
Medical Group Association
Donald H. Crane
President & CEO
915 Wilshire Blvd., Suite 1620
Los Angeles, CA 90017
P (213) 624-CAPG (2274)
F (213) 683-0032
[email protected]
www.capg.org
16
Convey Health Solutions
Daiichi Sankyo
Pharmaceutical Company
Teri Ross, RN
Account Manager
2 Hilton Court
Parsippany, NJ 07054
P (949) 294-1509
F (949) 721-8793
[email protected]
www.dsi.com
Associate Members
Diplomat Specialty Pharmacy
Firstsource Solutions USA, Inc.
Specialty Pharmacy
Business Process Management
Kim Foerster
Nancy Maze
Director, Managed Market Sales
1809 Excise Ave, Suite 205-208
Ontario, CA 91761
P (810) 768-9835
F (810) 282-0110
[email protected]
www.diplomatpharmacy.com
SVP Client Relations
4500 Campbell Drive
Fort Scott, KS 66701
P (620) 223-8217
F (620) 223-8216
[email protected]
www.na.firstsource.com
Eisai Inc
Genomic Health Inc.
Pharmaceutical Company
Medical Diagnostics
Olaf Reinwald
S Macey Johnson, III
Regional Account Manager
8969 Covey Court
Elk Grove, CA 95624
P (916) 417-9580
[email protected]
www.eisai.com
Director-Managed Care
301 Penobscot Drive
Redwood City, CA 94063
P (650) 569-2420
F (650) 556-0751
[email protected]
www.genomichealth.com
Emdeon
Payment Management
Gilead Sciences, Inc.
Gabby Lenzini
Biopharmaceutical Company
Client Director
3055 Lebanon Pike
Nashville, TN 37214
P (562) 598-0875
[email protected]
www.emdeon.com
Mark Reynolds
Envision Pharmaceutical Services
Pharmacy Benefit Management
John Ewell
EVP
1100 Investment Blvd
El Dorado Hills, CA 95762
P (925) 487-3266
[email protected]
www.envisionrx.com
Essette, Inc.
IT-Software
Andy Gaudette
CEO/SVP Business Development
4800 Baseline Rd. #E104-242
Boulder, CO 80303
P (303) 500-6930
[email protected]
www.essette.com
Excelsior Solutions, LLC
Pharmacy Consulting
Martha Allen
Vice President, Business Development
7401 Metro Blvd, Suite 210
Edina, MN 55439
P (952) 562-5548
F (952) 562-5558
[email protected]
www.excelsiorsolutions.com
Senior Manager, National Accounts
333 Lakeside Drive
Foster City, CA 94404
P (650) 465-0201
F (650) 362-3351
[email protected]
www.gilead.com
GTESS Corporation
Claims Processing
Vincent Vallejo
Vice President Sales Operations
2435 North Central Expressway, Suite 500
Richardson, TX 75080
P (972) 792-5500
F (972) 234-5763
[email protected]
www.gtess.com
Health Integrated, Inc.
Health Management
Steve Wigginton
President
10008 North Dale Mabry Highway
Tampa, FL 33618
P (813) 388-4061
F (813) 349-2178
[email protected]
www.healthintegrated.com
17
Associate Members
Healthx, Inc.
Lilly USA
Software (Portal Development)
Pharmaceutical Company
Chuck Rolfsen
Eric A. Eilers
Vice President, Payer Sales
9339 Priority Way, West Dr., Ste. 150
Indianapolis, IN 46240
P (877) 492-3633
[email protected]
www.healthx.com
Director, Regional Managed Markets
Eli Lilly & Company
Lilly Corporate Center
Indianapolis, IN 46285
P (858) 401-9267
[email protected]
www.lilly.com
HF Healthcare
Specialty Pharmacy
Local Health Plans of California
Cameron White
Policy and Legislative Association
President
411 N. Lombard Street, Suite B
Oxnard, CA 93030
P (866) 981-1171, or (805) 981-1171
F (805) 981-1121
[email protected]
www.insurance.hfhealthcare.com
John Ramey
HMS
Claims Processing
LogistiCare Solutions
Carrie Cunningham
Transportation Benefit Management
Vice President, Business Development
401 Park Avenue South
New York, NY 10016
P (916) 405-6780
[email protected]
www.hms.com
Bill Walter
Independent Living Systems
Healthcare Management Services Company
Sunil Joshi
Vice President & General Manager, Western Region
5201 Blue Lagoon Drive, Suite 270
Miami, FL 33126
P (786) 348-1240
F (305) 675-8398
[email protected]
www.ilshealthservices.com
LexisNexis
Fraud Detection
Carin Whitaker
Director of Sales
1000 Alderman Drive
Alpharetta, GA 30005
P (866) 396-7703
[email protected]
www.lexisnexis.com/risk/healthcare.aspx
18
Executive Director
1225 Eighth Street, Suite 440
Sacramento, CA 95814
P (916) 448-8292
F (916) 448-8293
[email protected]
www.lhpc.org
General Manager
1301 N Palm Canyon Dr., Suite 302
Palm Springs, CA 92262
P (866) 246-5875
F (866) 245-8142
[email protected]
www.logisticare.com
Lynk Software, Inc.
IT
Ron Kingsley
Project Manager-Healthcare Specialist
P.O. Box 5498
Scottsdale, AZ 85261
P (877) 998-1933
F (480) 998-4979
[email protected]
www.lynksoftware.com
Medco
Pharmacy Benefit Management
Michael Barone
Senior Vice President, General Manager
6161 Oak Tree Blvd, Suite 310
Independence, OH 44131
P (216) 901-7415
F (216) 901-7384
[email protected]
www.medco.com
Associate Members
MedImpact Healthcare Systems, Inc.
Novo Nordisk, Inc.
Pharmacy Benefit Management
Pharmaceutical Company
Janeen McBride
John Charles Healy
Vice President Business Development
10181 Scripps Gateway Court
San Diego, CA 92131
P (858) 790-6365
F (858) 790-6053
[email protected]
www.medimpact.com
Senior Account Executive
P.O. Box 16179
Long Beach, CA 90806
P (213) 819-2831
F (562) 920-5679
[email protected]
www.novonordisk-us.com
Moss Adams LLP
Nurse Response
Financial & Business Consulting
Nurse Advice Line
Chris Pritchard
Kim Tuck
Partner, National Practice Leader
for Health Plans
101 Second St., 9th Floor
San Francisco, CA 92614
P (415) 677-8262
[email protected]
www.mossadams.com
President and CEO
7700 Forsyth
St. Louis, MO 63105
P (314) 505-6355
F (314) 558-2424
[email protected]
www.nurseresponse.com
Munich Health North America
OptumHealth
Healthcare Reinsurer
Healthcare Technology,
Management & Services
Michael Shevlin
Senior Vice President
555 College Road East
Princeton, NJ, 08543
P (609) 577-2610
F (609) 951-8464
[email protected]
www.munichhealthNARe.com
MTM, Inc.
Eric Murphy
President, Payer Solutions
13625 Technology Drive
Eden Prairie, MN 55344
P (800) 765-6817
F (952) 833-7201
[email protected]
www.optum.com
Transportation and Home &
Community Based Services
Prometheus Labs
Rhonda Hollingsworth
Tim Sargent
Director, Business Development Operations
16 Hawk Ridge Drive
Lake Saint Louis, MO 63367
P (888) 561-8747 x 5563
F (636) 561-2962
[email protected]
www.mtm-inc.net
National Director Managed Markets
9410 Carroll Park Drive
San Diego, CA 92014
P (888) 423-5227
[email protected]
www.prometheuslabs.com
Navitus Health Solutions
Medical Diagnostics
PerformRx
Pharmacy Benefit Management
Pharmacy Benefit Management
John Butts
Jason Johnson
Director of Marketing Relations
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113
P (215) 937-8073
F (215) 863-5100
[email protected]
www.performrx.com
Vice President Managed Care
2601 West Beltline Highway, Suite 600
Madison, WI 53713
P (949) 887-0863
[email protected]
www.navitus.com
19
Associate Members
RAM Technologies, Inc.
US Script, Inc.
Claims Processing Systems
Pharmacy Benefit Manager
Mark A. Wullert
Pete Clagett
Director of Marketing
275 Commerce Drive, Suite 100
Fort Washington, PA 19034
P (877) 654-8810 x255
[email protected]
www.ramtechnologiesinc.com
President and CEO
2425 W Shaw Ave
Fresno, CA 93711
P (559) 244-3700
F (559) 244-3793
[email protected]
www.usscript.com
The Compliance Team
Accreditation Organization
VITAS Innovative Hospice Care
Sandra C. Canally, RN
Hospice Care
President
PO Box 160
Spring House, PA 19477
P (215) 654 9110
F (215) 654 9068
[email protected]
www.TheComplianceTeam.org
Sue Malter
Top Tier Consulting
Management Consulting
Watson Pharmaceuticals, Inc.
Zach Edwards
Pharmaceuticals
Business Analyst
21550 Oxnard Street, Third Floor
Woodland Hills, CA 91367
P (818) 338-2121
F (818) 338-2141
[email protected]
www.t2c.com
Mitchell Beavers
Total Transit
The Word & Brown Companies
Transportation
Health Insurance, Benefits Marketing
& Administration
James Rea
National Business Development Manager
4600 W Camelback Road
Glendale, AZ 85301
P (602) 200-5501 x1719
[email protected]
www.totaltransit.com
TMG Health, Inc.
Business Process Outsourcing (BPO)
John Montague
Director, Business Development
455 S. Gulph Road, Ste. 307
King of Prussia, PA 19406
P (610) 878-9111 x21206
F (610) 878-5525
[email protected]
www.tmghealth.com
20
Regional Director of Market Development
16830 Ventura Boulevard, Suite 315
Encino, CA 91436
P (800) 93VITAS
F (800) 564-8624
[email protected]
www.vitas.com
Manager, Managed Markets
3338 W Sunnyview Ave.
Visalia, CA 93291
P (800) 808-5208 x22469
[email protected]
www.watson.com
David Duker
Vice President Strategic
Business Development
721 South Parker
Orange, CA 92868
P (800) 869-6989
[email protected]
www.wordandbrown.com
Windsor Healthcare
Rehabilitation Services
Michael Brownstein
Director of Manager Care
9200 Sunset Boulevard, Suite 700
West Hollywood, CA 90069
P (310) 385-1010
[email protected]
www.snfmgt.com
B y Cate g o r y
Associate Members
Accreditation
Health Management Services
AAAHC
The Compliance Team
ACES
APS Healthcare
Health Integrated, Inc.
Independent Living Systems
Optum
The Word & Brown Companies
Advice Line
Healthcare Reinsurer
ABA treatment (Autism)
Nurse Response
Associations/Organizations
AIDS Healthcare Foundation/Positive Healthcare
Beacon Health Strategies
California Association of Physician Groups
(CAPG)
Local Health Plans of California (LHPC)
Billing/Claims Processing
Emdeon
GTESS Corporation
HMS
RAM Technologies, Inc.
Business Process Outsourcing (BPO)
Calibrated Healthcare Network LLC.
Convey Health Solutions
Firstsource Solutions USA, Inc.
TMG Health, Inc.
Clinical/Medical Diagnostics
Ambry Genetics Corporation
Genomic Health Inc.
Prometheus Labs
Consulting
Excelsior Solutions, LLC.
Moss Adams LLP
Top Tier Consulting
Munich Health North America
Medical Equipment
ATG Rehab
Pharmaceutical
Acorda Therapeutics, Inc.
Amgen
Amylin Pharmaceuticals
Avanir Pharmaceuticals Inc.
Celgene Corporation
Daiichi Sankyo
Eisai Inc
Gilead Sciences, Inc.
Lilly USA
Novo Nordisk, Inc.
Watson Pharmaceuticals, Inc.
Pharmacy Benefit Management (PBM)
Catamaran
Envision Pharmaceutical Services
Medco
MedImpact Healthcare Systems, Inc.
Navitus Health Solutions
PerformRx
US Script, Inc.
Specialty Pharmacy
LexisNexis
Amber Pharmacy
Coram LLC
Diplomat Specialty Pharmacy
HF Healthcare
Hospice Care
Rehabilitation Services
Fraud Detection
VITAS Innovative Hospice Care
Windsor Healthcare
IT/Software
Transportation
Availity, LLC
Essette, Inc.
