PPO PLANS DISCLOSURE FORM Blue Cross and Blue Shield of Arizona Effective on and after January 1, 2012

Transcription

1 PPO PLANS DISCLOSURE FORM Blue Cross and Blue Shield of Arizona Effective on and after January 1, 2012 This form applies to the following plans: BluePreferred 100/50, BluePreferred 90/70, BluePreferred 80/60, BluePreferred 70/50, BluePreferred HSA Plus 100, BluePreferred HSA Plus 90, BluePreferred HSA Plus 80, BluePreferred HSA Plus 70, BluePreferred Copay, BluePreferred Copay 100%, BluePreferred Saver 80%, BluePreferred Original, BluePreferred Basic, Blue Solutions and BlueEssential. PLEASE READ THIS NOTICE CAREFULLY. IT CONTAINS IMPORTANT INFORMATION YOU SHOULD KNOW BEFORE YOU ENROLL. This Disclosure Form is only a summary. Review the Benefit Book to determine governing contractual provisions. A. PRIMARY CARE PHYSICIANS ROSTER A provider directory listing primary care physicians, specialists, facilities and all other PPO providers is available on request and online at the BCBSAZ web site, azblue.com. Members do not have to select a primary care physician to receive covered services. B. PREMIUM 1. State the full premium cost of the plan: Refer to the attached Premium Rate Information Sheet. 2. State any reservations by the Plan to change premium and any factors that may affect changes in premium: Refer to the attached Premium Rate Information Sheet. 3. State the minimum employer contribution and group participation rules: Refer to the attached Premium Rate Information Sheet. C. HOW AND WHERE TO OBTAIN SERVICES 1. Where and in what manner a member may obtain services: General Provisions A PPO member may receive services from any licensed, eligible health care provider. Eligible provider types are listed in the member s benefit book, and generally do not include naturopathic or homeopathic physicians. PPO benefit plans have a network of hospitals and other health care providers that are contracted with BCBSAZ to provide health services. When a member uses PPO network providers, out-of-pocket costs are generally lower than if using noncontracted providers. PPO network providers will accept the BCBSAZ allowed amount for covered services, and file claims with BCBSAZ. The BCBSAZ allowed amount is the amount payable by or through BCBSAZ for a covered service, including any contractual arrangements and amounts payable by the member, i.e., deductibles, coinsurance, access fees or copayments. 1

2 Noncontracted providers have not agreed to accept the BCBSAZ allowed amount, are not required to file claims for members, and may bill members for full billed charges, which can be significantly more than the BCBSAZ allowed amount. Referrals to Out-of-Network Providers BCBSAZ does not guarantee that every specialist or facility will be included in the PPO network. When there is no PPO network specialist or facility available to provide covered services, BCBSAZ may precertify the member to receive services from an out-ofnetwork provider at in-network cost-sharing. This precertification is separate from any precertification already required for a particular procedure or service. The member s treating provider must obtain precertification from BCBSAZ for both the procedure or service (if required), and for the in-network cost-sharing before the member receives services from the out-of-network provider. In-network cost sharing means the services will be subject to the in-network deductible (if there are separate deductibles) and paid at the in-network coinsurance percentage; also, the member s coinsurance will count toward the in-network out-of-pocket coinsurance maximum out-of-pocket maximum. Even if BCBSAZ precertifies services with an out-of-network provider at the innetwork cost-sharing, the member is still responsible for the difference between the provider s billed charges and the BCBSAZ allowed amount. An out-of-network provider s charges may be significantly higher than the BCBSAZ allowed amount. A member should ask the provider about this difference before receiving services. If BCBSAZ does not precertify the out-of-network services, expenses for covered services will be paid at the out-of-network cost-sharing. Continuing Physician Care from an Out-of-Network Physician (MD or DO) You may be able to receive benefits at the in-network level for services provided by an out-of-network Arizona physician, under the circumstances described below. Continuity of care benefits are subject to all other applicable provisions of your benefit plan. Continuity of care applies only to otherwise covered services, rendered by doctors of medicine and osteopathy, who are located in Arizona. Continuity of care is not available for facility services. If the hospital or other facility at which your physician practices is not an in-network facility, out-of-network benefits will apply to the facility s services. New Members A new member may continue an active course of treatment with an outof-network Arizona physician during the transitional period after the member s effective date if: The member has: 1. A life-threatening disease or condition, in which case the transitional period is not more than thirty (30) days from the effective Current Members A current member may continue an active course of treatment with an out-of-network Arizona physician if BCBSAZ terminates the physician from the network for reasons other than medical incompetence or unprofessional conduct, if The member has: 1. A life-threatening disease or condition, in which case the transitional period is not more than thirty (30) days from the 2

