Under the Patient Protection and Affordable Care Act, also known as Health Care Reform, members should not be charged any cost-sharing (i.e., copayments, coinsurance, and deductibles) once their annual out-of-pocket limit for essential health benefits has been met. These limits are based on the member?s benefit plan. While individual and group benefit limits may be lower, they currently cannot exceed the following amounts:

• Individual: $6,350
• Family: $12,700

In addition, the out-of-pocket limit for essential health benefits includes cost-sharing for medical services only.

Changes for 2015

Beginning January 1, 2015, in addition to medical services, the out-of-pocket limit for essential health benefits will also include cost-sharing for prescriptions, pediatric dental services, and pediatric vision services for those members whose benefits include these services.

Also beginning January 1, 2015, while individual and group benefit limits may be lower, the annual limits cannot exceed the following amounts:

• Individual: $6,600
• Family: $13,200

How to verify if members have reached their out-of-pocket maximum

Once members have reached their out-of-pocket maximum for essential health benefits, providers should not collect additional cost-sharing. To verify if members have reached their out-of pocket maximum for essential health benefits, providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet^® web portal. Please note that, due to our transition to a new operating platform, the process differs depending on whether the member has been migrated.

For migrated members

Once on the Eligibility and Benefits Details screen, the member?s current out-of-pocket expense (Accumulated Amount) and the maximum dollar limit (Threshold Amount) will be displayed at the bottom of the screen in the Benefit Accumulator section.

For non-migrated members

Once on the Eligibility and Benefits Details screen, providers should first select the Additional Copays link to verify the copayment maximums, and second select the Dollar Accumulators link to view the total out-of-pocket amount accumulated to date.

Learn more

If your office is not yet NaviNet-enabled, you can sign up by going to NaviNet.

If you have any questions about these upcoming changes, please call Customer Service at 1-800-275-2583 for providers in Pennsylvania and Delaware and at 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey. If you have any questions regarding NaviNet transactions, please call the eBusiness Hotline at 215-640-7410 for providers in Pennsylvania and Delaware and at 609-662-2565 for providers in New Jersey.

Note: Cost-sharing amounts are available to members through their benefit materials or by logging on to our secure member website.

NaviNet^® is a registered trademark of NaviNet, Inc.