Healthx, Inc.
Lynk Software, Inc.
LogistiCare Solutions
MTM, Inc.
Total Transit
21
Crowell & Moring’s Health Care Practice is made up of a team of seasoned health care attorneys whose
practice is focused on representing leading health plans, health care associations and managed care
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For more information visit www.crowell.com/healthcare
experience. creativity. results.
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Nossaman is a long-standing partner with the managed
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Partner Members
Angela A. Mickelson, Inc.
Law Office of Michael Zablocki
Angela Mickelson
Michael Zablocki
President
2355 Westwood Blvd., No. 370
Los Angeles, CA 90064
P (310) 474-1184
[email protected]
Attorney
21250 Hawthorne Boulevard, Suite 500
Torrance, CA 90503
P (310) 316-0968
[email protected]
Barger & Wolen LLP
Nielsen Merksamer Parrinello
Gross and Leoni, LLP
John M. LeBlanc
Partner
633 West Fifth Street, 47th Floor
Los Angeles, CA 90071
P (213) 680-2800
F (213) 614-7399
[email protected]
www.BargerWolen.com
Brownstein Hyatt Farber Schreck
James Gross
Partner
1415 L Street, Suite 1200
Sacramento, CA 95814
P (916) 446-6752
F (916) 446-6106
[email protected]
www.nmgovlaw.com
Edward A. Stumpp
Nossaman LLP
Shareholder
2029 Century Park East, 21 st Floor
Los Angeles, CA 90067
P (310) 564-8681
F (310) 500-4602
[email protected]
www.bhfs.com
Richard Spohn
Crowell & Moring LLP
Healthcare Practice Group Leader
50 California Street, 34th Floor
San Francisco, CA 94111
[email protected]
P (415) 398-3600
F (415) 398-2438
www.nossaman.com
William A. Helvestine
Nossaman LLP
Partner
275 Battery Street, 23 rd Floor
San Francisco, CA 94111
P (415) 986-2800
F (415)986-2827
[email protected]
www.crowell.com
Mary Antoine
Katrina Pelto Consulting
Partner
621 Capitol Mall, 25th Floor
Sacramento, CA 95814
[email protected]
P (916) 442-8888
F (916) 442-0382
www.nossaman.com
Katrina Pelto
Sedgwick LLP
Consultant
8172 Bushwick Drive
Huntington Beach, CA 92646
P (714) 536-6799
F (714) 960-3260
[email protected]
David M. Humiston
Gary Pancer
Locke Lord LLP
Karen R. Palmersheim
Partner
300 S. Grand Avenue, Suite 2600
Los Angeles, CA 90071
P (213) 687-6742
F (213) 341-6742
[email protected]
www.lockelord.com
Partner
801 S. Figueroa Street, 19th Floor
Los Angeles, CA 90017-5556
P (213) 426-6900
F (213) 426-6921
[email protected]
[email protected]
www.sedgwicklaw.com
23
Partner Members
Wilke, Fleury, Hoffelt,
Gould & Birney, LLP
Michael Daponde
Curtis Leavitt
Partner
400 Capitol Mall, 22nd Floor
Sacramento, CA 95814
P (916) 441-2430
F (916) 442-6664
[email protected]
[email protected]
www.wilkefleury.com
Tin Kin Lee Law Offices
Tin Kin Lee
Attorney
55 South Lake Avenue, Suite 705
Pasadena, CA 91101
P (626) 229-9828
F (626) 229-9820
[email protected]
www.tinkinlee.com
Powerful Solutions for
California-Size Healthcare Challenges
As a leader in specialty healthcare management with
extensive Medicaid and Medicare experience, Magellan
provides powerful solutions to better manage many of
healthcare’s biggest challenges.
• Behavioral health
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solutions
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administration
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Magellan is well positioned to meet your unique needs
right here in California. Magellan’s network* in California
is over 10,600 providers strong with experience serving
nearly 3 million Californians.
To find out more, visit us online at MagellanHealth.com.
*Behavioral health providers as of 1/31/13.
24
Health Group Members
Delta Dental of California
Jeff Album
Vice President, Public and Government Affairs
100 First Street
San Francisco, CA 94105
P (415) 972-8418
F (415) 227-0972
[email protected]
www.deltadentalins.com
FirstSight Vision Services
U.S. Behavioral Health Plan, California dba
OptumHealth Behavioral Solutions of California
Eileen Innecken
Sr. Director, Regulatory Affairs & Compliance
3111 Camino del Rio North, #600
San Diego, CA 92108
P (619) 641-6907
F (619) 641-6916
[email protected]
www.unitedbehavioralhealth.com
Robert K. Patton
ValueOptions, Inc.
President & CEO
1202 Monte Vista Ave., Suite #17
Upland, CA 91786
P (909) 920-5008
F (626) 609-2391
[email protected]
www.firstsightvision.net
Steven Rockowitz
Gold Coast Health Plan
Vice President, CA Service Center
1199 South Beltline Road #100
Coppell, TX 75019
P (972) 906-2836
F (972) 906-2780
[email protected]
www.valueoptions.com
Guillermo Gonzalez
WellCare Health Plans, Inc.
Director, Government Relations & Communications
2220 East. Gonzales Road, Suite 200
Oxnard, CA 93036
P (805) 981-5324
F (805) 981-5314
[email protected]
www.goldcoasthealthplan.org
Alec Cunningham
CEO
8735 Henderson Road, Renaissance 2
Tampa, FL 33634
P (813) 206-3917
F (813) 206-3606
[email protected]
www.wellcare.com
Magellan Health Services
Jason Vega
Vice President, State Affairs
980 9th Street, 16th Floor, Suite 7
Sacramento, CA 95814
P (916) 402-4153
F (916) 446-7104
[email protected]
www.magellanhealth.com
MESVision
Aspasia Shappet
President & CEO
345 Baker Street
Costa Mesa, CA 92626
P (714) 619-4660
F (714) 619-4667
www.mesvision.com
Sutter Health Plan
Steve Nolte
CEO
2200 River Plaza Drive
Sacramento, CA 95833
P (916) 286-6620
[email protected]
www.sutterhealth.org
25
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Executive Vice President
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Your Partner In Non-Emergency Transportation Management
LogistiCare provides services to improve the effectiveness and efficiency of your
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•FulloutsourcingofyourPlan’stransportationbenefit–includingprovidercontractingandcredentialing,
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LexisNexis and the Knowledge Burst logo are registered trademarks of Reed Elsevier Properties Inc., used under license. Other products and services may be
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Health Plan Members
Not for profit.
For health and vitality.
Inter Valley Health Plan is a not-forprofit Medicare Advantage Organization with
a Medicare contract, focused on improving
the health and vitality of it’s members and the
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or tty/tdd 800-505-7150
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Take a look at Argus
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Health Plan Members
Aetna Health of California, Inc.
Kern Family Health Care
Alameda Alliance for Health
L.A. Care Health Plan
Anthem Blue Cross
Molina Healthcare of California
Blue Shield of California
Monarch Health Plan, Inc.
CalOptima
On Lok Lifeways
CalViva Health
Partnership HealthPlan of California
Care1st Health Plan
PrimeCare Medical Network, Inc.
CenCal Health
San Francisco Health Plan
Central California Alliance for Health
Santa Clara Family Health Plan
Central Health Medicare Plan
SCAN Health Plan
Chinese Community Health Plan
Sharp Health Plan
CIGNA HealthCare of California, Inc.
SIMNSA Health Plan
Community Health Group
UnitedHealthcare of California
Contra Costa Health Plan
Valley Health Plan
Easy Choice Health Plan
Ventura County Health Care Plan
GEMCare Health Plan, Inc.
Western Health Advantage
Health Net of California
Health Plan of San Joaquin
Health Plan of San Mateo
Heritage Provider Network
Inland Empire Health Plan
Inter Valley Health Plan
Kaiser Permanente
33
34
Anthem Blue Cross
Blue Shield of California
n
n
n
n
n
n
n
6
n
n
n
n
BUTTE
5
n
n
n
CALAVERAS
4
n
n
n
n
COLUSA
5
n
n
n
n
CONTRA COSTA
9
n
n
n
n
n
ALAMEDA
10
n
ALPINE
4
AMADOR
DEL NORTE
4
n
EL DORADO
8
n
n
n
FRESNO
8
n
n
n
n
n
INYO
4
n
KERN
11
n
n
n
KINGS
8
n
n
n
LAKE
4
n
n
n
LASSEN
4
n
n
n
LOS ANGELES
16
n
n
n
MADERA
7
n
n
n
MARIN
8
n
n
n
n
n
GLENN
5
n
HUMBOLDT
4
n
n
n
IMPERIAL
8
n
n
n
n
n
n
MARIPOSA
5
n
MENDOCINO
6
n
n
n
MERCED
8
n
n
n
MODOC
4
n
n
n
MONO
4
n
n
n
MONTEREY
5
n
n
n
NAPA
6
n
n
n
n
NEVADA
5
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
Western Health Advantage
Ventura County Health Care Plan
Valley Health Plan
UnitedHealthcare of California
SIMNSA Health Plan
Sharp Health Plan
SCAN Health Plan
Santa Clara Family Health Plan
San Francisco Health Plan
PrimeCare Medical Network, Inc.
Partnership HealthPlan of California
On Lok Lifeways
Monarch Health Plan, Inc.
Molina Healthcare of California
L.A. Care Health Plan
Kern Family Health Care
Kaiser Permanente
Inter Valley Health Plan
Inland Empire Health Plan
Heritage Provider Network
Health Plan of San Mateo
Health Plan of San Joaquin
Health Net of California
Gold Coast Health Plan
GEMCare Health Plan, Inc.
Easy Choice Health Plan
Contra Costa Health Plan
Community Health Group
CIGNA HealthCare of California, Inc.
Chinese Community Health Plan
Central Health Medicare Plan
Central California Alliance for Health
CenCal Health
Care1st Health Plan
CalViva Health
CalOptima
Aetna Health of California, Inc.
Alameda Alliance for Health
Number of plans present in 2012
2012 Plan Enrollment by County
n
n
n
n
n
n
n
SAN BENITO
4
n
SAN BERNARDINO
16
n
n
n
n
n
n
n
n
n
n
SACRAMENTO
10
n
n
n
n
n
Number of plans present in 2012
15
n
n
n
n
PLACER
8
n
n
n
n
n
n
SAN DIEGO
15
n
SAN FRANCISCO
11
n
n
n
SAN JOAQUIN
11
n
n
n
SAN LUIS OBISPO
9
n
n
n
SAN MATEO
9
n
n
n
SANTA BARBARA
8
n
n
n
SANTA CLARA
13
n
n
n
SANTA CRUZ
9
n
n
n
SHASTA
5
n
n
n
n
SIERRA
4
n
n
n
n
SISKIYOU
4
n
n
n
SOLANO
9
n
n
n
n
n
n
n
n
SONOMA
8
n
n
n
n
n
n
n
n
STANISLAUS
10
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
SUTTER
5
n
TEHAMA
4
n
n
n
n
TRINITY
4
n
n
n
n
TULARE
8
n
n
n
TUOLUMNE
4
n
n
n
VENTURA
12
n
n
n
n
YOLO
9
n
n
n
n
YUBA
5
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
Western Health Advantage
Ventura County Health Care Plan
Valley Health Plan
UnitedHealthcare of California
SIMNSA Health Plan
Sharp Health Plan
SCAN Health Plan
Santa Clara Family Health Plan
San Francisco Health Plan
PrimeCare Medical Network, Inc.
Partnership HealthPlan of California
On Lok Lifeways
Monarch Health Plan, Inc.
Molina Healthcare of California
L.A. Care Health Plan
Kern Family Health Care
Kaiser Permanente
Inter Valley Health Plan
Inland Empire Health Plan
Heritage Provider Network
Health Plan of San Mateo
Health Plan of San Joaquin
Health Net of California
Gold Coast Health Plan
GEMCare Health Plan, Inc.
Easy Choice Health Plan
Contra Costa Health Plan
Community Health Group
CIGNA HealthCare of California, Inc.