3 date of coverage; or 2. Entered the third trimester of pregnancy on the effective date of coverage, in which case the transitional period includes the covered physician services for delivery and any care that is related to the delivery for up to six (6) weeks from the delivery date; and effective date of the physician s termination: or 2. Entered the third trimester of pregnancy on the effective date of the physician s termination, in which case the transitional period includes the covered physician services for delivery and any care that is related to the delivery for up to six (6) weeks from the delivery date; and The member s physician agrees in writing to do all of the following: 1. Accept the BCBSAZ allowed amount applicable to covered services as if provided by an in-network physician, subject to the deductible, coinsurance and copay requirements of this benefit plan; 2. Provide BCBSAZ with any necessary medical information related to your care; and 3. Comply with BCBSAZ s policies and procedures, as applicable, including precertification, network referral, claims processing, quality assurance, and utilization review. 2. Whether services received outside of Arizona are covered and in what manner the services are covered: This plan covers services received outside of Arizona. If a member receives covered services outside of Arizona from a provider that participates as a PPO provider with the local Blue Cross and/or Blue Shield (BCBS) plan, benefits are paid at the innetwork level. Except for emergencies, amounts for covered services received outside of Arizona from a provider who does not participate as a PPO provider with the local BCBS plan are applied to the out-of-network deductible and paid at the out-of-network level. Out-of-state emergency services are covered at the in-network level of benefits, except that the member is responsible for the balance bill if the member receives emergency services from a noncontracted provider. Members may access PPO network providers in other states through the BlueCard Program by calling BLUE or by checking the BlueCard Doctor and Hospital finder online at bcbs.com. A member may also call BLUE when traveling outside of the United States for help in locating an international provider, to assist with foreign language translation and to submit claims. 3. The locations of contracted hospitals and outpatient treatment centers: Please consult the provider directory on our web site at azblue.com. 4. In the case of a network plan, a map or list of areas served: The BCBSAZ PPO network covers the state of Arizona. Please consult the provider directory on our web site at azblue.com 3

4 D. PRE-AUTHORIZATION AND REFERRAL PROCEDURES 1. The procedures a member must follow, if any, to obtain prior authorization for services: Precertification is required under PPO plans for certain services. If precertification is required, the member s treating provider must call BCBSAZ to get precertification before the member receives the service or treatment. BCBSAZ may require the provider to submit medical records or other information to support the request. The member is responsible, however, for making sure the provider obtains precertification when required. Precertification is not a pre-approval or a guarantee of payment. Precertification made in error by BCBSAZ does not constitute a waiver of any right of BCBSAZ to deny payment for noncovered services. If precertification is not obtained, benefits may be denied or a member will be required to pay a precertification charge as indicated in the benefit book. 2. The procedures to be followed by the member for consulting a physician other than the primary care physician: A member is not required to get a referral before seeing any specialist who is an eligible provider as defined by BCBSAZ. Precertification is required to see an out-of-network specialist at in-network costsharing (see Subsection (C)(1) above). 3. Whether the member s physician, the Plan s medical director or a committee must first authorize the referral: No authorization is required for specialist referrals except when the member is seeking precertification for an out-of-network specialist at in-network cost-sharing. (see Subsection (C)(1) above). 4. The necessity of repeating prior authorization if the specialist care is continuing: Not required for ongoing specialist care. Additional precertification may be required for certain inpatient stays if the initial precertification was for a fixed period of time or a certain number of services. 5. The circumstances under which the Plan may retroactively deny coverage for non-emergency treatment that had prior authorization under the Plan s written policies: When your provider requests precertification, BCBSAZ reviews whether coverage is active, whether the treating provider or location of service is within the appropriate network and the applicability of other benefit plan provisions (waiting periods, limitations, exclusions, benefit maximums). Some of these provisions may not be readily identifiable at the time precertification is given, but will still apply if discovered later in the claim process after services have been provided. During the precertification process, BCBSAZ may review certain procedures or treatments for medical necessity, based on applicable medical coverage guidelines and other medical information. Precertification is not a pre-approval or a guarantee of payment. Precertification made in error by BCBSAZ does not constitute a waiver of any right of BCBSAZ to deny payment for non-covered services. BCBSAZ may determine that precertification was made in error, and retroactively deny coverage if BCBSAZ received inaccurate or incomplete information about the services to be provided. Sometimes employers notify BCBSAZ that a member has lost eligibility after BCBSAZ precertifies a service. BCBSAZ may retroactively deny coverage if the member was not eligible for benefits at the time services were rendered 6. Whether a Point of Service option is available and how it is structured: BCBSAZ does not offer a Point of Service option. 4

