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Benefits changes and clarifications for commercial members
Professional; Facility; Ancillary
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Effective January 1, 2013, unless otherwise noted, the following member
benefits changes and clarifications will be
implemented for several commercial programs for Pennsylvania members:
Type of service
Plans affected
Change/clarification
Group premium change
All HMO, All POS, All PPO
Language is being revised to allow Independence Blue Cross premium adjustment
flexibility at any time during the
course of the benefit year upon mutual consent, not just on the anniversary
dates. Note: This change applies only to fully
insured contracts.
Podiatry capitation removal
All HMO, All POS
Language is being revised to remove capitation from Podiatry. Members with HMO
and POS products will have access to any podiatrist in the network with the
required referral. DPOS products will not require a referral.
Amendments to termination provisions
of contracts
All HMO, All POS, All PPO
Language is being revised to allow flexibility for termination of group
contracts and migration to other plans. Note: This
change applies only to fully insured contracts.
Timely filing for PPO claims
All PPO
To be consistent across all managed care products, the time frame for
commercial PPO members to submit a claim is being reduced from 24 months to 12
months.
Urgent Care Centers
All HMO, All POS, All PPO
New definitions and descriptions of the terms Urgent Care Center and Retail
Clinic are being added to member booklets and contracts.
Women?s Preventive Health
All HMO, All POS, All PPO
As required by the Patient Protection and Affordable Care Act, language is
being updated to state that preventive care
services for women are now covered at 100 percent. The new language will
include the following clarifications:
All FDA-approved contraceptive methods are covered at the in-network level with
no cost-sharing under the medical component and at the generic level under the
pharmacy component of coverage at retail and mail-order pharmacies.
Comprehensive lactation support and counseling during pregnancy and/or
postpartum period with no in-network cost-sharing are covered. One hundred
percent coverage for the in-network rentals of breast pumps is also provided
(subject to precertification).
Appeals process
All HMO, All POS, All PPO, All Traditional
The appeals process is being updated to reflect the external review process as
required by the Patient Protection and
Affordable Care Act.