Chinese Community Health Plan
Central Health Medicare Plan
Central California Alliance for Health
CenCal Health
Care1st Health Plan
CalViva Health
Alameda Alliance for Health
Aetna Health of California, Inc.
CalOptima
17
Blue Shield of California
4
RIVERSIDE
Anthem Blue Cross
PLUMAS
n
ORANGE
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
35
Aetna Health of California, Inc.
2625 Shadelands Drive • Walnut Creek, CA 94898
Ph: (925) 948-4700 • Fax: (925) 948-4264 • www.aetna.com
CALIFORNIA OFFICE
LOCATIONS
Fresno
Los Angeles
Rancho Cucamonga
Sacramento
San Diego
San Francisco
Santa Ana
Thousand Oaks
Walnut Creek
Woodland Hills
EXECUTIVE OFFICERS
Mark Bertolini
Chairman, CEO
and President
Joe M. Zubretsky
Senior Executive Vice
President and Chief
Financial Officer
Meg McCarthy
Executive Vice President,
Operations and
Technology
Beth Andersen
President, West Region
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Aetna, Inc.
None
1956
1956
For profit
2,100 full time
18,444,710 National
1,526,460 California
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracts with Physicians
0 owned, 388 contracted
0 owned, 3,106 contracted
0 owned, 73,363 contracted
0 owned, 18,315 contracted
0 owned, NA contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
All Markets: Capitation,
Negotiated Fee Schedule
All Markets: Capitation,
Negotiated Fee Schedule
All Markets: Per Diem, Capitation,
Discount off Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
EXECUTIVE STAFF
Gina Conflitti, M.D.
Regional Medical Director
Mary V. Anderson
Chief Legal Counsel
David Taaffe
Region Head of Sales
Greg Stevens
Region Head of
Network Operations and
Medical Economics
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO, PPO
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . HMO, POS, PPO, and Indemnity
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . EPO, HMO, PPO, POS, HRA, HAS, Other
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . No
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . Yes
Special Needs Plans (SNPs) . . . . . . . . . . . . . . . . . . . . . . . No
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . Yes
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . No
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . No
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indemnity: HMO, PPO, POS, Other
ANCILLARY PRODUCTS
PRIMARY CONTACTS
Kris Frank
Government Relations
(916) 503-1534
Anjie Coplin
Public Relations
(214) 200-8056
36
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Alameda Alliance for Health
1240 South Loop Road • Alameda, CA 94502
Ph: (877) 371-2222 • Fax: (510) 747- 4508 • www.alamedaalliance.org or www.alliancecompletecare.org
Ph: (877) 585-PLAN (for Medicare SNP sales) • TTY: 1-800-735-2929 (for Medicare SNP sales)
CALIFORNIA OFFICE
LOCATIONS
Community
Outreach Center
475 14th Street,
Stuite 730,
Oakland, CA 94612
1-877-585-PLAN (7526)
Ed Roberts Campus
3075 Adeline Street,
Suite 160,
Berkeley, CA 94703
(510) 225-7200
EXECUTIVE OFFICERS
Ingrid Lamirault
CEO
David Buhler
Chief Administrative
Officer
Lily Boris, MD
Chief Medical Officer
Zina Glover
Chief Operations Officer
Leila Saadat
Chief Strategy Officer
EXECUTIVE STAFF
Elia Gallardo
Executive Director, Duals
David Nolan
Executive Director, LTSS
PRIMARY CONTACT
Laura Burr
Interim Director,
Communications
and Marketing
(510) 747-6206
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Alameda Alliance Joint Powers Authority
None
1995
1995
Non profit
197 full time; 13 part time
149,000
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs;
Direct Contracting with Physicians
(Note: Excludes behavioral health)
0 owned, 7 contracted
0 owned, 14 contracted
0 owned, 1,367 contracted
0 owned, 252 contracted
0 owned, 406 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method) . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Fee-For-Service, Fee-For-Service including
Withhold or Bonus, Group Capitation,
Individual Capitation
Fee-For-Service, Group Capitation
Diagnosis-Related Group, Per Diem, Capitation
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other: Alliance Group Care . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
HMO
None
None
HMO
HMO
None
None
In-Home Supportive Services
Workers in Alameda County: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
None
HMO
HMO
None
None
None
None
None
None
HMO
HMO
None
37
Anthem Blue Cross
21555 Oxnard Street • Woodland Hills, CA 91367
Ph: (818) 234-2345 • Fax: (805) 713-7736 (for providers) • www.anthem.com/ca or www.wellpoint.com
CALIFORNIA OFFICE
LOCATIONS
Costa Mesa
Fresno (2 offices)
Glendale
Los Angeles
Newbury Park
North Hollywood
Pomona
Rancho Cordova
Riverside
Sacramento (2 offices)
San Diego (2 offices)
San Francisco
Santa Barbara
Thousand Oaks
(2 offices)
Visalia
Walnut Creek
Woodland Hills
EXECUTIVE OFFICERS
John Cannon
Interim Presidentand CEO
of WellPoint, Inc.
Pam Kehaly
California President
and General Manager
of Anthem Blue Cross
Wayne DeVeydt
CFO
Lori Beer
CIO
EXECUTIVE STAFF
Dr. Michael Belman
Medical Director,
Anthem Blue Cross
Craig Laidig
Legal Counsel
Darrel Ng
Public Relations
Laurie Amirpoor
Pharmacy Director
Aldo DeLaTorre
Provider Relations
PRIMARY CONTACTS
Allison Barnett
Government Relations
(916) 403-0529
Darrel Ng
Public Relations
(916) 403-0528
38
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
WellPoint, Inc./Anthem Blue Cross
Life and Health
Merged with Anthem, Inc. in November 2004
1937
1993
For profit
8,000 full time
33 million members WellPoint
8.5 million members California
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
191 contracted
378 contracted
55,945 contracted
None
0 owned, 20,931 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Other (Fee Schedule), Group Capitation,
Individual Capitation
Other (Fee Schedule), Group Capitation
Per Diem, Capitation, Case Rates,
Discounted Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other (California Kids, Interim High Risk). . . . . . . . . . . . .
HMO, PPO, Other
HMO, PPO
HMO, PPO, POS, Other
HMO, PPO
PPO
No
PPO
HMO, PPO
Other
HMO, PPO
No
PPO
PPO
ANCILLARY CARE
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO, PPO, POS
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO, PPO, POS
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO, PPO, POS
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . No
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Accidental Death & Dismemberment. . . . . . . . . . . . . . . . No
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO, PPO, POS
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . . None
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . PPO
CALIFORNIA
OFFICE LOCATIONS
Costa Mesa, El Dorado
Hills (2 offices), El Segundo,
Fresno, Lodi, Ontario, Redding,
Sacramento (2 offices),
San Diego, San Francisco
(2 offices), San Jose,
Valencia, Ventura, Walnut
Creek, Woodland Hills
Tina Kibler
Vice President,
Internal Audit Services
EXECUTIVE OFFICERS
Theresa
McManaman, R.N.
Vice President, Medical
Management
Paul Markovich
President and
Chief Executive Officer
Lou Lombardo
Vice President,
Sales Performance
Tom McCaffery
Vice President,
California State
Partnerships
Kristen Miranda
Ed Cymerys
Senior Vice President Vice President, Strategic
Partnerships and
and Chief Actuary,
Innovation
Interim CFO
Cathy Murphy
Juan Davila
Executive Vice President, Vice President, Human
Resources Operations
Health Care Quality and
Affordability
Michael O’Neil
Vice President, Product
Rob Geyer
and Market Alignment
Senior Vice President,
Customer Quality
Arminé Papouchian
Vice President,
John Hedberg
Provider Contracting
Senior Vice President,
Consumer and
Daniel Prettyman
Small Business Market
Vice President,
Finance, Markets
Jeff Hermosillo
Senior Vice President,
Julie Roberts
Employer Market
Vice President,
Health Care Reform
Marianne Jackson
Senior Vice President,
Mike Sears
Human Resources and
Vice President,
Internal Communications
Customer Care
Seth A. Jacobs, Esq.
Michael Sheils
Senior Vice President,
Vice President,
General Counsel
Business Intelligence
and Corporate Secretary
Steve Shivinsky
Peter Long
Vice President,
President and CEO,
Corporate
Blue Shield of California
Communications
Foundation
Michelle Simpson
Marcus Thygeson, M.D.
Vice President,
Senior Vice President,
CalPERS
Chief Health Officer
Jeff Smith
Janet Widmann
Vice President,
Executive Vice President,
Individual
Markets
and Family Plans
EXECUTIVE STAFF
David Arnold, Jr.
Vice President,
Shield Advance/Technology
Design and Infrastructure
Tom Brophy
Vice President, Finance and
Treasury Services
Nancy Stalker
Vice President,
Pharmacy Services
Charles Sweeris, Esq.
Vice President,
Deputy General Counsel
Kerim Turan
Vice President,
Chief Compliance and
Ethics Officer
Bill Brown
Vice President and Executive
Bob Wadsworth
Driver, Shield Advance
Business Readiness Vice President, Customer
Solutions Delivery
Edward A. Diver
Mark Weideman
Vice President, IT
Vice President,
Infrastructure and Operations
Government Affairs
Tom Epstein
Bryce Williams
Vice President, Public Affairs
Vice President, Wellness
Shirley Fierstadt
Amy Yao
Vice President, Claims and
Vice President,
Contracted Operations
Actuarial Services
Christopher Gorecki
Vice President
PRIMARY
and Corporate Controller
CONTACTS
Chris Henchey
Mark Weideman
Vice President, Executive
Vice President,
Driver, Shield Advance
Government Affairs
Brent Hitchings
Tom Epstein
Vice President,
Vice President,
Small Business
Public Affairs
Jennifer Hobart
Vice President,
Medical Informatics
Blue Shield of California
50 Beale Street • San Francisco, CA 94105
Ph: (415) 229-5000 • www.blueshieldca.com
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . California Physicians’ Service dba Blue Shield of California
Recent mergers or acquisitions within California . . . . . . . None
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1939
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1939
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees . . . . . . . . . . . . . . . . . . . . . . . . . ~ 5,000
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 1,007,911 (HMO); 1,742,439 (PPO); 2,900,056 (Total)
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
HMO – Direct contracting with Network of Medical Groups
and IPAs; PPO – Direct Contracting with Physicians
0 owned, 336 (HMO) contracted
0 owned, 313 (HMO) contracted;
0 owned, 369 (PPO) contracted
0 owned, 12,251 (HMO PCPs);
21,431 (PPO PCPs) contracted
0 owned, 24,636 (HMO Specialists);
49,356 (PPO Specialists) contracted
0 owned, 43,573 (HMO); 75,769 (PPO) contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type) . . . . . . . . . . . . . . . .
Fee Schedule (PPO), Capitation (HMO)
Fee Schedule (PPO), Capitation (HMO)
Predominately Per Diem, Case Rates,
Discount off Charges, Capitation
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO, PPO
HMO, PPO, POS
HMO, PPO, POS
HMO
Offered for individuals (a, c, d, f, k)
None
For individual and group plans
None
None
None
None
For individual and family plans (IFP)
Shared Advantage, BlueGroove
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PPO
Available as a discounted service: HMO; PPO
HMO, PPO
Not available as a stand-alone product
No
Offered
Offered in conjunction with our Life Insurance
Available as a discounted service: HMO; PPO
Not available as a stand-alone product
Available as a discounted service rather than
as an Ancillary Product
Not available as an Ancillary Product
Not available as an Ancillary Product
No
Not applicable
39
CalOptima (Orange County Health Authority)
505 City Parkway West • Orange, CA 92868
Ph: (714) 246-8400 • Fax: (714) 246-8492 • www.caloptima.org
EXECUTIVE OFFICERS
Michael Schrader
Chief Executive Officer
Dr. Richard Helmer
Chief Medical Officer
Michael Ewing
Chief Financial Officer
Michael Ruane
Chief of Strategy
and Public Affairs
Gary Crockett
Chief Counsel
Javier Sanchez
Interim Chief
Network Officer
EXECUTIVE STAFF
Ruth Watson
Executive Director,
Operations
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1995
2000
Public health agency
553 full time, 17 part time
418,786
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Medical groups/IPAs and HMOs
0 owned, 15 contracted
0 owned, 30 contracted
0 owned, 6,200 contracted
0 owned, 1,100 contracted
0 owned, 2,188 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Group Capitation, Fee-For-Service
Group Capitation, Fee-For-Service
Per Diem, Case Rates,
Diagnosis-Related Group, Capitation
PLAN PRODUCTS
PRIMARY CONTACT
Arif Shaikh
Government Affairs
(714) 246-8418
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . See SNP
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other (please specify). . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
None
None
None
None
None
None
None
None
None
None
None
None
None
None
CalViva Health (Fresno-Kings-Madera Regional Health Authority)
1315 Van Ness Avenue • Fresno, CA 93721
Ph: (559) 445-8735 • www.calvivahealth.org
CALIFORNIA
OFFICE LOCATIONS
1315 Van Ness Avenue
Fresno, CA 93721
7485 N. Palm Avenue, #101
Fresno, CA 93711-5764
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . Fresno Kings Madera Regional Health Authority Recent mergers or acquisitions within California . . . . . . . No recent mergers or acquisitions
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2009 Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2010 Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Not-for-profit Number of employees . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Staff, subcontracted for administrative services Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 189,705
EXECUTIVE OFFICERS
Gregory Hund
CEO
William Gregor
CFO
Patrick Marabella, M.D.