5 E. EMERGENCY CARE 1. Circumstances under which prior authorization is required for emergency medical care: Precertification is not required for emergency services. 2. Whether and where the Plan provides twenty-four hour emergency services: Benefits are available for covered emergency services 24 hours a day at contracted and noncontracted hospitals. 3. Procedures for emergency room, nighttime or weekend visits and referrals to specialist physicians: Members should proceed to the nearest emergency room or call 911 if emergency services are needed. No referrals are necessary. Benefits for covered services received after initial emergency treatment are paid the same as nonemergency covered services. If a member needs treatment for a condition that is not an emergency but requires prompt medical attention, the member may be able to receive treatment during the evenings or weekends at a free-standing (not on a hospital campus) BCBSAZcontracted Urgent Care Center. The member will pay the urgent care cost-sharing amount applicable to his or her benefit plan each time the member visits a BCBSAZcontracted Urgent Care Center. 4. The circumstances under which the Plan may retroactively deny coverage for emergency medical treatment that had prior authorization under the Plan s written policies: BCBSAZ does not require precertification or prior authorization of emergency medical treatment. BCBSAZ may deny coverage if the member was not eligible for benefits at the time services were rendered. F. PRESCRIPTION MEDICATIONS 1. Whether the Plan physician is restricted to prescribing medications from a Plan list or Plan formulary: Providers rendering services to BCBSAZ members are not limited to a prescription medication formulary. 2. The extent to which a member will be reimbursed for the costs of a medication that is not on the Plan list or Plan formulary: BCBSAZ does not have a Plan formulary. Most BCBSAZ plans have a tiered medication benefit so that most medications are available at tiered cost share levels. Under some BCBSAZ plans, members pay deductible and coinsurance for covered medications. BCBSAZ generally covers prescription medications that are FDA approved and meet BCBSAZ quantity, age and gender limitations, with limited exclusions for certain drugs such as weight loss drugs and drugs for sexual dysfunction. Medications that do not meet these criteria are denied as noncovered services. BCBSAZ does not reimburse members for the costs of medications that are not covered medications, with the exception of offlabel use of certain medications when required by applicable Arizona law for the treatment of cancer. G. GRIEVANCE PROCEDURES/APPEALS PROCESS Grievance procedures for claim and treatment denials, creditable coverage determinations. dissatisfaction with care and access to care issues: Members and their treating providers may participate in all levels of the appeal process, which is described in detail in the Health Coverage Appeal Information Packet, a separate document provided to you. You may view the appeals process on line or request an 5

