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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 out-of-pocket limit for
essential health benefits 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 for essential health
benefits, providers should not collect additional cost-sharing. To verify if
members have reached their out-of pocket maximum for essential health benefits,
providers should use the Eligibility and Benefits Inquiry transaction on the
NaviNet® web portal. However, due to our transition to a new
operating platform, the process differs depending on whether the member has
been migrated.
For migrated 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.
Learn More
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-ASK-BLUE. If you have questions regarding NaviNet transactions,
please call the eBusiness Hotline at 215-640-7410.
Note: Cost-sharing amounts are available to members through their
benefit materials or by logging on to our secure member website.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
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