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/service | Plans affected | Change/clarification
|
|---|
| Value-based programs reimbursement disclosure
language | PPO ? 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 ? All | Language
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.