Effective January 1, 2012, 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
Air or ground ambulance
All HMO, All POS,
All DPOS
Language is being added to this benefit to permit HMO/POS members to be
transferred back into the service area via air or ground ambulance for covered
rehabilitative care after an out-of-area emergency.
Appeals
All HMO, All POS,
All DPOS, All PPO, Traditional
Language is being revised to comply with Health Care Reform.
Benefit period calendar year vs. contract year
All HMO, All POS,
All DPOS, All PPO
Language is being clarified to clearly state whether the group?s benefit period
is the contract year or calendar year in the group and member?s Schedule of
Benefits and that a calendar year is from January 1 through December 31.
Capitated laboratory
services
All HMO, All POS,
All DPOS
Language is being added to clarify that laboratory services are covered
capitated services.
Dependents to 26
All HMO, All POS,
All DPOS, All PPO, Traditional
Language is being revised in our policy for removing dependents who have
reached the maximum age.
Discretionary language
All HMO, All POS,
All DPOS, All PPO, Traditional
Language is being added to clarify that IBC has the discretion to interpret
benefit plans and to determine whether or not a member is entitled to benefits.
Durable medical
equipment ? safety
equipment
All HMO, All POS,
All DPOS, All PPO
Language is being added to clarify that ?equipment for safety? is not
considered durable medical equipment because it is not primarily medical in
nature and is not covered.
Genetic testing
All HMO, All POS,
All DPOS, All PPO
Language is being clarified to bring it into alignment with the evolving field
of genetic testing.
Medical Policy defined
All HMO, All POS,
All DPOS, All PPO
Language is being added to clarify that Medical Policy is
used to determine whether covered services are medically
necessary.
Nutrition counseling and diabetic education Effective December 1, 2011
All HMO
Language is being revised to state that HMO referral
requirements for nutrition counseling and diabetic education are being removed.
Preventive care
immunizations
All HMO, All POS,
All DPOS, All PPO
Language is being added to state that a full list of pediatric and adult
immunization schedules can be found by accessing the Advisory Committee on
Immunization Practices website.
Reliable Evidence
All HMO, All POS,
All DPOS, All PPO
Language is being added to clearly identify what is considered appropriate
Reliable Evidence in determining whether a drug, biological, product, device,
medical treatment, or procedure is Experimental/Investigational.
Retroactive terminations
Effective March 1, 2012
All HMO, All POS,
All DPOS, All PPO,
Traditional
Language is being revised to reflect the changes to the period of time in which
IBC will retroactively terminate members.
Rosa?s Law ? Federal mandate
All HMO, All POS,
All DPOS, All PPO,
Traditional
Language will comply with Federal law that requires that the terms ?mental
retardation? and ?retarded? be replaced with the term ?intellectual disability.?
If you have questions regarding these benefits changes and clarifications,
please call Customer Service at 1-800-ASK-BLUE.