6 information packet at any time. Below is a summary of those issues that can be appealed, and those that are not subject to the appeal process but can be reviewed through the BCBSAZ Grievance Process. Claim and Treatment Denials: Subject to the BCBSAZ appeals process. You can appeal the following decisions: 1. BCBSAZ* does not approve a service that you have or your treating provider has requested, but that you have not yet received. 2. BCBSAZ* does not pay for a service that you have already received. 3. BCBSAZ* does not authorize a service or pay for a claim because it is not medically necessary or because BCBSAZ has determined that it is experimental or investigational. 4. BCBSAZ* does not authorize a service or pay for a claim because it is not covered under your insurance policy, and you believe it is covered. 5. BCBSAZ does not precertify a referral to a specialist. 6. Where precertification for a service is required by your benefit plan, BCBSAZ* does not approve or deny your precertification request within ten (10) business days. *The chiropractic benefits administrator (CBA) handles appeals and grievances related to chiropractic services. If your plan offers behavioral and mental health services through the behavioral services administrator (BSA), the BSA handles the first level of appeals relating to services provided by the BSA. You cannot appeal the following decisions, but may be able to challenge them through the grievance process described below: Although the decisions listed below are not appealable under state law, you and/or your authorized representative may have the right to dispute some of the following types of decisions under federal law or the right to submit a grievance through the BCBSAZ Grievance Process, which is explained further below. 1. You disagree with BCBSAZ s decision as to the amount of the BCBSAZ allowed amount. 2. You disagree with how BCBSAZ or the CBA is coordinating benefits when you have health insurance with more than one insurer. 3. You disagree with how BCBSAZ or the CBA has applied your claims to your plan deductible. 4. You disagree with the amount of coinsurance or copayments that you paid. 5. You disagree with BCBSAZ s decision upon completion of a possible nondisclosure investigation. 6. You are dissatisfied with any rate increases you may receive under your insurance. 7. You believe BCBSAZ has violated any other parts of the Arizona Insurance Code. Types of Appeal: Expedited and Standard Expedited Appeals are for urgently needed services not yet received. Your provider must certify that proceeding under the time frames for a standard appeal will seriously jeopardize your life, health or ability to regain maximum function, or subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. Standard Appeal (for non-urgent services or denied claims) 6

7 Levels of Appeal: Both expedited and standard appeals have three levels of review. If you are dissatisfied with the decision at one level, you can appeal up to the third level, which is external independent review. At each level, you need to provide BCBSAZ* with information about the decision you disagree with, what you think BCBSAZ* should do differently, and records and information that support a different decision. Level 1 Expedited Medical Review Level 2 - Expedited Appeal Level 3 - Expedited External Independent Review Level 1 Informal Reconsideration Level 2 Formal Appeal Level 3 External Independent Review Grievance Process: For disputes about cost share, payment, access to care and other issues. If you have a disagreement that is not subject to the Appeal Process, you may direct a complaint or reconsideration request to BCBSAZ or the CBA. Your complaint or reconsideration request must be made to BCBSAZ or the CBA within one (1) year of the occurrence. These time limits may be extended by BCBSAZ or the CBA in its sole and absolute discretion for good cause. Examples of good cause include a death in the immediate family or serious illness of you or someone in your immediate family. Good cause does not include travel for any reason other than death or serious illness. BCBSAZ or the CBA will then review all available information and notify you of a decision within thirty (30) days of receipt for pre-service issues and within sixty (60) days of receipt for claims and other post services issues. The 30 or 60-day limit may be extended if necessary and in accordance with applicable law, and you will be notified if for any reason the 30 or 60-day time period will not be met. If you are not satisfied with the initial decision, you may send a written request for a second level grievance review to BCBSAZ or the CBA. You must file your request for a second level review within sixty (60) days of receiving the initial decision. The written grievance must state your reason for the grievance, including the reason for dissatisfaction with the initial decision, and any additional information for review. BCBSAZ or the CBA will review your grievance and notify you of the final decision within sixty (60) days of receiving your grievance. Complaints about creditable coverage If you believe that BCBSAZ has not properly credited you for prior coverage, you may contact BCBSAZ Enrollment services. If you are unable to resolve your complaint, you may file a grievance as described above. Complaints about quality of care Providers in the BCBSAZ network are independent contractors exercising independent medical judgment. However, if you are concerned about the quality of care you received from a PPO network provider, please contact customer service so we can refer your complaint for investigation by the BCBSAZ Clinical Quality Department. 7