CMO
Mary Beth Corrado
CCO
EXECUTIVE STAFF
Cindy Reiter, EA
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
All direct contracts with physician providers 2 IPAs
7 Hospitals, Contracted
800 contracted Physicians
250
COMPENSATION METHODS
Physicians – primary care . . . . . . . . . . . . . . . . . . . . . . . . FFS percent of Medi-Cal Rates and Capitation
Physicians – specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . FFS percent of Medi-Cal Rates
Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Percent of Medi-Cal Rates
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
PRIMARY CONTACT
Cindy Reiter, EA
Government Relations
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . Yes
Special Needs Plans (SPD). . . . . . . . . . . . . . . . . . . . . . . . Yes
MSO Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
ANCILLARY PRODUCTS
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . . Yes
41
Care1st Health Plan
601 Potrero Grande Drive • Monterey Park, CA 91755
Ph: (323) 889-6638 • Fax: (323) 889-6270 • www.care1st.com
CALIFORNIA
OFFICE LOCATIONS
601 Potrero Grande Drive
Monterey Park, CA 91755
3131 Camino Del Rio, #350
San Diego, CA 92108
100 N. Winchester Blvd, #290
Santa Clara, CA 95050
2609 E. Hammer Lane
Stockton, CA 95210
833 Auto Center Drive #D
Palmdale, CA 93551
44426 10th Street West
Lancaster, CA 93534
EXECUTIVE OFFICERS
Dr. S.Y. Wong
Chair
Anna Tran
CEO
Jorge Weingarten, MD
CMO
Janet Jan
CFO
Brooks Jones
CCO
Dr. Daryl Leong
CMIO
Dawn Maroney
Chief Medicare Officer
EXECUTIVE STAFF
Alan Bloom
Legal and Regulatory
Dawn Maroney
Marketing
Steven Chin
Provider Network Operations
Tracie Howell
Member Services
Beverly Gibbs, RN
Utilization Management
David Wedemeyer, LVN
Quality Management
PRIMARY CONTACT
Walter L. Gray, VP
Government Affairs/
Public Affairs
(323) 889-6638, ext 6270
42
PLAN ORGANIZATION
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
2006
1994
1995
For profit
500
338,980
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order)
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
101
95
11,500
0
14,510
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation, Individual Capitation
Physicians – specialty (ranked by method). . . . . . . . . . . . . Under Group Capitation, Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Capitation
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . HMO
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . HMO
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Denti-Cal: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
None
HMO
HMO
None
None
None
None
HMO
None
HMO
HMO
None
CenCal Health
4050 Calle Real • Santa Barbara, CA 93110
Ph: (805) 685-9525 • Fax: (805) 685-8292 • www.cencalhealth.org
CALIFORNIA
OFFICE LOCATIONS
Santa Barbara, CA
San Luis Obispo, CA
EXECUTIVE OFFICERS
Robert Freeman
CEO
David Ambrose
CFO
Paul Jaconette
COO
Lowell Gordon, MD
CMO
EXECUTIVE STAFF
Caitlin Larsen, JD
Director of Legal Affairs
Dave Siebel
IT Director
Jeffrey Januska, PharmD
Pharmacy Director/
Health Services Lead
Marina Gordon
Provider Services Director
Donna Slimak
Member Services Director
Carlos Hernandez
Director of Quality and
Decision Support
Karyn Fish
Interim Human
Resources Directorr
Lulu Von Alvensleben
Claims Operations Director
PRIMARY CONTACT
Robert Freeman
CEO
(805) 685-9525, ext. 1011
Robert Freeman
Government Relations
(805) 685-9525, ext. 1011
Robert Freeman
Public Affairs
(805) 685-9525, ext. 1011
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . Santa Barbara/San Luis Obispo
Regional Health Authority
Recent mergers or acquisitions within California . . . . . . . CenCal Health is a public entity
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1983
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2000
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 147 full time
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 106,000
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of provider offices. . . . . . . . . . . . . . . . . . . . . . . .
Direct Contracting with Physicians
0 owned, 9 contracted
0 owned, 1,252 contracted
0 owned, 246 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Individual and Group Capitation, Fee-For-Service,
Withhold and Pay for Performance
Fee-For-Service, Group Capitation
Per Diem/DRG (Inpatient), Percent of Charges
(Inpatient and Outpatient), Fee-For-Service (Outpatient)
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . None
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . HMO
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In-Home Supportive Services Workers: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
None
HMO
HMO
None
None
HMO
HMO
None
HMO
HMO
None
43
Central California Alliance for Health
(Santa Cruz-Monterey-Merced Managed Medical Care Commission)
1600 Green Hills Road, Suite 101 • Scotts Valley, CA 95066
Ph: (831) 430-5500 • Fax: (831) 430-5882 • www.ccah-alliance.org
CALIFORNIA
OFFICE LOCATIONS
Scotts Valley (Main office)
Salinas and Merced
(Regional offices)
EXECUTIVE OFFICERS
Alan McKay
Executive Director
Richard Helmer, MD
Chief Medical Officer
Patti McFarland
Chief Financial Officer
Rachael Nava
Chief Operating Officer
Kathy Neal
Chief Health Services Officer
EXECUTIVE STAFF
David Altman, MD
Associate Medical Director
Danita Carlson
Government Relations Director
Lilia Chagolla
Regional Operations
Director – Monterey
Scott Fortner
Human Resources and
Administrative Services Director
Christine Gerbo
Utilization Management Director
Richard Johnson, PharmD
Pharmacy Director
Jennifer Mockus
Regional Operations
Director – Merced
Jim Murphy
Deputy Chief Operating Officer
Julio Porro, MD
Associate Medical Director
Steven Slack, MD
Associate Medical Director
Stephanie Sonnenshine
Provider Services Director
Frank Souza
Finance Director
Michelle Stott
Quality Improvement Director
Liza Warren
Care Management Director
Traci Webb
Projects Director
Jan Wolf
Member Services Director
PRIMARY CONTACTS
Danita Carlson
Government Relations
(831) 430-5603
Traci Webb
Public Affairs
(831) 430-5617
44
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1996
2000
Non profit
279
210,270
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Direct Contracting with Physicians
0 owned, 242 contracted
0 owned, 16 contracted
0 owned, 1,917 contracted
0 owned, 171 contracted
0 owned, 562 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method) . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Individual and Group Capitation,
Fee-For-Service, Incentive Program
Fee-For-Service, Incentive Program
Per Diem, Case Rates, Discounted Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
County Organized Health System
None
None
None
HMO
HMO
HMO
None
In-Home Supportive Services: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COHS, HMO
COHS, HMO
HMO: Healthy Kids
COHS, HMO
COHS
None
None
COHS, HMO
HMO
None
COHS, HMO
None
None
None
Central Health Medicare Plan
1540 Bridgegate Drive • Diamond Bar, CA 91765
Ph: (626) 388-2390 • Fax: (626) 388-2361 • www.centralhealthplan.com
EXECUTIVE OFFICER
Sam Kam, M.D.
Chief Executive Officer
EXECUTIVE STAFF
An Pang Chieng, M.D.
Medical Director
David Chen, M.D.
Assistant Medical Director
PRIMARY CONTACT
Annie Hsu Shieh
Senior Compliance Counsel
(626) 388-2390, ext. 2885
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
AHMC Central Health LLC
Acquired on 11/18/2011
2004
2004
For profit
77 full time
12,242 (as of 1/7/2013)
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
IPAs, Direct Contracting with Physicians
25
54
3,971
515
12,266 (as of 1/7/13)
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Capitation, Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Diagnosis-Related Group, Per Diem
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
HMO
HMO
HMO
HMO
45
Chinese Community Health Plan
445 Grant Ave • San Francisco, CA 94108
Ph: (415) 955-8800 • Fax: (415) 955-8818 • www.CCHPhmo.com
EXECUTIVE OFFICER
Brenda Yee
CEO
EXECUTIVE STAFF
Carmen Dobry
Director, Compliance
and Regulatory
Larry Loo
Director, Business
Development and
Operations
Karen Rennie
Director, Clinical Services
Edward Chow, MD
Senior Advisor
Craig Reich, MD
Medical Director
Amy Tsui
CFO
PRIMARY CONTACT
Carmen Dobry
Director, Compliance
and Regulatory
(415) 955-8800
46
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Tax Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . .
Chinese Hospital Association
For profit
1984
1985
91
14,785
PLAN-PROVIDER ARRANGEMENTS
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
1 contracted
5 contracted
289 contracted
8 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Fee-For-Service
Fee-For-Service
Capitation, Per Diem, Discounted Charges,
Differential by Service Type, Case Rates
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
CIGNA HealthCare of California, Inc.
400 N. Brand Boulevard, #400 • Glendale, CA 91203
Ph: (818) 500-6262 • Fax: (818) 500-6365 • www.cigna.com/healthcare
CALIFORNIA
OFFICE LOCATIONS
Glendale
Irvine
San Francisco
San Diego
Visalia
Walnut Creek
EXECUTIVE OFFICERS
Peter B. Welch
President
Anand Raghavan
CFO
Jennifer Gutzmore
Regional Medical
Executive
Maricel Del Rosario, R.N.
Director of Health Services
Valerie James
Quality Management
and Credentialing
Susan Hallett
Regional Vice President,
Provider Contracting/
Services
Benjamin Katz
Provider Contracting/
Services, Northern
California
Michelle Demonteverde
Provider Contracting/
Services, Southern
California
Karen Baker
Claims Manager
Kathy O’Neal
Customer Service
Manager
William S. Jameson
Chief Counsel
PRIMARY CONTACTS
George Price
Government Relations
(818) 500-6467
Amy Turkington
Public Affairs
(440) 934-5385
PLAN ORGANIZATION
Parent Company/Affiliates. . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
HealthSource, Inc./CIGNA Dental Health of CA, Inc.,
CIGNA Behavioral Health of CA, Inc. (CBH),
Connecticut General Life Insurance Company (CGLIC)
None
1929
1979
For profit
155 full time
857,564 total members
216,532 California HMO and Open Access
641,032 California PPO and Open Access Plus
(offered by CGLIC)
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
0 owned, 240 contracted
0 owned, 281 contracted
0 owned, 48,923 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation, Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation, Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Capitation, Case Rates, Discounted Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OAP, POS
HMO, POS, OA, OAP, PPO
HMO, POS, OA, OAP, PPO
None
None
None
Medicare Part D
None
None
None
None
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO, POS, OA, OAP, PPO
HMO, POS, OAP, PPO
CIGNA Dental HMO & PPO
HMO, POS, OAP, PPO
CGLIC
CGLIC
CGLIC
HMO, POS, OAP, PPO
CBH
HMO, POS, OAP, PPO
HMO, POS, OAP, PPO
HMO, POS, OAP, PPO
CGLIC
International
47
Community Health Group
740 Bay Boulevard • Chula Vista, CA 91910
Ph: (619) 422-0422 • Fax: (619) 422-5930 • www.chgsd.com
EXECUTIVE OFFICERS
Norma Diaz
Chief Executive Officer
Bill Rice
Chief Financial Officer
Mike McGarrigle
Chief Operating Officer
Jonathan Tamayo
Chief Information Officer
Edward D. Hutt, M.D., M.B.A.
