Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Reminder: Out-of-pocket maximums for commercial HMO, POS, and PPO members

May 30, 2014

Under the Patient Protection and Affordable Care Act, also known as Health Care Reform, members should not becharged any cost-sharing (i.e., copayments, coinsurance, and deductibles) once their annual out-of-pocket limit foressential health benefits has been met. These limits are based on the member's benefit plan. While individual andgroup benefit limits may be lower, they cannot exceed the following amounts:

  • Individual: $6,350
  • Family: $12,700

Once members have reached their out-of-pocket maximum for essential health benefits, providers should not collectadditional 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. However, due to ourtransition to a new operating platform, the process differs depending on whether the member has been migrated. Thesteps are outlined below.

For migrated members

Once on the Eligibility and Benefits Details screen, the member's current out-of-pocket expense (AccumulatedAmount) and the maximum dollar limit (Threshold Amount) will be displayed at the bottom of the screen in the BenefitAccumulator section.

For non-migrated members

Once on the Eligibility and Benefits Details screen, providers will first need to select the Additional Copays link toverify the copayment maximums and secondly select the Dollar Accumulators link to view the total out-of-pocketamount accumulated to date.

If your office is not yet NaviNet-enabled, you can sign up by going to NaviNet and selecting Sign Up at thetop right.

If you have any questions about this change, please call Customer Service at 1-800-ASK-BLUE. If you have questionsregarding 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 securemember website.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.