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
currently cannot exceed the following amounts:
- Individual: $6,350
- Family: $12,700
In addition, the out-of-pocket limit for essential health benefits includes
cost-sharing for medical services only.
Changes for 2015
Beginning January 1, 2015, in addition to medical services,
the out-of-pocket limit for essential health benefits will also include
cost-sharing for prescriptions, pediatric dental services, and pediatric vision
services for those members whose benefits include these services.
Also beginning January 1, 2015, the annual limits will be changed to the
following amounts:
- Individual: $6,600
- Family: $13,200
How to verify if members have reached their out-of-pocket maximum
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. Please note that, 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 should first
select the Additional Copays link to verify the copayment maximums,
and second 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.
If you have any questions about these upcoming changes, 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.