Chief Medical Officer
Ann Warren
Chief Regulatory and Legal
Affairs Officer
EXECUTIVE STAFF
R. Michael Scarano, Jr., Esq.
Chief Legal Counsel
Noreen Koizumi, Pharm.D.
Director of Health Care
Operations
Nora Pintado
Director of Health
Plan Operations
Martha Jazo-Bajet, R.N.
Director of Utilization
Management Services
David Ritchie
Director of Contract
Administration
PRIMARY CONTACT
Ann Warren
(619) 498-6516
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . None
Recent mergers or acquisitions within California. . . . . . . . None
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1982
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1985
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees (full time/part time). . . . . . . . . . . . 149 full time, 25 per diem, 12 part time
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 150,000
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracts with Physicians
0 owned, 25 contracted
0 owned, 26 contracted
0 owned, 4,481 contracted
0 owned, 1,090 contracted
0 owned, 556 contracted (pcp)
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Fee-For-Service, Individual Capitation,
Group Capitation
Fee-For-Service, Group Capitation
Per Diem, Discounted Charges, DRG
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TPA)
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
None
None
None
None
None
None
None
None
None
None
None
None
None
None
Contra Costa Health Plan (Contra Costa County Medical Services)
595 Center Avenue, Suite 100 • Martinez, CA 94553
Ph: (925) 313-6000 • Fax: (925) 313-6002 • www.contracostahealthplan.org
EXECUTIVE OFFICERS
Patricia Tanquary, MPH, Ph.D.
CEO
Patrick Godley
CFO
David J. Runt
CIO
EXECUTIVE STAFF
James Tysell, M.D.
Medical Director
Frank Lee, J.D.
Chief Legal Counsel
Wendy Mailer
Marketing, Sales and
Outreach Manager
Luke Lim, R.Ph
Pharmacy Director
Judi Louro
Member Services Manager
Terri Lieder
Provider Relations Manager
Kevin Drury
Director of
Quality Management
PRIMARY CONTACTS
Frank Lee, J.D.
Government Relations
(925) 313-6082
Judi Louro
Public Affairs
(925) 313-6000
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Division of Contra Costa County Health Services Dept.
None
1973
1973
Non profit
107 full time, 38 part time
110,463
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Staff, Direct Contracting with Physicians
1 owned, 6 contracted
0 owned, 1,308 contracted
0 owned, 435 contracted
8 owned, 506 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Fee-For-Service, Salary
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service, Salary
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Diagnosis-Related Group
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
None
HMO
None
HMO
HMO
HMO
None
HMO
Commercial: In-Home Support Service Workers: HMO
Public: Basic Health Care – County Indigent Program,
plus Pharmacy-Only Program
Health Care Coverage Initiative (HCCI)
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
None
None
None
HMO
HMO
None
HMO
HMO
None
None
49
Easy Choice Health Plan
180 East Ocean Blvd. • Suite 700 • Long Beach, CA 90802
Ph: (866) 999-3945 • Fax: (877) 999-3945 • www.easychoicehealthplan.com
EXECUTIVE OFFICERS
Joshua Martin
Market President
Eric E. Spencer
Chief Operating Officer
Alex Martin, M.D.
Chief Medical Officer
EXECUTIVE STAFF
Joya Bond
VP/CCO
Koh Kerdsri
CIO
PRIMARY CONTACTS
Joya Bond
VP/CCO
Government Relations
(562) 343-9715
Eric Spencer
Chief Operating Officer
Public Affairs
(562) 343-9713
PLAN ORGANIZATION
Parent Company/Affiliate . . . . . . . . . . . . . . . . . . . . . . . . WellCare Health Plans, Inc.
Recent mergers or acquisitions within California . . . . . . . None
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006
Year licensed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2007
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For profit
Number of employees . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 51,000
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of Medical Groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Delegated IPA
80 contracted
140 contracted
25,000 contracted
5,000 contracted
20,000 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . . 10,000 Capitated
Physicians – specialty (ranked by method) . . . . . . . . . . . . 15,000 Capitated
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . 138 Per Diem/DRG; 2 Capitated
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees) . . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees) . . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs) . . . . . . . . . . . . . . . . . . . . . . . Yes
Medicare Part D stand-alone . . . . . . . . . . . . . . . . . . . . . Yes
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other (please specify) . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
HMO
HMO
HMO
HMO
None
None
None
HMO
HMO
None
HMO
HMO
None
Transportation
GEMCare Health Plan, Inc.
4550 California Avenue, Suite 100, Bakersfield, CA 93309
Ph: (661) 716-8800 • Fax: (661) 716-4820 • www.gemcarehealthplan.com
CALIFORNIA
OFFICE LOCATIONS
Corporate Office:
4550 California Ave., Ste. 100,
Bakersfield, CA 93309
San Luis Obispo
and Oxnard
EXECUTIVE OFFICER
Michael Myers
President and CEO
PRIMARY CONTACT
Michael Myers
President and CEO
Government Relations
Public Affairs
(661) 716-8820
PLAN ORGANIZATION
Parent Company/Affiliate . . . . . . . . . . . . . . . . . . . . . . . . GEMCare Mercy Memorial Health
Systems, LLC (GMMHS)
Recent mergers or acquisitions within California . . . . . . . None
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For profit
Number of employees . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 full time
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 21,767 (21,357 HMO; 410 PPO)
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of Medical Groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Single Medicare Group IPA, Ancillary, Hospital
0 owned, 7 contracted
0 owned, 20 contracted
0 owned, 876 contracted
0 owned, 145 contracted
0 owned, 614 contracted
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A
Small group (2 – 50 employees) . . . . . . . . . . . . . . . . . . . . HMO Commercial, PPO Commercial
Large group (50+ employees) . . . . . . . . . . . . . . . . . . . . . HMO Commercial; PPO Commercial
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . . N/A
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . N/A
Special Needs Plans (SNPs) . . . . . . . . . . . . . . . . . . . . . . . N/A
Medicare Part D stand-alone . . . . . . . . . . . . . . . . . . . . . N/A
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . N/A
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . N/A
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other (please specify) . . . . . . . . . . . . . . . . . . . . . . . . . . .
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
51
Gold Coast Health Plan
2220 E. Gonzales Road • Suite 200 • Oxnard, CA 93036-8294
Ph: (888) 301-1228 • Fax: (805) 981-5314 • www.goldcoasthealthplan.org
EXECUTIVE OFFICER
Michael P. Engelhard
Chief Executive Officer
EXECUTIVE STAFF
Michael P. Engelhard
CEO
Michelle Raleigh
CFO
Charles Cho, M.D.
CMO
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None None
July 1, 2011
Non profit
65 100,000 PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order)
Number of Medical Groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
3 contracted 8
549 153 PRIMARY CONTACT
Guillermo Gonzalez
Director,
Government Relations
and Communications
(805) 889-5503
Public Affairs
see Primary Contact
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . . CAP/FFS
Physicians – specialty (ranked by method). . . . . . . . . . . . FFS/CAP
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
None
None
None Yes
None
None
None
None
None
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
52
Yes None
Denti-Cal
Yes
Yes None
None
None
Carve Out
None
Yes
Yes
None
Health Net of California
CALIFORNIA OFFICE LOCATIONS
Bakersfield, Chatsworth,
Fresno, Huntington Beach,
Modesto, Oakland,
Pasadena, Rancho Cordova,
San Bernardino, San Diego,
San Jose, San Rafael,
Stockton, Woodland Hills
NATIONAL
EXECUTIVE OFFICERS
Jay M. Gellert
National President and CEO
Steven Tough
President,
Government Programs
James E. Woys
Executive Vice President and COO
Joseph Capezza
Executive VP and CFO
Patricia Clarey
Senior VP and Chief Regulatory
and External Relations Officer
Angelee Fox Bouchard
Senior VP and
General Counsel/Secretary
Karin Mayhew
Senior VP of
Organization Effectiveness
Carol Aroyan
Chief Provider
Contracting Officer
Juanell Hefner
Senior VP, Customer
and Technology Services
Jonathan Scheff, M.D.
Chief Medical Officer
Dan Lieberman
Chief Marketing Officer
CALIFORNIA
EXECUTIVE OFFICERS
Steven Sell
President, Western Region
Health Plan and President,
Health Net of California
Scott St. Clair
VP, Sales
Larry Tallman
VP, Sales
Eric Hause
VP, Strategy and
Business Development
EXECUTIVE STAFF
Douglas Schur
VP and Deputy General Counsel
PRIMARY CONTACTS
Dan Chick
Government Relations
(916) 552-5285
21281 Burbank Blvd. • Woodland Hills, CA 91367
Ph: (818) 676-6775 • Fax: (818) 676-6992 • www.healthnet.com
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . Health Net, Inc.
Recent mergers or acquisitions within California . . . . . . . None
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1979
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1979
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For profit
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 6,000
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 2,248,000 California
5,436,000 National
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups or IPAs,
Direct Contracting with Physicians
0 owned, 178 contracted
0 owned, 301 contracted
0 owned, 55,629 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation, Other (RBRVS)
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation, Other (RBRVS)
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Capitation, Discounted Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO, PPO
HMO, PPO, POS, Indemnity
HMO, PPO, POS, EPO, Indemnity
HMO, PPO, Salud cón Health Net HMO
Medicare Supplement
HMO
Prescription Drug Plan (PDP)
HMO
HMO
HMO, EPO
HMO, EPO
None
Salud Con Health Net: HMO, PPO, EPO
California Farm Bureau: PPO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
HMO, PPO, POS
HMO, PPO, POS
HMO, PPO, POS
HMO, PPO, POS
None
HMO, PPO, POS, EPO, Indemnity
HMO, PPO, POS, EPO, Indemnity
HMO, PPO, POS
HMO
HMO, PPO, POS
HMO, PPO, POS
HMO, PPO, POS
None
Brad Kieffer
Communications
(818) 676-6833
53
Health Plan of San Joaquin (San Joaquin County Health Commission)
7751 S. Manthey Road • French Camp, CA 95231
Ph: (209) 942-6300 • Fax: (209) 942-6305 • www.hpsj.com
EXECUTIVE OFFICERS
John R. Hackworth
Chief Executive Officer
Paul Antigua
Chief Financial Officer
Cheron Vail
Chief Information Officer
Dale Bishop, MD
Chief Medical Officer
EXECUTIVE STAFF
David Eibling, MD
Medical Director
David Wooten
Chief Legal Counsel
David Hurst
Vice President, Marketing
Victoria Hazen
Vice President,
Human Resources
Kathryn Kutz
Vice President,
Project Management
Al Scott
Director of Contracting
Christa Vandarwarka
Director, Customer Service
PRIMARY CONTACTS
Nancy Raymond
Government Relations
(209) 461-2265
David Hurst
Public Affairs
(209) 461-2241
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . None
Recent mergers or acquisitions within California . . . . . . . None
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1995
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1996
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 164 full time
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 126,817
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Individual Capitation, Group Capitation
Fee-For-Service including Withhold or Bonus,
Group Capitation
Per Diem
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
HMO
HMO
HMO
None
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
54
Direct Contracting with Physicians,
Network of Medical Groups and IPAs
0 owned, 140 contracted
0 owned, 19 contracted
0 owned, 3,443 contracted
0 owned, 38 contracted
0 owned, 6,360 contracted
None
None
None
None
None
None
None
None
None
None
None
None
None
Health Plan of San Mateo (San Mateo Health Commission)
701 Gateway Boulevard, Suite 400 • So. San Francisco, CA 94080
Ph: (650) 616-0050 • Fax: (650) 616-0060 • www.hpsm.org
EXECUTIVE OFFICER
Maya Altman
Chief Executive Officer
EXECUTIVE STAFF
Ron Robinson
Director of Finance and
Administrative Services
Ellen R. Dunn-Malhotra
Director of Compliance
and Regulatory Affairs
Fiona Donald
Medical Director
(open position)
Director of Health and
Provider Services
Edward Ortiz
Director of Provider
Network Development
and Services
Carolyn Thon
Director of Member
Services and Outreach
Eben Yong
Director of MIS
Chris Baughman
Director of System
Improvement
Cindy Lem
Director of Human
Resources
Khoa Nguyen
Manager of Governmental
Affairs and Business
Development
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . None
Recent mergers or acquisitions within California . . . . . . . None
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1986
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1987
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 194 full time, 15 part time
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 101,618
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
0 owned, 11 contracted
0 owned, 3,556 contracted
0 owned, 273 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Individual Capitation, Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, DRG
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
HMO
None
None
HMO
HMO
HMO
None
Public: In-Home Supportive Service
Workers in San Mateo: HMO
Third Party Administrator for County Indigent Programs
ANCILLARY PRODUCTS
PRIMARY CONTACT
Ellen R. Dunn-Malhotra
Director of Compliance
and Regulatory Affairs
(650) 616-0050
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
HMO
None
None
HMO
HMO
None
HMO
HMO
None
None
55
Heritage Provider Network
8510 Balboa Boulevard, Suite 285 • Northridge, CA 91325
Ph: (818) 654-3461 • Fax: (818) 654-3460 • www.heritageprovidernetwork.com
EXECUTIVE OFFICERS
PLAN ORGANIZATION
Jaya Kurian
CFO
Parent Company/Affiliate . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . .
