SUMMARY OF CONTRACT CHANGES

Transcription

1 SUMMARY OF CONTRACT CHANGES Alaska Insured Non-Grandfathered Group Plans (51-99 employees) For renewals from January 1, 2014 to December 1, 2014 Premera Blue Cross Blue Shield of Alaska has made changes to medical plans for Alaska groups that will take effect at your upcoming renewal. This summary lists the major changes and also shows which changes are mandated by federal or state law or regulation. Not all the changes listed may apply to your plan or plans. Please see your contract for details. MEDICAL BOOKLETS Location Description of Change Reason for Change All benefits If non-emergency care services are received from any out-of-network provider when there isn t an in-network provider located within 50 miles of the member s home, those services are now covered at the in-network level. The member is still responsible for any amounts over the allowable charge. We suggest that the member contact us before receiving non-emergency care from an out-of-network provider. We have clarified that when a member receives care from non-network providers for State mandate Clarification covered stays at in-network hospitals and has no choice as to who provides that care, those services are covered at the in-network level. The member is still responsible for any amounts over the allowable charge. What Do I Need to Know Before I Get Care? The waiting period for pre-existing conditions has been removed. If your plan includes copays for medical services, these copays will count towards your plan s out-of-pocket maximum. However, copays for prescription drugs, adult vision exam and hearing exam do not count towards your plan s out-of-pocket maximum. What Are My Benefits? The annual plan maximum has been removed. A few benefits will continue to have their own annual or lifetime maximums as allowed by law. Ambulance Services benefit Autism Spectrum Disorders Services benefit We clarified that any air ambulance transport for a non-emergent condition is subject to the standard plan cost shares based on the whether the air ambulance is in-network or out-of-network. The state of Alaska now requires that coverage be provided for autism spectrum disorders. A new Autism Spectrum Disorders Services benefit has been added to the plan. For members under the age of 21, coverage is provided for medically necessary treatment, services or supplies related to autism disorders and is not subject to any benefit limits. Services provided by autism service providers or a provider supervised by an autism service provider are covered under this new benefit for members under the age of 21. State mandate Page ( ) An Independent Licensee of the Blue Cross Blue Shield Association

2 Location Description of Change Reason for Change Chemical Dependency We have added specific exclusions about services and programs that don't qualify for Treatment benefit coverage. Clinical Trials benefit (previously Cancer Clinical Trials) Contraceptive Management and Sterilization benefit Medical Equipment and Supplies benefit (breast pumps only) Preventive Care benefit (women's preventive care) Prescription Drugs benefit (prescription contraceptive drugs and devices) Contraceptive Management and Sterilization benefit Preventive Care benefit (BRCA genetic testing and Fall Prevention) Per the Affordable Care Act, non-grandfathered plans are required to provide coverage for national clinical trials for life-threatening conditions beginning with plan years on or after 1/1/2014. Member cost-shares do not apply to preventive women's health services furnished by network providers. Member cost-shares still apply for out-of-network providers. We have added additional preventive benefits based on new guidance. Prescription Drugs benefit Diagnostic Services benefit Surgical Services benefit Infertility Services benefit Medical Equipment and Supplies benefit Mental Health Care benefit Preventive Care benefit We have clarified that full anesthesia delivered by an anesthesiologist is covered only if there are specific risk factors or likelihood of complications or intolerance to moderate anesthesia. For plans that cover infertility testing and treatment: We have clarified that testing prior to an infertility diagnosis is covered under the Diagnostic Services benefit. Testing after an infertility diagnosis has been established is covered under the Infertility benefit. The benefit states that it will now cover sales tax on covered items. We have added specific exclusions about services and programs that don't qualify for coverage. The benefit now covers whooping cough immunizations at a pharmacy, grocery store or other mass immunizer location. Clarification Clarification ( ) Page 2

3 Location Description of Change Reason for Change Clarification has been added that laboratory and pathology services related to colonoscopy and sigmoidoscopy are covered under the Diagnostic Lab and X-ray benefit. Clarification has been added that generic emergency contraceptives are covered under the HCR Preventive drug list, and Plan B emergency contraceptives are covered and subject to the applicable Prescription Drug cost share. We have clarified that this benefit covers travel immunizations. We have clarified that when preventive care is received at a hospital based clinic or a hospital based physician s office, the member must pay the medical cost-shares when there are any extra facility charges. Clarification Clarification Prescription Drugs benefit Vision benefit (mandated) Vision Hardware benefit Care Management BlueCard Program and Other Inter-Plan Arrangements All plans now include a prescription drug benefit. A member can request an early refill for topical eye medication when prescribed for a chronic eye condition. The plans no longer limit benefits for certain specified drugs to specific pharmacies. This does not apply to specialty drugs that are required to be dispensed by specialty pharmacies. The benefits for the mandate vision benefit have changed. Please refer to the State- Mandated Benefit Offerings page of this document. We have clarified that any applicable sales tax, shipping and handling charges for covered items are included in the hardware benefit maximum. Your plan now requires Premera Blue Cross Blue Shield of Alaska to approve certain medical services before a member receives the care. This is called prior authorization. We have added prior authorization language to the member s benefit booklet. The Benefit Level Exception has been deleted and is now replaced by the Prior Authorization provision. We have added the Clinical Review section to outline how we determine medical necessity. We have revised our Non-Network Providers section to align with our network pricing methodology. State mandate State mandate State mandate Premera pricing policy What's Not Covered? Assisted reproduction procedures, regardless of the reason. We have clarified that the exclusion for felonies does not apply to a victim of domestic Clarification ( ) Page 3

