Temporary Insurance Plans Quick Guide
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- Diane Murphy
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1 January 2019 Temporary Insurance Plans Quick Guide We re offering temporary insurance plans to help individuals under age 65 who need short-term coverage. Temporary insurance plans are based on our existing BlueOptions SM (NetworkBlue) and BlueSelect (BlueSelect network) plans. We developed this quick guide to help you understand our temporary insurance plans and how they differ from other health plans. Provider Networks Our NetworkBlue and BlueSelect provider networks are in-network for temporary insurance plans. Traditional Payment for Hospital Services/Payment for Professional Services (PHS/PPS) network pricing applies to covered out-of-network services. Benefits Please Keep in Mind: Temporary insurance plans do not have the same level of! coverage as Affordable Care Act (ACA) plans. An important difference is that they do not provide coverage for pre-existing conditions. If a member has a temporary insurance plan and is treated for an injury, illness or ongoing health condition that they had in the 24-month period before the plan effective date, they will have to pay the full cost of any care. Be sure to verify a member s benefits and eligibility electronically through Availity 1 at availity.com. Below is a high-level comparison between temporary insurance and ACA plans. Benefit Temporary Insurance Plans ACA Plans X = Not Covered = Covered Pre-existing conditions X Pediatric oral and vision care X Maternity and newborn care Only if maternity rider is purchased Preventive and wellness services Children only Habilitative services (those that help patients acquire, maintain or improve X skills necessary for daily functioning) Retail prescription drugs BlueRx Discounts SM program only Outpatient ambulatory services Emergency room services Hospitalization Mental health and substance use disorder services, including behavioral health treatment Laboratory services 1
2 Temporary Insurance Benefits Pre-existing Conditions If a member receives treatment for an injury, illness or ongoing health condition such as asthma, diabetes or cancer that they had in the 24-month period before the temporary insurance start date, they will have to pay the full cost of any care. Even if a member had a health plan that covered pre-existing conditions, pre-existing conditions are not covered under temporary insurance plans. Please see the examples below
3 Member purchases a temporary insurance plan with Florida Blue Preventive Care Services Preventive care is covered for children only up to their 17th birthday. With the exception of mammograms, adult preventive care is not covered. Preventive care for children includes: Periodic examinations including a history, physical examination and developmental assessment, and guidance necessary to monitor the normal growth and development of a child Oral and/or injectable immunizations Laboratory tests normally performed for a well child Services should be provided according to current medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics, and the U.S. Preventive Services Task Force or the Advisory Committee on Immunization Practices established under the Public Health Service Act. Medical Pharmacy Benefits Prescription drugs provided in a physician s office are covered subject to the member s medical pharmacy cost share. Note that allergy injections and immunizations are not part of the medical pharmacy benefit. 3
4 Retail Pharmacy Benefits Your patients enrolled in temporary insurance plans do not have retail pharmacy benefits. However, they do have access to the BlueRx Discounts SM program. The BlueRx Discounts program is managed on our behalf by Prime Therapeutics LLC, our pharmacy benefits manager. Through this program, discounts for prescription drugs are available at over 40,000 pharmacies across the country for drugs listed in our Care Choice Medication Guide at a discounted price. You can find the drug list at floridablue.com> Providers> Tools & Resources> Medical & Pharmacy Policies and Guidelines> Medication Guides. Maternity and Newborn Benefits Maternity and newborn benefits are not covered unless a member purchased a maternity rider along with the temporary insurance plan. Please note that a maternity rider has a separate deductible from the temporary insurance plan. Members are only eligible for this rider if a pregnancy occurs after a temporary insurance plan has been in effect for at least 30 days. Maternity rider benefits include: Physician or midwife services provided for a routine pregnancy, delivery and postpartum follow-up. Hospital or birth center services for labor and delivery of the baby, including a physical assessment of the mother and any necessary clinical tests according to current medical standards, newborn assessment, room and board for the mother, and routine nursery care. The member may also choose to deliver her baby at home. Routine nursery care for the newborn child during the covered portion of the mother s maternity stay is included under this benefit. However, when a newborn requires non-routine treatment during or after the mother s stay, the newborn is considered a patient in his or her own right and is covered only if enrolled under the mother s plan. The newborn s hospital admission in this case would be subject to separate cost share amounts according to the terms of the member contract. Member ID Cards BlueOptions and BlueSelect temporary insurance plan members have a unique ID card. Please see sample ID cards below. 4
5 Referrals and Authorizations Referrals are not required if a member needs to see a specialist. Preauthorization is not required for most inpatient or outpatient services or surgical procedures. However, we strongly recommend that you request voluntary preservice reviews. Please note that the terms and benefits of a member s contract will overrule an authorization when applicable. For example, if a health condition is determined to be pre-existing, the services will deny and the member will have to pay the full cost of the services. Certain medical services such as advanced imaging require authorization. Examples of Pre-existing Conditions Note: All services are subject to a review for pre-existing conditions. Pre-existing conditions include, but are not limited to: Alcohol and substance abuse disorders, including mental and behavioral disorders due to substance use Diseases, disorders, infections and malformations of the brain, nervous, circularity and/or respiratory systems Injuries to the abdomen, head, neck, thorax, back, spine, pelvis or genitals Neoplasms, malignant and benign Congenital malformations (e.g., musculoskeletal, genital, etc.) and chromosomal abnormalities Complications of surgical and medical care Heart disease and disorders, including hypertension and diseases of the arteries, arterioles and capillaries Organ (e.g., gallbladder, kidneys) and blood disorders Mental and behavioral diseases and disorders including birth trauma Infectious diseases including but not limited to HIV, bacterial and viral infections, influenza and pneumonia Aplastic and other anemias and other bone marrow failure syndromes Diabetes Degenerative diseases of the nervous system Cerebral palsy and other paralytic syndromes Tuberculosis 5
6 How Pre-Existing Conditions Apply to Back-to-Back Temporary Insurance Plans Policies for Three Months or Less: The look-back for pre-existing conditions will always be 24 months from the effective date of each policy. Please note that accumulators will reset between policies. Each Policy: 24-month pre-existing look-back Each Policy: 24-month pre-existing look-back For Six-Month Policies Only: To create a policy that feels more like 12 months, Florida Blue allows members to purchase two six-month policies back-to-back so that the pre-existing condition look-back is done only once. Please note that accumulators will reset between policies. Pre-existing Pre-existing conditions and accumulators restart For more information about temporary insurance policies, please refer to the Manual for Physicians and Providers at floridablue.com> Providers. 6
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Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.empireblue.com or by calling 1-800-342-9816. Important
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Important Questions Answers Why This Matters: If took HealthQuotient:
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What is the overall deductible?
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