Rich Lipeles
COO
PLAN-PROVIDER ARRANGEMENTS
Richard N. Merkin, M.D.
President
S. Ian Drew, M.D.
Medical Director
EXECUTIVE STAFF
Scott Bae
Information Technology
PRIMARY CONTACTS
Jaya Kurian
Government Relations
(818) 654-3461
Ann Wymer
(310) 823-5250
Rich Lipeles
Public Affairs
(714) 908-5613
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups . . . . . . . . . . . . . . . . . . . . . . .
Number of IPAs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of PCP, Specialists . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
None
0
1996
1997
For profit
2,884 full time
N/A
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
9 owned, 0 contracted
9 owned, 2 contracted
376 contracted
2,201 PCPs, 5,990 Specialists
363 owned (salaried)
52 contracted
COMPENSATION METHODS
Physicians-primary care (ranked by method). . . . . . . . . . .
Physicians-specialty (ranked by method). . . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Other (Fee schedule), Group Capitation,
Individual Capitation, Salary
Other (Fee schedule), Group Capitation
Per Diem, Case Rates, Discount Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY SERVED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees) enrollment. . . . . . . . . . . .
Large group (50+ employees) enrollment. . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs) . . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO, PPO
HMO
HMO, POS
HMO, Supplemental, FFS
HMO, FFS
None
HMO
None
None
HMO
HMO
PPO, FFS
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
56
None
None
None
None
None
None
None
None
None
None
None
None
FFS Contract
Industrial Physical, Champus
Inland Empire Health Plan
303 E. Vanderbilt Way • San Bernardino, CA 92408
Ph: (909) 890-2000 • Fax: (909) 890-2019 • www.iehp.org
EXECUTIVE OFFICER
PLAN ORGANIZATION
Rohan Reid
Chief Operations Officer
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Susan Arcidiacono
Chief Marketing Officer
PLAN-PROVIDER ARRANGEMENTS
Bradley P. Gilbert, M.D., M.P.P.
Chief Executive Officer
EXECUTIVE STAFF
Kurt Hubler
Chief Network Officer
Chet Uma
Chief Financial Officer
William Henning, D.O.
Chief Medical Officer
Michael Deering
Chief Information Officer
Jinny Yang, Esq.
Legal Counsel
None
None
1994
1996
Not-for-profit
748 full time
573,234
Model types (ranked in descending order). . . . . . . . . . . . . Network of IPAs and Direct Physician Contracting
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . . 12 contracted
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 contracted
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,577 contracted
Number of other licensed clinicians. . . . . . . . . . . . . . . . . . 927 contracted
Number of provider offices. . . . . . . . . . . . . . . . . . . . . . . . 5,175 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Individual Capitation, Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Diagnosis-Related Group
PLAN PRODUCTS
PRIMARY CONTACT
Bradley P. Gilbert, M.D., M.P.P.
Government Relations/
Public Affairs
(909) 890-2010
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
None
None
57
Inter Valley Health Plan
300 South Park Avenue • Pomona, CA 91769-6002
Ph: (909) 623-6333 • Fax: (909) 397-9039 • www.ivhp.com
EXECUTIVE OFFICERS
Ronald H. Bolding
CEO
Donald D. McCain
CFO
EXECUTIVE STAFF
Susan Tenorio, R.N.
Vice President
Health Operations
Ken Smith, M.D.
Chief Medical Officer
Cyndie O’Brien
Vice President
Sales and Marketing
Larry Baca
Sales Director
Michelle Hageman
Provider Relations
Judy Johnson
Member Relations
Bill Chen
IT Director
PRIMARY CONTACTS
Gail Blacklock
Government Relations
(909) 623-6333
Cyndie O’Brien
Public Affairs
(909) 623-6333
58
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1979
1979
Non profit
110 full time
20,250 (Medicare Only)
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . . Network of Medical Groups and IPAs
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . . 0 owned, 14 contracted
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 owned, 21 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Capitation, Per Diem
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Kaiser Permanente (Kaiser Foundation Health Plan, Inc.)
CALIFORNIA
OFFICE LOCATIONS
See website for most updated list
of all office locations. www.kp.org
EXECUTIVE OFFICERS
George C. Halvorson
Director, Chairman and National CEO
Bernard J. Tyson
President and COO
Gregory A. Adams
Group President and Regional
President, Northern California
Daniel P. Garcia
Senior Vice President,
Chief Compliance Officer
Benjamin K. Chu, M.D.
Group President and Regional
President, Southern California
Wade Overgaard
Senior Vice President,
California Health Plan Operations
Kathryn Lancaster
Executive Vice President and
National Chief Financial Officer
Michael D. Rowe
Chief Financial Officer and
Senior Vice President of Finance,
Northern California
George A. Disalvo
Senior Vice President and Chief
Financial Officer, Southern California
Philip Fasano
Executive Vice President and
Chief Information Officer
EXECUTIVE STAFF
Robert M. Pearl, M.D.
Executive Medical Director and
CEO, Northern California
Edward M. Ellison, M.D.
Executive Medical Director and
Chairman of the Board,
Southern California
Sandra Golze
VP and Regional Counsel,
Northern California
John Yamamoto
Vice President and Assistant General
Counsel, Southern California
Christine Paige
Senior Vice President,
Marketing and Internet Services
Alan T. Kiyohara, Pharm.D.
VP Pharmacy Operations and Services,
Southern California
Suzanne B. Shea
VP Pharmacy Operations and
Services, Northern California
Lisa Koltun
Vice President, Health Plan
Regulatory Services
PRIMARY CONTACTS
John Garcia
Vice President Legal and Government
Relations, Northern California
(916) 448-3209
Yvette Radford
Vice President External and
Community Affairs, Northern California
(510) 987-4190
Diana Halper
Vice President, Communications and
Media Services, Southern California
(626) 405-5890
Debby Cunningham
SVP Strategy and Business
Development, Northern California
(510) 987-3995
Northern California Region • 1950 Franklin Street, 20th Floor • Oakland, CA 94612
Ph: (510) 987-1000 • Fax: (510) 987-4303
Southern California Region • 393 East Walnut Street • Pasadena, CA 91188
Ph: (626) 405-5000 • Fax: (626) 405-2583
www.kaiserpermanente.org
PLAN ORGANIZATION
Parent Company. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees* . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
*Headcount includes all non-physician employees.
None
None
1945
1977
Non profit
173,896 Nationally
(109,028 full time; 64,868 part time)
9,020,339 Nationally
3,390,910 Northern California
3,574,991 Southern California
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians**. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices***. . . . . . . . . . . . . . . . . . . . . . .
Group Model HMO
0 owned, 2 exclusive contracts (TPMG, SCPMG)
36 owned, 11 plan hospitals
13,582 TPMG, SCPMG, 3,017 contracted
4,871 TPMG & SCPMG, 471 contracted
13,426 offices
**As of Sept 30, 2012. PMG physician counts include FTEs and not actual headcount of employees.
Contracted physicians and clinicians represent the credentialed non-PMG contracted providers for California.
***Excludes administrative offices, offices located in inpatient or diagnostic/ treatment areas, non-MD offices.
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Group Capitation
Group Capitation
Cost Reimbursement (Kaiser)
Discounted Charges, Per Diem, Case Rates (non-Kaiser)
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO, POS, PPO
HMO, POS, PPO
HMO (with and without Part D)
None
1 SNP
None
HMO
HMO
HMO
None
HMO
HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO, PPO, POS
HMO, PPO, POS
HMO, PPO, POS
HMO, PPO, POS
None
None
None
HMO, PPO, POS
HMO, PPO, POS
None
HMO, PPO, POS
HMO, PPO, POS
Injury Care and Occupational Health and Safety Services
N/A
59
Kern Family Health Care (Kern Health Systems)
9700 Stockdale Highway • Bakersfield, CA 93311
Ph: (661) 664-5000 • Fax: (661) 664-5178 • www.kernfamilyhealthcare.com
EXECUTIVE OFFICERS
Douglas A. Hayward
President and CEO
Keith Quinlivan
Chief Financial Officer
Becky Davenport
Chief Operating Officer
Robert Woodard
Chief Analytics and
Project Officer
Vacant
Chief Compliance Officer
Richard Pruitt
Chief Information Officer
EXECUTIVE STAFF
John Fisher M.D.
Medical Director
Remington Brooks, M.D.
Associate Medical Director
Beverly Dolberg, M.D.
Associate Medical Director
Deborah Murr, R.N.
Director of Health Services
Linda Howells, R.N.
Director of Quality
Improvement,
Disease Management
and Health Education
Louie Iturriria
Director of Marketing and
Member Services
Bruce Wearda, Pharm. D.
Director of Pharmacy
Denise Crossley-Weinberg
Director of Human Resources
Carl R. Breining, CHC
Director of Compliance and
Regulatory Affairs
Vacant
Director of Provider Relations
PRIMARY CONTACT
Douglas A. Hayward
Government Relations
Douglas A. Hayward
Public Affairs
60
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1994
1996
Non profit
229 full time,1 part time
124,111 (Medi-Cal); 10,631 (Healthy Families)
PLAN-PROVIDER ARRANGEMENTS
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
0 owned, 11 contracted
0 owned, 602 contracted
0 owned, 157 contracted
0 owned, 274 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Fee-For-Service
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
HMO
HMO
None
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
None
None
L.A. Care Health Plan (Local Initiative Health Authority for Los Angeles County)
1055 W 7th Street, 10th Floor • Los Angeles, CA 90017
Ph: (213) 694-1250 • Fax: (213) 694-1246 • www.lacare.org
EXECUTIVE OFFICERS
Howard A. Kahn
Chief Executive Officer
John R. Wallace
Chief Operating Officer
Trudi Carter, M.D.
Chief Medical Officer
Tim Reilly
Chief Financial Officer
Jonathan Freedman
Chief of Strategy,
Regulatory and
External Affairs
Augustavia Haydel, Esq.
General Counsel
Barbara Cook
Chief of Human and
Community Resources
PRIMARY CONTACTS
Cherie Fields
Government Relations
(916) 945-9251
Elena Stern
Public Affairs
(213) 694-1250
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1994
1997
Not-for-profit
706
1,055,780
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Plan Partner/Delegated,
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
0 owned, 116 contracted
0 owned, 80 contracted
0 owned, 2,405 contracted
0 owned, 9,842 contracted
0 owned, 4,281 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation, Fee-For-Service,
Individual Capitation
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation, Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Case Rates, Diagnosis Related Groups,
Discount Charges, Differential by Service Type, Capitation
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Medicare Advantage Special Needs Plans (SNPs). . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
None
None
61
Molina Healthcare of California
200 Oceangate, Suite 100 • Long Beach, CA 90802
Ph: (562) 499-6191 • Fax: (562) 499-6170 • www.molinahealthcare.com
CALIFORNIA
OFFICE LOCATIONS
Sacramento
2277 Fair Oaks Blvd,
Suite 195
Sacramento, CA 95825
Inland Empire
887 E 2nd Street
2nd Floor
Pomona, CA 91766-2009
San Diego
9665 Chesapeake Dr.,
Suite 305
San Diego, CA 92123
EXECUTIVE OFFICERS
Richard Chambers
Chairman
Richard Chambers
CEO
Greg Hamblin, CPA
CFO
Teri Lauenstein
V.P. Provider Network
Management and Operations
EXECUTIVE STAFF
Richard Bock, MD
CMO
Kristen Cerf, Esq.