4 Location Description of Change Reason for Change violence. Who Is Eligible For Coverage? Subscriber Eligibility Dependent Eligibility Certificate of Health Coverage COBRA Special Enrollment What If I Have A Question or An Appeal? Employees and dependents do not have to be U.S. citizens or live in the U.S. to be eligible for coverage. If your plan requires employees to wait more than 60 days for coverage to start: The Affordable Care Act allows a maximum of 90 calendar days. However, in order to allow for groups' enrollment options, Premera's longest probationary period option will be 60 calendar days. This is because more than just the probationary period counts toward the 90 day limit. If a plan requires employees to wait for coverage to start until the first of the month that follows the date the probationary period ended, those additional days must also be counted toward the 90-day maximum. In addition, the maximum period cannot be extended beyond 90 days to allow for 31-day months, weekends, or holidays. The new maximum also applies to employees who started their probationary period before the group's 2014 renewal. The plan can no longer exclude a child who is younger than age 26 from coverage if the child is eligible for other group coverage that is not through a parent. Foster children of the subscriber or spouse are now eligible for coverage. There must be a court order or other order signed by a judge or state agency which grants guardianship of the child to the subscriber or spouse as of a specific date. When the court order terminates or expires, the child is no longer an eligible child. We have clarified that a member may receive credit toward any waiting period for preexisting conditions if the new plan includes one. In the COBRA section, we have clarified that covered dependent grandchildren have the same rights to COBRA coverage as do covered dependent children. The Involuntary Loss Of Other Coverage section has been changed to state that when we receive the employee and/or dependent s completed enrollment application and any required subscription charges within 60 days of the date other coverage ended, coverage under this plan will become effective on the first of the month following the date the other coverage was lost. We have clarified who can enroll when a dependent is added through birth, adoption or marriage. We have clarified that a Level II appeal requires that the appeal reviewer must hold the same professional license as the treating provider. State mandate ( ) Page 4

5 EMPLOYER AGREEMENT Location Description of Change Reason for Change BlueCard Program and Other We have revised our Non-Network Providers section to align with our network pricing Premera pricing policy Inter-Plan Arrangements methodology. Retroactive Changes To Enrollment Compliance With Law We have revised the Return of Overpayments section to state that the full recovery amount must be received and applied by the Host Blue as stated in the contract language. Any compensation due to third parties for the recovery must be handled in a separate transaction. We revised this section to better accommodate COBRA timelines. We have added language that the group must also comply with any applicable requirements for distribution of any medical loss-ratio rebates and actuarial value requirements. Blue Cross Blue Shield Association policy to clarify the revenue stream ( ) Page 5

6 STATE-MANDATED BENEFIT OFFERINGS FOR INSURED GROUPS At each renewal, all health carriers must present the following state-mandated benefit offerings to insured groups that do not include them in their plans currently. Please review your current coverage, then indicate and initial below if you would like to upgrade to any of these optional benefits to your plan. If you would like additional information about these offerings, please contact your Premera Blue Cross representative. Benefit Vision Care Hearing Care Dental Care If Your Current Coverage Is This: Not covered or You have elected another vision care plan option (other than the mandated offering). Not covered or You have elected another hearing care plan option (other than the mandated offering). Not covered or You have elected another dental care plan option (other than the mandated offering). You Can Upgrade Coverage To This: Yes No Initials Vision Benefit Maximum - $350 per member per calendar year and includes any applicable sales tax, shipping and handling costs. Examinations - 90% of allowable charges; one examination per member each calendar year. Eyeglass Lenses - 1 pair of eyeglass lenses (single vision, bifocal, trifocal, lenticular) per member per calendar year. Contact Lenses $170 per member per calendar year Frames - one pair of frames in any 2 consecutive calendar years up to $90 per member. Hearing Examination - 80% of allowable charges (subject to plan coinsurance and deductible on High Deductible Health plans); one exam every 3 consecutive calendar years. Hearing Hardware - 80% of allowable charges (subject to plan coinsurance and deductible on High Deductible Health plans). Maximum Benefit - $800 in a period of 3 consecutive years. Calendar Year Deductible - None. Diagnostic and Preventive Services - 100% of allowable charges. Basic Services - 80% of allowable charges. Major Services - 50% of allowable charges. Dental Benefit Maximum - $1,500 per member in a calendar year ( ) Page 6

7 PLEASE NOTE: Rates will be provided upon request. OTHER PLAN CHANGES In the space below, please tell us about any other changes you want to make to your plan at this year's renewal. Please include changes in eligibility. If you have an IRS Section 125 cafeteria plan, please make sure your book explains any midyear family status changes that trigger enrollment or plan changes. Please note any change in the Group's legal name or address, or if you want to add or drop affiliates or subsidiaries from your plan ( ) Page 7

8 WOMEN S HEALTH ACT ANNUAL NOTICE TO MEMBERS Federal law requires employers to give an annual notification to plan participants of their rights under the Women s Health and Cancer Rights Act. As required by the Women s Health and Cancer Rights Act of 1998, your plan provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). Refer to your benefit booklet for more information ( ) Page 8