8 H. PLAN PROVIDER REQUIREMENTS AND COMPENSATION Whether Plan provider compensation programs include any incentives or penalties that are intended to encourage plan providers to withhold services or minimize or avoid referrals to specialists. Whether the Plan provider must comply with any specified numbers, targeted averages, or maximum duration of patient visits. If these types of incentives or penalties are included, provide a concise description of them: BCBSAZ provider compensation does not include any incentives or penalties to encourage plan providers to withhold services or minimize or avoid referrals to specialists. BCBSAZ does not require plan providers to comply with any specified numbers, targeted averages or maximum durations of patient visits. BCBSAZ standard plans do not require referrals to specialists. I. EXPLANATION OR JUSTIFICATION FOR USE OF INCENTIVES AND PENALTIES Not applicable. J. DESCRIPTION OF BENEFITS RENEWABILITY OF COVERAGE 1. Whether services outside the plan are covered and in what manner they are covered: Description of Benefits: See attached Benefit Summary. See also above response in Section C (1). To be covered, a service must be all of the following: a benefit of the plan; rendered by an eligible provider acting within the provider s scope of practice, as determined by BCBSAZ. (You may call the BCBSAZ Customer Service Department for a provider s eligibility status); not excluded; precertified where precertification is required; medically necessary as determined by BCBSAZ; not experimental or investigational as determined by BCBSAZ; and provided while the benefit plan is in effect and while the person claiming benefits is eligible for benefits. 2. In concise and specific terms, any copayment, coinsurance or deductible requirements that a member or member s family may incur in obtaining coverage under the plan: See attached Benefit Summary for cost-sharing amounts. Additional information is also available in the benefit book, provided at enrollment or prior to enrollment upon request. 3. The health care benefits to which a member would be entitled: See attached Benefit Summary for a description of benefits and cost-sharing amounts. A complete description of benefits and services is contained in the benefit book provided at enrollment or prior to enrollment upon request. Benefits of this plan are available only for covered services received while this benefit plan is in effect and the member claiming benefits is eligible for coverage under this benefit plan and the group s contract with BCBSAZ. Benefits may be modified during the term of the plan as specifically provided under the terms of group s contract. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to covered services processed on or after the effective date of the modification. There is no vested right to receive the benefits of the benefit plan. 8

9 4. Renewability of coverage: The group master contract controls the administration of the group coverage. Coverage terminates when the group master contract terminates. The group must renew the contract each year in order for coverage to continue. Failure of the group to return the rate acceptance form, intent to renew or other required form, on or before the last day of the current contract will be deemed a rejection of an offer to renew the group master contract and the contract will terminate as of the date specified in the contract. It is the responsibility of the group to notify employees and dependents if the group terminates the group master contract or if the group master contract is terminated for non-payment of premiums. BCBSAZ will notify employees if the group master contract is terminated for any other reason. BCBSAZ may terminate its contract with the group immediately at any time only for the reasons set forth in the Group Master Contract. K. LIMITATIONS AND EXCLUSIONS THAT APPLY TO SERVICES AND BENEFITS List all limitations and exclusions that have not already been disclosed in another section. Specifically include any pre-existing condition exclusions or limitations or any affiliation period requirements: See attached benefit summary for information on preexisting conditions and a list of conditions and services that are limited or excluded. Expenses for services that exceed benefit limitations are not covered. Detailed information about benefits, limitations and exclusions is in the benefit plan booklet and is available prior to enrollment, upon request. AN 11 MONTH WAITING PERIOD FOR PRE-EXISTING CONDITIONS MAY APPLY FOR MEMBERS AGE 19 AND OLDER. A pre-existing condition is defined as a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) month period immediately preceding the member s enrollment date. 9

