Under the Patient Protection and Affordable Care Act, also known as Health Care
Reform, members should not be charged any cost-sharing (i.e., copayments,
coinsurance, and deductibles) once their annual limit has been met. These
limits are based on the member's benefit plan. While individual and group
benefit limits may be lower, they cannot exceed the following amounts:
Individual: $6,350
Family: $12,700
Once members have reached their out-of-pocket maximum, providers should not
collect additional cost-sharing.
To verify if members have reached their out-of-pocket maximum, providers should
use the Eligibility and Benefits Inquiry transaction on the NaviNet
?
web portal. However, due to our transition to a new operating platform for
AmeriHealth Pennsylvania members, the process differs depending on whether the
member has been migrated. The steps are outlined below.
For migrated AmeriHealth Pennsylvania members
Once on the Eligibility and Benefits Details screen, the member's current
out-of-pocket expense (Accumulated Amount) and the maximum dollar limit
(Threshold Amount) will be displayed at the bottom of the screen in the Benefit
Accumulator section.
For non-migrated members
Once on the Eligibility and Benefits Details screen, providers will first need
to select the
Additional Copays link to verify the copayment maximums
and secondly select the
Dollar Accumulators link to view the total
out-of-pocket amount accumulated to date.
If your office is not yet NaviNet-enabled, you can sign up by going to
NaviNet and selecting
Sign Up at the
top right.
If you have any questions about this change, please call Customer Service at
1-800-275-2583 for providers in Pennsylvania and
Delaware and at
1-888-YOUR-AH1 (
1-888-986-7241) for providers In New Jersey. If you have
any questions regarding NaviNet transactions, please call the eBusiness Hotline
at
215-640-7410 for providers in Pennsylvania and
Delaware and at
609-662-2565 for providers in New
Jersey.
Look for additional information about this requirement in future editions of
Partners in Health UpdateSM.
Note: Cost-sharing amounts are available to members through their
benefit materials or by logging on to our secure member website,
amerihealthexpress.com.
NaviNet? is a registered trademark of NaviNet,
Inc.