Reference Based Benefits (RBB) Questions and Answers (Revised 12/2/2015)

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1 Reference Based Benefits (RBB) Questions and Answers (Revised 12/2/2015) What is the Reference Based Benefits program? In a Reference Based Benefits (RBB) Program, insurers, such as Anthem, establish a price point that will be the maximum amount the plan will cover for certain common medical services that have wide cost variations. These common procedures typically have low complication rates and can be scheduled in advance. By choosing providers whose charges fall at or below the benefit maximum, members can save money. The RBB program s online tools, including Estimate Your Cost, Anthem Care Compare and Find a Doctor, provide members the information needed to compare options and find local high quality providers at the best price. If a member chooses a provider whose charges exceed the RBB price point, the member may be responsible for the difference. The primary goal of RBB is to encourage member consumerism and wise use of plan resources. What procedures will be included in CVT s RBB design? Effective 10/1/2015, the following inpatient procedures will be subject to the RBB design: Hip Replacement Knee Replacement Laminectomy (back surgery) Hysterectomy What plans will be affected by RBB? RBB will only be implemented on Anthem PPO plans (excluding Medicare plans). Blue Shield of California does not offer a RBB design at this time. What are the price points or benefit maximums and how are they set? A reference price point or benefit maximum is the dollar amount limit that CVT will pay for certain inpatient procedures. Reference price points vary by procedure and regional cost (determined by the first 3-digits of the patient s residential zip code). Developing reference price points based on geography ensures the price points take into account variations in cost that occur geographically within California. Reference price points for each inpatient procedure are set at the 50th percentile for each geography, based on Anthem s National Consumer Cost tool. The 50th percentile simply means that 50% of the providers in the geographic area will perform the surgery for a cost at or below the price point. How does a member find out how much a provider charges for an RBB procedure? 1

2 There are two options: 1) members can visit anthem.com/ca and select Useful Tools to find a link to Estimate Your Cost. This will allow members to see cost averages for providers in their area, out of pocket responsibility, and other useful information and (2) CVT members can work directly with a customer service representative from our dedicated Anthem unit to find an appropriate RBB provider. Step-by-step instructions for the Estimate Your Cost tool are included at the end of this FAQ. What if the provider the member wants charges more than the benefit maximum? Members can choose an in network provider that charges more than the maximum, but they will have to pay for any facility charges above the reference price. For instance, if the regional benefit maximum for a given procedure is $20,000, and the facility the member chooses charges $22,000, in addition to the member s deductible, copays, and coinsurance, they will also pay the $2,000 overage. Overages are not subject to the member s OOP Max. Are there exclusions to the RBB program? Yes. The RBB program does not apply to: emergency claims; claims for a procedures associated with a cancer diagnosis; claims for dependents under the age of 18; claims associated with complicated procedures and multiple surgeries, such as double hip or knee replacements; or claims where another carrier is primary. Where can the member get more information? CVT s website will have page in the member section will additional information. Members can also call Anthem at for a dedicated RBB Anthem team member who will assist them. 2

3 How do I access Anthem s Estimate Your Cost tool? Step 1: Log into (registration required), then click on the Estimate Your Cost link at the top of the page or on the right side panel. 3

4 Step 2: Once you are in the Estimate Your Cost Screen, enter the location (City/State/Zip) of your residence, distance/mile radius, and name of the procedure. A brief description of the selected procedure will appear. Click the Search Cost Estimates button. A pop-up box will appear with the Cost Estimate Terms of Use agreement. You must read and agree to these terms before you will be able to access cost information. 4

5 Step 3: The tool will display a sortable listing of providers with the total estimated costs for the selected procedure. This includes estimates for You pay, which automatically takes into consideration amounts that have been applied to any applicable deductible or out-of-pocket maximum. 5

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7 Step 4: Once you have selected a provider by clicking on the link, click the Procedure Estimate link to view additional details regarding the cost estimate, such as deductible, coinsurance and Overage, which is the amount exceeding the reference price point. 7