10 PREMIUM INFORMATION AND CONTRIBUTION & PARTICIPATION REQUIREMENTS FOR GROUPS WITH 2-99 PARTICIPANTS / EMPLOYEES ( POOLED GROUPS ) INCLUDING SMALL GROUPS OF 2-50 ELIGIBLE PARTICIPANTS General Information: Rates for groups with 2-99 participants/employees are based on BCBSAZ pool (community) rates. Participant means the individual who is eligible for enrollment in the plan due to his or her affiliation with the group, and is most commonly the employee of an employer who is sponsoring the group health plan. Pool rates are developed from the claims experience of all insured groups with 2-99 eligible participants/employees. The pool claims experience is used to develop a medical base rate, which is then adjusted to reflect each of the benefit plan designs offered to groups within the pool. New groups: A new group s medical rates are developed using the eligible enrolling population, on the group s original effective date. The enrolling population s age/gender distribution is applied to BCBSAZ s medical base rates. The resulting rates are then adjusted based on the information provided by the group, its participants/employees, or other sources. Renewing groups: A group s renewal rates are developed using the group s enrolled population prior to the group anniversary date. The corresponding age/gender distribution is applied to BCBSAZ medical base rates. The resulting age/gender rates are then adjusted based on the information previously provided by the group, its participants/employees or other sources. The final renewal rates may include further adjustment(s) based on group specific claims experience or newly emerging medical conditions. General Factors that Impact Rates New and Renewing Groups: Rating factors may include but are not limited to: Industry Geographic area Group size COBRA participation (if applicable) Employer-defined eligibility criteria Health status of the group and its individual members (see further explanation below) Duration of coverage (applicable to renewing groups) Broker commissions (see further explanation below) Impact of claims experience and health status on groups with 2-50 eligible employees/participants; compliance with A.R.S (C): New Groups: Rates may be adjusted based on the group s health status (actual or expected variation in claims costs or health conditions). This factor may cause the rate to be above or below the established index rate by no more than 60%. The index rate means the arithmetic average of the lowest premium rate and the corresponding highest premium rate for groups with the same case characteristics, effective date, and benefit plan. Renewing groups: The maximum annual increase attributable to a group s health experience or duration of coverage will not exceed 15%. This may not represent the total amount of the renewal rate action because rate renewal can also reflect changes to base rates due, for example, to general claims and medical trends. Impact of Broker Commissions: BCBSAZ sells its insurance and other health and dental coverage products either directly or through licensed insurance brokers, some of whom are BCBSAZ employees. Generally BCBSAZ pays commissions and/or other incentives to selling 10

11 brokers, and includes this cost as a factor in calculating premiums. For groups with 2-50 eligible employees/participants, BCBSAZ does not calculate premiums differently - based on whether a product is sold by a broker or sold by BCBSAZ directly. For groups with 51 or more eligible employees/participants, BCBSAZ adjusts premiums to reflect actual commissions paid for the group, if the commission payment varies from BCBSAZ s standard commission schedule. Rate changes: BCBSAZ may change rates when any one of the following occurs: on a plan s anniversary date; prior to the anniversary date if the enrolled membership changes by more than 10%; during the policy period if the employer changes contribution levels or eligibility requirements; if the government imposes a new tax or fee on group health plans or insurers, or requires coverage of additional benefits; and, after giving the group a sixty (60) day written notice. Any changes will be in accordance with the rating policies described above. Group/Employer Contribution and Participation Requirements: A group must contribute a minimum of 50% of the participant/employee medical premium. BCBSAZ may require documentation (e.g., payroll deduction records) of compliance with contribution requirements. If a group contributes 100% of participant/employee medical premium, BCBSAZ requires 100% participation of eligible participants/employees, excluding those with other qualifying medical coverage. If a group contributes less than 100% of the participant/employee medical premium, BCBSAZ requires 75% participation of eligible participants/employees. Employees excluded from participation requirements: To determine whether a group meets the participation requirements, BCBSAZ does not count participants/employees who have other qualifying medical coverage. Qualifying medical coverage in accordance with A.R.S (B)(3) and (C) includes Medicare, Champus, AHCCCS, Indian Health Services, and coverage available through a spouse s or parent s medical plan. All participants/employees desiring to waive coverage for themselves and/or their dependents must indicate the waiver on the application for health coverage. Those participants/employees who are covered by other group health plans must also indicate the type of coverage on the application. D /12 11