Legal Counsel
Maggie Hollon
and Steven Soto
Provider Relations
Hilario Wilson
Member Relations
PRIMARY CONTACTS
Michael Mayers
Government Relations
(916) 646-9193
Juan Jose Orellana
Public Affairs
(562) 435-3666
62
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Molina Healthcare, Inc.
None
1980
1994
For profit
293 full time
1,826,000 National
346,000 California
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracting with Physicians, Staff
1 owned, 2,053 contracted
0 owned, 66 contracted
22 owned, 10,906 contracted
10 owned, 850 contracted
16 owned, 6,763 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Group Capitation, Individual Capitation,
Salary, Fee-For-Service
Fee-For-Service, Capitation
Per Diem, Capitation
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . HMO
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . . HMO
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
None
Monarch Health Plan, Inc.
11 Technology Drive • Irvine, CA 92618
Ph: (949) 923-3350 • Fax: (949) 923-3585 • www.monarchhealthplan.com
EXECUTIVE OFFICERS
Nancy Boerner, MD
CEO
Jay Cohen, MD
Executive Chairman,
Board of Directors
EXECUTIVE STAFF
Karen Goldstein
General Manager
PRIMARY CONTACT
Karen Goldstein
General Manager
(949) 923-3350
PLAN ORGANIZATION
Parent Company/Affiliate . . . . . . . . . . . . . . . . . . . . . . . . Monarch Healthcare, A Medical Group, Inc.
Recent mergers or acquisitions within California . . . . . . . None
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2007
Year licensed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2007
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Profit
Number of employees . . . . . . . . . . . . . . . . . . . . . . . . . . .16 FTE’s
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . MHP takes global risk for other
Health Plans’ members
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and
Independent Practice Associations (IPAs)
1 contracted
15 contracted
None
None
None
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . . None
Physicians – specialty (ranked by method). . . . . . . . . . . . None
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Diagnosis Related Group
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees) . . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees) . . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs) . . . . . . . . . . . . . . . . . . . . . . . None
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MHP takes global risk for other
Health Plans’ members
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other (please specify) . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
None
None
63
On Lok Lifeways (On Lok Senior Health Services)
1333 Bush Street • San Francisco, CA 94109
Ph: (415) 292-8888 • Fax: (415) 292-8745 • www.OnLok.org
EXECUTIVE OFFICERS
Robert E. Edmondson
CEO
Sue Wong
CFO
Jay Luxenberg, MD
Chief Medical Officer
Grace Li
Chief Operating Officer
Eileen Kunz
Director of Policy and
Regulatory Affairs
Kelvin Quan
Chief Administrative
Officer
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
On Lok, Inc.
None
1971
1999
Non profit
450 full time, 250 part time
1,220
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Staff Model
0 owned, 48 contracted
0 owned, 15 contracted
20 employed, 300 contracted
0 owned, 55 contracted
9 owned, 150 contracted
COMPENSATION METHODS
PRIMARY CONTACTS
Eileen Kunz
Government Relations
(415) 292-8722
Kelvin Quan
Public Affairs
(415) 292-8318
Physicians – primary care (ranked by method). . . . . . . . . . Employed
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Fee-For-Service
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
PACE: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
64
None
None
None
None
None
None
None
None
None
None
None
None
None
None
Partnership HealthPlan of California
4665 Business Center Drive • Fairfield, CA 94534
Ph: (707) 863-4100 • Fax: (707) 863-4117 • www.partnershiphp.org
CALIFORNIA
OFFICE LOCATIONS
Headquarters
4665 Business Center Drive
Fairfield, CA 94534
Regional Office
495 Tesconi Circle
Santa Rosa, CA 95401
EXECUTIVE OFFICERS
Jack Horn
Executive Director/
Chief Executive Officer
EXECUTIVE STAFF
Robert Moore, MD, MPH
Chief Medical Officer
Gary Erickson
Chief Financial Officer
Paula Frederickson
Senior Claims Director
Elizabeth Gibboney
Deputy Executive Director/Chief
Operations Officer
Mary Kerlin
Senior Provider
Relations Director
Marshall Kubota, MD
Regional Medical Director
Sue Monez
Senior Human
Resources Director
Kirt Kemp
Chief Information Officer
Debbie Shafer
Senior Member Services
and Marketing Director
Peggy Hoover, R.N.
Senior Health
Services Director
Lynn Scuri
Associate Regional Director
Sonja Bjork
Director of Policy
and Program Development
Tammy Fisher
Quality and Performance
Improvement Director
PRIMARY CONTACT
Elizabeth Gibboney
Deputy Executive Director/COO
(Government Relations,
Public Affairs)
(707) 863-4232
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1994
2005
Non profit
317
191,033
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Direct Contracting with Physicians,
Network of Medical Groups and IPAs
0 owned, 6 contracted
0 owned, 40 contracted
0 owned, 2,807 contracted
0 owned, 416 contracted
0 owned, 687 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Individual and Group Capitation, Fee-For-Service
Fee-For-Service, Individual Capitation,
Group Capitation
Per Diem, Capitation, Diagnosis-Related Group
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . None
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . None
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . HMO
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
HMO
None
None
HMO
HMO
HMO
HMO
HMO
None
None
65
PrimeCare Medical Network, Inc.
3990 Concours, Suite 500, 5th Floor • Ontario, CA 91764
Ph: (909) 605-8000 • Fax: (909) 605-8033
EXECUTIVE OFFICERS
Leigh Hutchins
President,
Chief Operating Officer
T.K. Desai, MD
Sr. Vice President and
Chief Medical Officer
EXECUTIVE STAFF
Elizabeth Haughton
Vice President,
Legal Affairs
Karen Gee
Vice President,
Development
PRIMARY CONTACT
Elizabeth Haughton
Government Relations/
Public Affairs
(909) 605-8000
66
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of Employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Optum
None
1994
1998
For profit
65
223,000
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limited Knox-Keene
15
16
2,510
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . . Capitated
Physicians – specialty (ranked by method) . . . . . . . . . . . . Capitated/FFS
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . FFS
San Francisco Health Plan (San Francisco Health Authority)
201 Third Street, 7th Floor • San Francisco, CA 94103
Ph: (415) 547-7818 • Fax: (415) 615-6435 • www.sfhp.org
EXECUTIVE OFFICERS
PLAN ORGANIZATION
Sunny Cooper
CIO
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . None
Recent mergers or acquisitions within California. . . . . . . . None
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1997
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1996
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit/Public Agency
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 180 full time
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 79,058
John Gregoire
CFO
PLAN-PROVIDER ARRANGEMENTS
John F. Grgurina, Jr.
CEO
EXECUTIVE STAFF
Deena Louie
Chief Operations Officer
Nina Maruyama
Officer, Regulatory
Affairs and Compliance
(includes Community
Relations and Marketing)
Kelly Pfeifer, MD
Chief Medical Officer
Sumi Sousa
Officer, Policy
Development and
Coverage Programs
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Staff (Kaiser)
0 owned, 7 contracted
0 owned, 6 contracted
0 owned, 2,202 contracted (PCP & Specialists)
0 owned, 177 contracted (Mid-Level providers)
0 owned, 129 contracted (PCP sites)
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation, Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation, Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Capitation, Fee-For-Service
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
PRIMARY CONTACTS
Sumi Sousa
Officer, Policy
Development and
Coverage Programs
(415) 615-5121
Nina Maruyama
Officer, Regulatory
Affairs and Compliance
(includes Community
Relations and Marketing)
(415) 615-4217
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
HMO
None
None
None
None
HMO
HMO
None
Healthy Workers: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
None
None
None
HMO
HMO
None
HMO
HMO
None
None
67
Santa Clara Family Health Plan (Santa Clara County Health Authority)
210 E. Hacienda Avenue • Campbell, CA 95008
Ph: (408) 376-2000 • Fax: (408) 376-2191 • www.scfhp.com
CALIFORNIA
OFFICE LOCATIONS
Ancillary Office
San Jose, CA
1-877-688-7234
Corporate Office
Campbell, CA
(408) 376-2000
Fax: (408) 376-2191
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
1995
1997
Non profit
117 full time, 3 part time
138,370
PLAN-PROVIDER ARRANGEMENTS
EXECUTIVE OFFICERS
Elizabeth Darrow
Chief Executive Officer
Dave Cameron
Chief Financial Officer
Matthew Woodruff
Chief Operating Officer
Rayne Johnson
Chief Information Officer
Jeff Robertson, MD
Chief Medical Officer
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
0 owned, 8 contracted
0 owned, 8 contracted
0 owned, 3,906 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . .
Physicians – specialty (ranked by method). . . . . . . . . . . . .
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . .
Medical Group Capitation, PCP Capitated,
Fee-For-Service including risk sharing
Fee-For-Service, Medical Group Capitation
Per Diem, Capitation, Diagnosis-Related Group
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
EXECUTIVE STAFF
Pat McClelland
VP, Member
Support Services
Michael Lipman
VP, Provider Operations
Diane Brown
Director, Medical
Management
Sarah Moline
Director, Pharmacy
Beth Paige
Director,
Compliance and
Grievance & Appeals
PRIMARY CONTACTS
Elizabeth Darrow
Public Affairs
(408) 874-1702
Robin Bilinski
Government Relations
(408) 874-1822
68
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
HMO
None
None
HMO
None
None
None
None
HMO
HMO
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
None
None
None
None
None
None
None
None
None
None
None
SCAN Health Plan
®
3800 Kilroy Airport Way, Suite 100 • Long Beach, CA 90806
Ph: (562) 989-5100 • Fax: (562) 989-5200 • www.scanhealthplan.com
EXECUTIVE OFFICERS
Chris Wing
Chief Executive Officer
Randy Stone
Chief Financial Officer
Timothy Schwab, M.D.
