2017 Affordable Care Act (ACA)/Exchange Plans. Note! Contents are subject to change and are not a guarantee of payment.
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1 2017 Affordable Care Act (ACA)/Exchange Plans Note! Contents are subject to change and are not a guarantee of payment.
2 Agenda Essential Health Benefits BlueCross BlueShield of South Carolina ACA/Exchange Plans BlueChoice HealthPlan ACA/Exchange Plans Covered Drug List Utilization Management Transition of Care ACA Updates Helpful Tips for Small Group Exchange Members Resources Questions 2
3 Essential Health Benefits 10 Categories of Benefits 1. Ambulatory patient services 6. Prescription drugs 2. Emergency services 7. Habilitative and rehabilitative services and devices 3. Hospitalization 8. Laboratory services 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 9. Preventive and wellness services and chronic disease management 10.Pediatric services, including vision care 3
4 BlueCross ACA/Exchange Plans: Small Group Plans Plans are offered through the Federally Facilitated Marketplace (FFM) and private marketplaces to businesses with 2 50 employees. Product Name(s) Alpha Prefixes Network(s) Business BlueEssentials SM ZCR and ZCV Preferred Blue PPO Network Prescription Drug Plan Four tier plan with drug card and mail service benefits managed through CVS/caremark Compound drugs require prior authorization as of Jan. 1, 2017 CVS/caremark is an independent company that administers pharmacy benefits on behalf of BlueCross and BlueChoice Vaccination Network Vaccinations for flu, pneumonia and other illnesses are available at CVS pharmacies without a copay Available under member s medical benefit Requirement for Referral to Specialist Precertification No referral required Verify benefits and eligibility requirements, and initiate a prior authorization request using My Insurance Manager.
5 BlueCross ACA/Exchange Plans: Small Group ID Cards 5F
6 BlueCross ACA/Exchange Plans: Small Group Plans Business BlueEssentials members have a sustained health benefit that provides benefits for preventive screenings. Benefits are applied to preventive services and screenings that are not covered 100 percent under the United States Preventive Service Task Force (USPSTF) guidelines. $ benefit maximum Examples: Preventive/screening CBC (complete blood count) testing, vitamin D tests and chest X rays (when not performed for diagnostic purposes). 6
7 BlueCross ACA/Exchange Plans: Individual Plans These are non grandfathered plans that offer a core package of benefits and services. Product Name(s) Alpha Prefixes Network(s) Prescription Drug Plan Vaccination Network Requirement for Referral to Specialist Precertification BlueEssentials SM ZCF, ZCQ and ZCU BlueEssentials Network (EPO) Four tier plan with drug card and mail service benefits managed through CVS/caremark and uses the Advanced Choice Network TM Compound drugs require prior authorization as of Jan. 1, 2017 Vaccinations for flu, pneumonia and other illnesses are available at CVS pharmacies without a copay Available under member s medical benefit No referral required Verify benefits and eligibility requirements, and initiate a prior authorization request using My Insurance Manager.
8 BlueCross ACA/Exchange Plans: Individual Plans ID Cards BlueEssentials is a line of individual plans BlueCross offers using the BlueEssentials network. This network is unique to these plans. Alpha Prefixes ZCU Individual Private ZCF Individual FFM ZCQ Individual FFM Members do not have out of network or out of state benefits. 8
9 BlueCross ACA/Exchange Plans: Individual Plans Each plan includes limited dental and limited vision benefits for all members not just children. Vision services are available through Vision Service Plan (VSP)* and include: One exam per benefit period with a $25 copayment for a VSP provider (adults 20 or older). One exam per benefit period with a $25 copayment (members 19 or younger) $50 copay for glasses/frames for children (lenses every year, frames every two years) Preventive dental benefits include: One exam every six months ($27 allowance first visit and $20 on the second) One cleaning every six months ($40 allowance for adults 20 or older and $31 for children) *VSP is an independent company that offers eye care benefits on behalf of BlueCross and BlueChoice. 9
10 BlueCross ACA/Exchange Plans: Individual Plans Members have a Wellness Plus+ benefit that provides an additional benefit toward preventive screenings. Applies towards preventive services and screenings that are not covered 100 percent under the USPSTF guidelines. $ benefit maximum Examples: Preventive/screening CBC testing, vitamin D tests and chest X rays (when not performed for diagnostic purposes). 10
11 BlueChoice ACA/Exchange Plans: Small Group Plans These are non grandfathered plans that offer a core package of benefits and services. Product Name(s) Alpha Prefixes Network(s) Prescription Drug Plan Vaccination Network Requirement for Referral to Specialist Precertification BusinessADVANTAGE ZCL and ZCG ADVANTAGE Network (PPO) Six tier plan with drug card and mail service benefits through CVS/caremark Compound drugs require prior authorization as of Jan. 1, 2017 Vaccinations for flu, pneumonia and other illnesses are available at CVS pharmacies without a copay Available under member s medical benefit No referral required Verify benefits and eligibility requirements, and initiate a prior authorization request using My Insurance Manager.
