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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
cannot exceed the following amounts:
- Individual: $6,350
- Family: $12,700
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.
However, due to our transition to a new operating platform for AmeriHealth
Pennsylvania members, the process differs depending on whether the member has
been migrated.
For migrated AmeriHealth Pennsylvania 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 will first
need to select the Additional Copays link to verify the copayment maximums and
secondly 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 and selecting Sign Up
at the top right. If you have any questions about this change, 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, amerihealthexpress.com.
NaviNet® is a registered trademark of
NaviNet, Inc.
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