[
What providers need to know as coverage for new plans becomes
effective
As the Patient Protection and Affordable Care Act (also known as Health Care
Reform) brings unprecedented change to our industry, IBC is leading the way in
transforming health care and delivering what members need to meet these new
challenges. This includes innovative strategies to:
- increase flexibility and efficiency in administering health care;
- provide tools for managing costs and improving outcomes;
- establish a coordinated health care system that rewards providers for
providing safe, effective care.
IBC offers new health plans both on and off the Health Insurance Marketplace
(Marketplace). These commercial plans are available 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 IBC offering on the
Marketplace?
A. Individuals and small groups can choose from 13 unique health insurance
plans, including PPO and HMO plans, as well as more affordable versions of
these plans, such as PPO plans with a health savings account (HSA) and HMO
plans with a tiered provider
network. Plans that are available on the Marketplace are also available for
purchase off of the Marketplace (i.e., directly through IBC). Plans fall into
one of four metallic tiers (Platinum, Gold, Silver, Bronze).
The following is a list of plans available to individuals and small groups both
on and off the Marketplace. Coverage for these plans began as early as January
1, 2014.
-
Keystone HMO Platinum
-
Keystone HMO Gold
-
Keystone HMO Gold Proactive (tiered
network plan)
-
Keystone HMO Silver
-
Keystone HMO Silver Proactive
(tiered network plan)
-
Keystone HMO Bronze
-
Personal Choice? PPO Platinum
-
Personal Choice PPO Gold
-
Personal Choice PPO Silver
-
Personal Choice PPO Silver Reserve
-
Personal Choice PPO Bronze
-
Personal Choice PPO Bronze Reserve
-
Personal Choice PPO Catastrophic
All IBC 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, IBC covers certain designated preventive services with no
cost-sharing (i.e., copayments, coinsurance, and deductibles) when the services
are 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 the current version of 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 IBC 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 IBC.
Q. What will the member ID cards look like if members purchase an IBC
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 (i.e., Keystone Health Plan East, Personal
Choice), 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 our Keystone HMO
Proactive plans, the member ID card will indicate "Gold Proactive" or
"Silver Proactive," and copayment information will be listed by provider
benefit tier level (i.e., Preferred, Enhanced, Standard).
Q. How does Keystone HMO Proactive differ in terms of pricing from
other IBC plans being offered on the Marketplace?
A. Keystone HMO Proactive is a
tiered network product being offered at both the Silver and Gold metallic tier
levels. The 2014 premiums for Keystone HMO Proactive are priced approximately
15 percent lower than comparable HMO products within the Silver and Gold
metallic tiers.
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 comprehensive website 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.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
]