What providers need to know as coverage for new plans becomes effective

The Patient Protection and Affordable Care Act (also known as Health Care Reform) is bringing unprecedented change to the health care industry. Under Health Care Reform, AmeriHealth New Jersey offers health plans both on and off the Health Insurance Marketplace (Marketplace) to small groups and individuals for coverage as of January 1, 2014. These commercial plans are covered under your current Provider Agreement and are reimbursed in accordance with your payment rates for commercial products.

Frequently Asked Questions

Q. What specific benefit packages is AmeriHealth New Jersey offering on the Marketplace?
A. Individuals and small groups can choose from a variety of health insurance plans, including HMO (Health Maintenance Organization), POS (Point-of-Service), and EPO (Exclusive Provider Organization) plans, as well as more affordable versions of these plans, such as EPO plans with a health savings account (HSA) or tiered network. Plans that are available on the Marketplace are also available for purchase off of the Marketplace (i.e., directly through AmeriHealth New Jersey). Plans fall into one of four metallic tiers (Platinum, Gold, Silver, Bronze).

The following table lists plans available to individuals and small groups both on and off the Marketplace. Coverage for these plans began as early as January 1, 2014. Individual Health Care (IHC) plans Small Employer Health (SEH) plans IHC POS Plus (a no-referral POS plan) SEH POS IHC EPO SEH POS Plus (a no-referral POS plan) IHC EPO HSA SEH EPO IHC HMO Plus (a no-referral HMO plan) SEH EPO HSA IHC HMO (new HMO product that provides comprehensive coverage) SEH HMO Plus (a no-referral HMO plan) IHC Tier 1 Advantage (tiered network plan) SEH HMO IHC Cooper Advantage (tiered network plan) SEH Tier 1 Advantage (tiered network plan) IHC Catastrophic Plans (AmeriHealth Simple Saver Regional Preferred, AmeriHealth Simple Saver Local Value) SEH Cooper Advantage (tiered network plan)

All AmeriHealth New Jersey plans available through the Marketplace cover the ten essential health benefits that are required by Health Care Reform:

• preventive, wellness, and disease management services (e.g., annual physical, flu shot, gynecological exam, birth control);
• emergency care;
• ambulatory services (e.g., minor surgeries, blood tests, X-rays);
• hospitilization;
• maternity and newborn services (i.e., care through the course of a pregnancy, delivery of the baby, and check-ups after the baby is born);
• pediatric services (includes dental and vision);
• prescription drugs;
• laboratory services (blood tests);
• mental health and substance abuse services;
• rehabilitation and habilitation services (e.g., physical therapy, speech therapy, occupational therapy).

In addition, AmeriHealth covers certain designated preventive services with no cost-sharing (i.e., copayments, coinsurance, and deductibles) when received from a participating provider, such as wellness visits, immunizations, screenings for cancer, and other diseases. That means that members will not pay any cost-sharing for these services. For more information about services covered as preventive care, go to our Medical Policy site and review Medical Policy #00.06.02: Preventive Care Services.

Q. How can providers verify eligibility and benefits for plans purchased on the Marketplace?
A. Just as you would for existing AmeriHealth New Jersey products, continue to verify member eligibility and benefits (including cost-sharing amounts) for plans purchased on the Marketplace through the NaviNet^? web portal. Be sure to obtain a copy of the member?s current ID card at every visit to ensure that you submit the most up-to-date information to AmeriHealth.

Q. What will the member ID cards look like if members purchase an AmeriHealth New Jersey plan via the Marketplace?
A. Member ID cards for plans purchased on the Marketplace will contain the same information as ID cards for non-Marketplace plans, which includes member name, member ID number, provider network (e.g., Value Network), coverage effective date, basic copayment information, and indicators for benefits such as vision and pharmacy. There are no differences in ID cards for plans purchased on or off the Marketplace.

Note: For the Tier 1 Advantage and Cooper Advantage tiered plans, the member ID card will indicate the plan name, and copayment information will be listed by provider benefit tier level.

Resources available to you and your patients

Your patients, our members, may require more information to understand Health Care Reform. To help, we have created a web page devoted exclusively to the topic of Health Care Reform. We encourage you to visit this site if you or your patients have questions about Health Care Reform.

On this site, existing and prospective members can access a guide called Health Care Law & You, which includes the ABCs of health insurance, major changes for 2014, and information to help them better understand their health coverage options. If you would like a supply of our Health Care Law & You guide for display or distribution at your office/facility, please submit an online request or call the Provider Supply Line at 1-800-858-4728. A Spanish version of the guide is also available.

If you have specific questions about submitting claims for members with coverage under the new products listed in this article, please contact your Network Coordinator or Hospital/ Ancillary Services Coordinator.

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