Chief Medical Officer
Nancy Monk
Chief Risk Officer
William Roth
Chief Operating Officer
Douglas Jaques
Senior Vice President,
General Counsel
Roy Swackhamer
Chief Information Officer
Cathy Batteer
Senior Vice President
and General Manager,
All SCAN Markets
Gil Miller
Senior Vice President,
National Sales
Sherry Stanislaw
General Manager,
Southern California
Peter Begans
Senior Vice President,
Public and
Government Affairs
EXECUTIVE STAFF
Andrew Whitelock
Vice President and
Compliance Officer
Karen Sugano
Vice President, California
Network Management
Hans Eckardt
Marketing Vice President
Sharon Bakshi
Pharmacy Vice President
Grace Mayeda
Director, Customer Services
(Member Relations)
PRIMARY CONTACTS
Peter Begans
Government Relations
(202) 756-2279
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . SCAN Group
Recent mergers or acquisitions within California . . . . . . . None
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1977
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1985
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 903 full time, 35 part time
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 115,342
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . . Network of Medical Groups and IPAs
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . . 0 owned, 72 contracted
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 owned, 100 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Diagnosis-Related Group, Capitation
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
None
None
HMO
None
HMO
None
None
HMO
None
None
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
HMO
HMO
None
None
None
HMO
None
HMO
None
None
None
Sherry Stanislaw
Public Affairs
(562) 989-5216
69
Sharp Health Plan
8520 Tech Way, Suite 200 • San Diego, CA 92123
Ph: (858) 499-8377 • Fax: (858) 499-8244 • www.sharphealthplan.com
EXECUTIVE OFFICERS
Melissa Hayden Cook
President and Chief
Executive Officer
Rita Datko
Chief Financial Officer
Leslie Pels-Beck
Chief Operations Officer
Lori Stone, MD
Chief Medical Officer
EXECUTIVE STAFF
Michael Byrd
Business Development
Officer
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Sharp HealthCare
None
1992
1992
Non profit
110 full time
66,414
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physician practices (including specialists). . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups, IPAs,
Individual Practices, Physician Practices
0 owned, 6 contracted
0 owned, 12 contracted
0 owned, 2,086 contracted
0 owned, 1,279 contracted
COMPENSATION METHODS
PRIMARY CONTACTS
Stacy Baker
Government Relations
(858) 499-8237
Leslie Pels-Beck
Public Affairs
(858) 499-8327
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation, Fee-For-Service
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation, Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Capitation, Discounted Charges, Per Diem
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
HMO
HMO, POS
None
None
None
None
None
None
None
None
None
None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
70
HMO
HMO/Other
Other
HMO
None
None
None
HMO/Other
HMO
Other
HMO
HMO
None
None
SIMNSA Health Plan
333 H Street, Suite 6040 • Chula Vista, CA 91910
Ph: (619) 407-4082 • www.simnsa.com
EXECUTIVE OFFICERS
Frank Carrillo
Chief Executive Officer
Christina Suggett
Chief Operating Officer
Claudia Da Costa
Chief Financial Officer
EXECUTIVE STAFF
Elizabeth B. Daniels
Chief Legal Counsel
PRIMARY CONTACT
Elizabeth B. Daniels
Chief Legal Counsel
Government Relations/
Public Affairs
(619) 407-4082, ext. 121
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Sistemas Medicos Nacionales, SA de CV
None
1980
2000
For profit
104 full time
33,505
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network, Direct Contracts and Staff
3 owned
0 owned, 13 contracted
3 owned groups, 300 contracted
20 contracted
200
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . . Individual Capitation
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Fee-For-Service
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . HMO
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
None
HMO
HMO
HMO
None
None
None
HMO
HMO
HMO
HMO
HMO
71
UnitedHealthcare of California
5995 Plaza Drive • Cypress, CA 92630
Ph: (714) 952-1121 • Fax: (866) 383-0428 • www.uhcwest.com or www.securehorizons.com
EXECUTIVE OFFICERS
Brandon Cuevas
UnitedHealthcare
of California,
President and CEO
Peter Horn
UnitedHealthcare
of California,
Chief Financial Officer
Jeffrey Mason, MD
UnitedHealthcare
of California,
Medical Director
Claire Hannan
UnitedHealthcare
of California,
VP Operations
Payman Pezhman
UnitedHealthcare
of California,
VP Regulatory Affairs
PRIMARY CONTACTS
John Doherty
Government Relations
(916) 447-8815
Elizabeth Hays
Regulatory Affairs
(714) 226-3106
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . . UnitedHealth Group
Ultimate Parent Company. . . . . . . . . . . . . . . . . . . . . . . . UnitedHealth Group
Health plan products and services are offered by UnitedHealthcare of California,
Indemnity insurance products (including PPO, medical, dental, life/AD&D and short term
disability products) are underwritten by UnitedHealthcare Insurance Company.
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1975
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1978
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for profit
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . . 5,000+ UHG employees
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 876,727
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs
0 owned, 570 contracted
0 owned, 320 contracted
56,817 contracted
13,645 contracted
COMPENSATION METHODS
Physicians– primary care (ranked by method). . . . . . . . . . Depends on IPA/PMG subcontracts
Physicians– specialty (ranked by method). . . . . . . . . . . . . Depends on IPA/PMG subcontracts
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Capitation, Per Diem
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO
HMO
HMO
None
by affiliate
HMO
by affiliate
None
None
None
None
None
ancillary products
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
PPO
HMO, PPO
HMO, PPO
HMO, PPO
None
Other
Other
HMO, PPO
HMO, PPO
None
HMO, PPO
None
None
Infertility: HMO, PPO
Valley Health Plan (Santa Clara County)
2480 North 1st Street, Suite 200 • San Jose, CA 95131
Ph: (408) 885-4080 • Fax: (408) 885-5921 • www.valleyhealthplan.org
EXECUTIVE OFFICERS
(ACTING)
Pat Cox, RN
CEO
Vacant
COO
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . .
Santa Clara County
N/A
1985
1985
Non profit
100 FTE
82,420
EXECUTIVE STAFF
Dolly Goel, MD
Medical Director
PRIMARY CONTACTS
Georgette Cook
Regulatory Affairs
(408) 885-5606
Joy Alexiou
Public Affairs
(408) 885-4164
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs. . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians. . . . . . . . . . . . . . . . .
Two-Plan Model
5 contracted
5 contracted
839 staff/contracted
400 contracted
COMPENSATION METHOD
Physicians – primary care (ranked by method). . . . . . . . . . Fee-For-Service, Capitation, Salary
Physicians – specialty (ranked by method). . . . . . . . . . . . . Fee-For-Service, Salary
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Capitation, Per Diem, Percentage of Billed
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . .
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . .
Medicare Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . .
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . .
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . .
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . .
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . .
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
HMO
HMO
None
None
None
None
None
HMO
HMO
HMO
None
COBRA: HMO
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment. . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
None
HMO
None
HMO
None
None
None
HMO
HMO
None
HMO
HMO
None
None
73
Ventura County Health Care Plan
2220 E. Gonzales Rd., Suite 210B • Oxnard, CA 93036
Ph: (805) 981-5050 • Fax: (805) 981-5026 • www.vchealthcareplan.org
EXECUTIVE OFFICERS
County Board
of Supervisors
EXECUTIVE STAFF
Dr. Robert Gonzalez
Health Care
Agency Director
Health Care Plan
Administrator
Narcisa Reyes-Egan
Assistant Chief
Financial Officer
Dr. Albert Reeves
Chief Medical Officer
PRIMARY CONTACTS
Narcisa Reyes-Egan
Assistant Chief
Financial Officer
Government Relations
(805) 981-5023
Dee Pupa
Fiscal Manager
(805) 981-5006
PLAN ORGANIZATION
Parent Company/Affiliate . . . . . . . . . . . . . . . . . . . . . . . . County of Ventura
Recent mergers or acquisitions within California . . . . . . . None
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1993
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1996
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Non profit
Number of employees . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Health Plan Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 24,500
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups/IPAs . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of other licensed clinicians . . . . . . . . . . . . . . . . .
Number of provider offices . . . . . . . . . . . . . . . . . . . . . . .
COMPENSATION METHODS
Physicians – primary care (ranked by method) . . . . . . . . . FFS
Physicians – specialty (ranked by method) . . . . . . . . . . . . FFS
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Per Diem, Case Rates, % Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
HMO
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No
Small group (2 – 50 employees) . . . . . . . . . . . . . . . . . . . . Yes
Large group (50+ employees) . . . . . . . . . . . . . . . . . . . . . Yes
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . No
Medi-Cal Managed Care . . . . . . . . . . . . . . . . . . . . . . . . No
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . No
Special Needs Plans (SNPs) . . . . . . . . . . . . . . . . . . . . . . . No
Medicare Part D stand-alone . . . . . . . . . . . . . . . . . . . . . No
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . Yes
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . No
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .
Other (please specify) . . . . . . . . . . . . . . . . . . . . . . . . . . .
74
Direct Contract
None
2 County operated, 7 contracted
0 owned, 450 contracted
0 owned, 135 contracted
0 owned, 50 contracted
HMO
No
No
No
Yes
No
No
No
No
Yes
No
Yes
No
No
No
Western Health Advantage
2349 Gateway Oaks Drive, Suite 100 • Sacramento, CA 95833
Ph: (916) 563-3180 • Fax: (916) 563-3182 • www.westernhealth.com
EXECUTIVE OFFICERS
Garry Maisel
President and CEO
Rita Ruecker
Chief Financial Officer
EXECUTIVE STAFF
Donald Hufford, M.D.
Chief Medical Officer
Mark Sloan
Chief Administrative
Officer
Bill Figenshu
Chief Sales Officer
Rebecca Downing
Chief Legal Officer
Rick Heron
Chief Marketing and
Brand Officer
PRIMARY CONTACTS
Rebecca Downing
Government Relations
(916) 563-3183
Rick Heron
Public Affairs
(916) 614-6009
PLAN ORGANIZATION
Parent Company/Affiliate. . . . . . . . . . . . . . . . . . . . . . . . .
Subsidiaries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recent mergers or acquisitions within California . . . . . . .
Year founded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year licensed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Plan Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . .
None
Western Health Advantage
Community Health Plan
None
1995
1997
Non exempt
117 full time, 4 part time
91,790
PLAN-PROVIDER ARRANGEMENTS
Model types (ranked in descending order) . . . . . . . . . . . .
Number of medical groups . . . . . . . . . . . . . . . . . . . . . . .
Number of IPAs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Network of Medical Groups and IPAs,
Direct Contracting with Physicians
0 owned, 4 contracted
0 owned, 1 contracted
0 owned, 8 contracted
COMPENSATION METHODS
Physicians – primary care (ranked by method). . . . . . . . . . Group Capitation
Physicians – specialty (ranked by method). . . . . . . . . . . . . Group Capitation
Hospitals (ranked by payment type). . . . . . . . . . . . . . . . . Capitation, Discount Charges
PLAN PRODUCTS
PRODUCTS CURRENTLY OFFERED
Individual market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HMO
Small group (2 – 50 employees). . . . . . . . . . . . . . . . . . . . HMO
Large group (50+ employees). . . . . . . . . . . . . . . . . . . . . HMO
Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Medi-Cal Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . None
Medigap (Supplemental Insurance) . . . . . . . . . . . . . . . . . None
Special Needs Plans (SNPs). . . . . . . . . . . . . . . . . . . . . . . None
Medicare Part D stand-alone. . . . . . . . . . . . . . . . . . . . . . None
Access for Infants and Mothers. . . . . . . . . . . . . . . . . . . . None
Healthy Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Healthy Kids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
Major Risk Medical Insurance/GIP. . . . . . . . . . . . . . . . . . None
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
ANCILLARY PRODUCTS
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long Term Health Care . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accidental Death & Dismemberment . . . . . . . . . . . . . . . .
Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Massage Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . .
Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers’ Compensation. . . . . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HMO/PPO
HMO
HMO/PPO
HMO
None
None
None
HMO
HMO
None
HMO
HMO
None
Health coaching
International travel assistance services
75
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© 2013 American Regent, Inc. VENCAHP Rev. 1/2013
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Janet Balbutin, Pharm. D.
Owner
Drug Therapy Systems, Inc.
Chico Pharmacy
Chico Medical Supply
Paradise Drug
Chico, CA
DMEPOS
I’m an EP!
W
ith two pharmacies and a full-service medical
supply company to run, achieving Exemplary
Provider™ (EP) accredited status seemed out of
the realm of possibilities when Janet Balbutin first looked
into Medicare’s DMEPOS accreditation.
All that changed once this enterprising pharmacist
turned small business owner and industry consultant
realized that The Compliance Team’s measured continuous improvement regimens represent the best value
among the CMS “deemed” accreditation organizations.
“The Compliance Team really worked with my staff,”
Balbutin observed. “They provided mentoring and support
instead of ‘marks’ on a piece of paper. It became readily
apparent that they cared about our small
business, and wanted us to succeed.”
All true, but there’s more.
The Compliance Team offers a full array of patient-centric
Exemplary Provider™ accreditation programs that are
customized to virtually every sector of our healthcare delivery
system. Each features expert mentoring, manuals, selfassessment checklists, corporate compliance/anti-fraud
plans, and access to electronic outcomes benchmarking that
help both large and small organizations like Janet’s streamline
their everyday operations to help them achieve healthcare
delivery excellence.
To learn more about our industry leading programs, please
visit us at www.TheComplianceTeam.org or call us at
215.654.9110.
HEALTHCARE
ACCREDITATION
ORGANIZATION
Growing Strong
into the Future.
IEHP is one of the fastest growing
not-for-profit health plans in California.
IEHP serves more than 580,000
members in Medi-Cal, Healthy Kids
and a Medicare Special Needs Plan in
Riverside and San Bernardino counties.
IEHP membership could grow
to 1 million by 2016!
IEHP team has grown to 750 strong –
and by 2016 could reach 1,200!
IEHP is building up for the CCI,
the Medi-Cal expansion and other
new programs.
IEHP has earned “Commendable”
Accreditation for Medi-Cal from NCQA.
Our future looks strong. And because
of the changing healthcare landscape,
IEHP is working on new ideas to better
serve our members and support our
providers for tomorrow.
To learn more about IEHP,
visit www.iehp.org
©2013 Inland Empire Health Plan. All Rights Reserved. MK 01968-0113-1