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PPACA and our tiered network products  

August 29, 2013    


As the Patient Protection and Affordable Care Act of 2010 (PPACA) brings unprecedented change to our industry, IBC is leading the way in transforming health care and delivering what members need to meet these new challenges. This includes innovative strategies to:

  • increase flexibility and efficiency in administering health care;
  • provide tools for managing costs and improving outcomes;
  • establish a coordinated health care system that rewards providers for providing safe, effective care.

Under PPACA, each state is required to establish a Health Insurance Marketplace by January 1, 2014. Health Insurance Marketplaces are a new way for certain consumers to buy health insurance. They will offer a choice of different health plans for those who buy their own individual and/or small group coverage, certify health plans that participate, and provide information to help consumers better understand their health coverage options.

IBC will participate in the federally facilitated Health Insurance Marketplace for Pennsylvania by providing various commercial products that are covered under your current Provider Agreement and will be reimbursed in accordance with your payment rates for commercial products. These commercial products will be available beginning January 1, 2014, and will include lower-cost tiered provider network products named Keystone HMO Proactive.

Keystone HMO Proactive

We want to help members become informed consumers of health care by making them aware that there are cost differences among providers in our network for the same service depending on the physician or facility they choose. Our tiered Keystone HMO Proactive products recognize this, assigning all hospitals, primary care physicians (PCP), specialists, and ancillary providers (including sleep study, home health, dialysis centers, and ambulatory surgical centers) in our HMO network to one of three benefits tiers:

  • Tier 1 - Preferred: Members pay the lowest cost-sharing for most services.
  • Tier 2 - Enhanced: Members pay a higher cost-sharing for most services compared to Tier 1 - Preferred.
  • Tier 3 - Standard: Members pay the highest cost-sharing for most services.

Benefit tier placement

Benefit tier placement for Keystone HMO Proactive is based upon specific criteria that vary by provider type:

  • PCPs: Criteria include contracted fee schedule (i.e., relative cost), minimum quality criteria (where applicable), and hospital and outpatient surgical utilization (i.e., the facilities where members associated with a provider office location receive care when available).
  • Specialists: Criteria include contracted fee schedule (i.e., relative cost) as compared to other network providers in their specialty and hospital and outpatient surgical utilization, when available.
  • Ancillary providers: Placement is based upon their contracted fee schedule (i.e., relative cost) as compared to other network providers in their specialty.
  • Hospitals: Placement is based on how their average costs for inpatient and outpatient services compared to the average cost for inpatient and outpatient services across our network hospitals.

Providers in our HMO network have been sent their benefit tier placement for the 2014 calendar year by mail. IBC will re-evaluate the benefit tier placements each year and will provide advance written notice of any changes that will become effective on January 1 of the following year.

For more information

If you have questions about these new products or about your benefit tier placement, please contact your Network Coordinator.





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