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: $6,350Family: $12,700Once 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, the process differs depending on whether the member has been migrated. The steps are outlined below.
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.
Figure 1
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.
Figure 2
Figure 3
Figure 4
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.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,
ibxpress.com.
NaviNet® is a registered trademark of NaviNet, Inc., an independent company.