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Verifying cost-sharing for Vital Care Program members 

July 31, 2017    

As previously communicated, the Vital Care Program is a voluntary pilot program offered by Independence to members of Keystone 65 Select HMO and Keystone 65 Preferred HMO who have been diagnosed with both congestive heart failure and diabetes.

The Vital Care Program is part of the Value-Based Insurance Design (VBID) test model, which is a new initiative that the Centers for Medicare & Medicaid Services is conducting and regulating through the Center for Medicare & Medicaid Innovation. It is designed to increase the quality and decrease the cost of care for beneficiaries in Medicare Advantage plans. Specific to this program is a reduced copayment for VBID-eligible members when they visit their cardiologist, endocrinologist, or podiatrist. The lower cost-share can help make these visits more affordable, encouraging members to see their specialists more regularly to help better manage their care.

Under the Vital Care Program, the 2017 reduced copayments for specialist office visits are as follows:

  • Endocrinologist and Cardiologist: $10 copayment
  • Podiatrist: $5 copayment; $5 copayment also applies to both Medicare-covered and six routine podiatry visits per year

Eligible members are automatically enrolled into the program, but they may opt out if they choose to do so. There are no additional participation requirements. Since both Keystone 65 Select HMO and Keystone 65 Preferred HMO are HMO plans, referrals are still required from the primary care physician for a specialist visit.

Identifying Vital Care Program members

Eligible members are issued an ID card that indicates they are enrolled in the Vital Care Program and will receive a written summary of benefits (the “Notice of VBID Benefits”). The copayment amount for specialists is listed as “varies” on the member’s ID card as shown.

Please be sure to use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to verify the member’s information at the time of service to ensure the correct copayment is being collected.

From the Eligibility and Benefits Details screen, select Professional (Physician) Visit – Outpatient from the Benefits section to view the appropriate copayments for endocrinologist and cardiologist services.

Select Podiatry from the Benefits section to view the appropriate copayment for podiatrist services.

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