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Benefits changes and clarifications for commercial members 

November 1, 2011    


Effective January 1, 2012, unless otherwise noted, the following member benefits changes and clarifications will be implemented for several commercial programs for Pennsylvania members:
Type of service Plans affected Change/clarification
Air or ground ambulance All HMO, All POS, All DPOS Language is being added to this benefit to permit HMO/POS members to be transferred back into the service area via air or ground ambulance for covered rehabilitative care after an out-of-area emergency.
Appeals All HMO, All POS, All DPOS, All PPO, Traditional Language is being revised to comply with Health Care Reform.
Benefit period calendar year vs. contract year All HMO, All POS, All DPOS, All PPO Language is being clarified to clearly state whether the group’s benefit period is the contract year or calendar year in the group and member’s Schedule of Benefits and that a calendar year is from January 1 through December 31.
Capitated laboratory services All HMO, All POS, All DPOS Language is being added to clarify that laboratory services are covered capitated services.
Dependents to 26 All HMO, All POS, All DPOS, All PPO, Traditional Language is being revised in our policy for removing dependents who have reached the maximum age.
Discretionary language All HMO, All POS, All DPOS, All PPO, Traditional Language is being added to clarify that IBC has the discretion to interpret benefit plans and to determine whether or not a member is entitled to benefits.
Durable medical equipment — safety equipment All HMO, All POS, All DPOS, All PPO Language is being added to clarify that “equipment for safety” is not considered durable medical equipment because it is not primarily medical in nature and is not covered.
Genetic testing All HMO, All POS, All DPOS, All PPO Language is being clarified to bring it into alignment with the evolving field of genetic testing.
Medical Policy defined All HMO, All POS, All DPOS, All PPO Language is being added to clarify that Medical Policy is used to determine whether covered services are medically necessary.
Nutrition counseling and diabetic education Effective December 1, 2011 All HMO Language is being revised to state that HMO referral requirements for nutrition counseling and diabetic education are being removed.
Preventive care immunizations All HMO, All POS, All DPOS, All PPO Language is being added to state that a full list of pediatric and adult immunization schedules can be found by accessing the Advisory Committee on Immunization Practices website.
Reliable Evidence All HMO, All POS, All DPOS, All PPO Language is being added to clearly identify what is considered appropriate Reliable Evidence in determining whether a drug, biological, product, device, medical treatment, or procedure is Experimental/Investigational.
Retroactive terminations Effective March 1, 2012 All HMO, All POS, All DPOS, All PPO, Traditional Language is being revised to reflect the changes to the period of time in which IBC will retroactively terminate members.
Rosa’s Law — Federal mandate All HMO, All POS, All DPOS, All PPO, Traditional Language will comply with Federal law that requires that the terms “mental retardation” and “retarded” be replaced with the term “intellectual disability.”

If you have questions regarding these benefits changes and clarifications, please call Customer Service at 1-800-ASK-BLUE.

Note: This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Plan (HMO, PPO, etc.), and/or employer group. HMO and PPO member coverage can be verified by calling Customer Service at 1-800-ASK-BLUE.





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