12 BlueChoice ACA/Exchange Plans: Small Group Plans Business Advantage SM plans are a line of small group plans BlueChoice offers to businesses with two to 50 employees. These plans use the existing BusinessADVANTAGE network. Alpha Prefixes ZCL Small Group Private ZCG Small Group FFM 12
13 BlueChoice ACA/Exchange Plans: Individual Plans These are non grandfathered plans that offer a core package of benefits and services. Product Name(s) Alpha Prefixes Network(s) Prescription Drug Plan Vaccination Network Requirement for Referral to Specialist Precertification Blue Option ZCJ Blue Option Network (EPO) Six tier plan with drug card and mail service benefits managed through CVS/caremark and use Advanced Choice Network Compound drugs require prior authorization as of Jan. 1, 2017 Vaccinations for flu, pneumonia and other illnesses are available at CVS pharmacies without a copay Available under member s medical benefit No referral required Verify benefits and eligibility requirements, and initiate a prior authorization request using My Insurance Manager.
14 BlueChoice ACA/Exchange Plans: Individual Plans Blue Option is a line of individual plans BlueChoice offers. The network name indicates that the Blue Option Network is being used. Alpha Prefix ZCJ Individual Private Members do not have out of state or out of network benefits. 14
15 Important Reminder: BlueChoice plans are no longer offered through the FFM Became effective Jan. 1, 2017 Members that had the alpha prefix ZCX opted for a comparable BlueEssentials plan on the FFM or a private ACA plan 15
16 Covered Drug List You can review our 2017 Covered Drug List for both BlueCross and BlueChoice plans on our websites Caremark handles prior authorization questions about: Step therapy Formulary exceptions 16
17 Utilization Management You must get prior authorization for certain services. Failure to get prior authorization may result in claim denial. Prior authorization is not a guarantee that we will cover the service. Benefits are subject to patient eligibility. Verify benefits and eligibility through My Insurance Manager from the BlueChoice or BlueCross website provider sections. 17
18 Utilization Management Types of service or treatment that require authorization include: Hospital admission, including maternity notifications Skilled nursing facility (SNF) admission Continuation of a hospital stay or SNF for a medical condition Outpatient radiation therapy (through NIA) Nuclear cardiology (through NIA) Outpatient hysterectomy or septoplasty Home health care or hospice services Dialysis Certain labs (through Avalon) National Imaging Associates (NIA) is an independent organization that provides radiology services on behalf of BlueCross and Blue Choice. Avalon is an independent organization that provides laboratory services on behalf of BlueCross and BlueChoice. 18
19 Utilization Management Types of service or treatment that require authorization include: Durable medical equipment, when the purchase price or rental is $500 or more Admissions for habilitation, rehabilitation and/or human organ and/or tissue transplants Treatment for hemophilia Mental health and substance use disorders Certain prescription drugs and specialty drugs Advanced radiological services (through NIA) Breast reconstructive surgeries 19
20 Transition of Care Form If a BlueEssentials or Blue Option member is under the care of a physician who is not in the network, the member can request special consideration to have us apply benefits as innetwork using this form. UM may approve a member to continue care with the out of network provider for a specified time. The member must complete the request prior to services and the request must be approved in order to be covered. Members are responsible for the difference between the amount the health plan pays for those services and what the provider charges. The form is available in the Member sections of and (shown). 20
21 ACA Updates All ACA/Exchange plans require prior authorization for compound drugs as of Jan. 1, ACA requires health insurance plans to cover certain drugs at no charge, including: Aspirin Oral Fluoride Agents Female Contraceptives Vaccines Folic Acid Tobacco Cessation Products Iron Supplements Coverage of these medications, including those that are over thecounter (OTC), require a prescription from a licensed health care provider. 21
22 Helpful Tips For Small Group Exchange Members Are You Eligible to See Small Group Members? If you are a provider who is in the But not in the You can still service members who have Because benefits are payable at Preferred Blue PPO Network BlueEssentials Network BlueCross Small Group Preferred Blue PPO (ZCV or ZCR) Preferred Blue PPO Network rates Business Advantage Network Blue Option Network Business Advantage (ZCL or ZCG) BlueChoice Network rates 22
23 Resources We have three medical policies that address ACA preventive benefits. or You can also refer to our Preventive Care Guide for details about applicable ACA preventive benefits. We will continue to add or update information as we get new regulations or further guidance from the federal government. 23
24 Other Helpful Resources ID Card Guide Frequently Asked Questions 2017 ACA/Exchange Plans presentation Visit or to find these resources and more. 24
25 Questions? 25
26 26
2016 Health Insurance Marketplaces (Exchanges) Note! Contents are subject to change and are not a guarantee of payment.
2016 Health Insurance Marketplaces (Exchanges) Note! Contents are subject to change and are not a guarantee of payment. Essential Health Benefits 10 Categories of Benefits 1. Ambulatory patient services
Health Insurance Marketplaces (Exchanges)
Health Insurance Marketplaces (Exchanges) Essential Health Benefits Starting in 2014, non-grandfathered health plans in the individual and small group markets, within the Health Insurance Marketplace (exchanges),
2015 Health Insurance Marketplaces (Exchanges)
2015 Health Insurance Marketplaces (Exchanges) Affordable Care Act (ACA) Affordable Care Act (ACA) Essential Health Benefits Benefits include services in 10 categories: 1. Ambulatory patient services 2.
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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 https://eoc.anthem.com/eocdps/fi or by calling (855) 333-5735.
Important Questions Answers Why this Matters: $50 person/$150 family per year. What is the overall deductible?
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 New Castle County Government : Blue Choice PPO Coverage for: Individual/Family
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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 PacificSource.com/montana/small-group-plan-details-2017Jan