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Member benefit changes and clarifications for commercial members  

October 30, 2015    


Effective January 1, 2016, unless otherwise noted, the following member benefit changes and clarifications will be implemented for several commercial programs for Independence members:
Type of benefit/servicePlans affectedChange/clarification
Value-based programs reimbursement disclosure languagePPO – All Language is being updated to include value-based programs reimbursement disclosure language that explains the range of pricing arrangements for claims for services received outside a member’s plan service area.
Bariatric surgery* (weight loss surgery) HMO – All
POS – All
DPOS – All
PPO – All
Language is being added to include a reference to bariatric surgery as a surgical treatment for obesity when certain requirements are met. Also being added is language to clarify that weight loss surgery to treat any medical condition (e.g., diabetes) is limited to one surgery per lifetime.
Specialty drug list HMO – All
POS – All
DPOS – All
PPO – All
Language is being revised to indicate the changes made to the list of injectable/infusion therapy drugs for which members covered under a commercial plan (non-Medicare Advantage plan) are required to pay cost-sharing. The drugs on this list are covered under a member’s medical benefit and are typically administered by a health care provider. The cost-sharing amount will be collected at the provider’s office or facility each time the drug is administered. The actual cost-sharing amount is based on the terms of the member’s benefit contract. The updated drug list is available on our website or by calling 1-800-ASK-BLUE. Members should review the list at their earliest convenience and discuss any questions with their providers.
Preventive care*HMO – All
POS – All
DPOS – All
PPO – All
Language is being added about Affordable Care Act (ACA) preventive care requirements. The new language directs members to visit our website to view the most up-to-date list of preventive services that the ACA requires Independence to cover, which will be available on January 1, 2016.
Medical foods* HMO – All
POS – All
DPOS – All
PPO – All
Major Medical – All
CMM – All
Language is being updated regarding coverage of medical foods to clarify the items that are excluded from coverage.
Diabetic supplies* HMO – AllLanguage is being updated to clarify that diabetic supplies that are not available at a pharmacy may be purchased from a durable medical equipment (DME) provider and will be subject to the plan’s DME cost-sharing.
Exclusion for amounts payable by Medicare (Applies only to Medicare-eligible individuals who do not enroll in Medicare)HMO – All
POS – All
DPOS – All
PPO – All
Language is being added to indicate that for purposes of this program exclusion, coverage is not available for a service, supply, or charge that is “payable under Medicare” when the member is eligible to enroll for Medicare benefits, regardless of whether the member actually enrolls for, pays applicable premium for, or maintains, claims, or receives Medicare benefits. The amount excluded for these claims will be either the amount “payable under Medicare” or the applicable plan fee schedule for the service, at the discretion of the plan.

* Visit our Medical Policy Portal to review the medical and/or claim payment policies for these benefits/services.
Change is effective January 1, 2017.

Please call Customer Service at 1-800-ASK-BLUE with any questions.





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