What providers need to know as coverage for new plans becomes effective

As the Patient Protection and Affordable Care Act (also known as Health Care Reform) brings unprecedented change to our industry, IBC is leading the way in transforming health care and delivering what members need to meet these new challenges. This includes innovative strategies to:

• increase flexibility and efficiency in administering health care;
• provide tools for managing costs and improving outcomes;
• establish a coordinated health care system that rewards providers for providing safe, effective care.

IBC offers new health plans both on and off the Health Insurance Marketplace (Marketplace). These commercial plans are available to small groups and individuals for coverage as of January 1, 2014. These commercial plans are covered under your current Provider Agreement and are reimbursed in accordance with your payment rates for commercial products.

Frequently Asked Questions

Q. What specific benefit packages is IBC offering on the Marketplace?
A. Individuals and small groups can choose from 13 unique health insurance plans, including PPO and HMO plans, as well as more affordable versions of these plans, such as PPO plans with a health savings account (HSA) and HMO plans with a tiered provider network. Plans that are available on the Marketplace are also available for purchase off of the Marketplace (i.e., directly through IBC). Plans fall into one of four metallic tiers (Platinum, Gold, Silver, Bronze).

The following is a list of plans available to individuals and small groups both on and off the Marketplace. Coverage for these plans began as early as January 1, 2014.

• Keystone HMO Platinum
• Keystone HMO Gold
• Keystone HMO Gold Proactive (tiered network plan)
• Keystone HMO Silver
• Keystone HMO Silver Proactive (tiered network plan)
• Keystone HMO Bronze
• Personal Choice^? PPO Platinum
• Personal Choice PPO Gold
• Personal Choice PPO Silver
• Personal Choice PPO Silver Reserve
• Personal Choice PPO Bronze
• Personal Choice PPO Bronze Reserve
• Personal Choice PPO Catastrophic

All IBC plans available through the Marketplace cover the ten essential health benefits that are required by Health Care Reform:

• preventive, wellness, and disease management services (e.g., annual physical, flu shot, gynecological exam, birth control);
• emergency care;
• ambulatory services (e.g., minor surgeries, blood tests, X-rays);
• hospitilization;
• maternity and newborn services (i.e., care through the course of a pregnancy, delivery of the baby, and check-ups after the baby is born);
• pediatric services (includes dental and vision);
• prescription drugs;
• laboratory services (blood tests);
• mental health and substance abuse services;
• rehabilitation and habilitation services (e.g., physical therapy, speech therapy, occupational therapy).

In addition, IBC covers certain designated preventive services with no cost-sharing (i.e., copayments, coinsurance, and deductibles) when the services are received from a participating provider, such as wellness visits, immunizations, screenings for cancer, and other diseases. That means that members will not pay any cost-sharing for these services. For more information about services covered as preventive care, go to our Medical Policy site and review the current version of Medical Policy #00.06.02: Preventive Care Services.

Q. How can providers verify eligibility and benefits for plans purchased on the Marketplace?
A. Just as you would for existing IBC products, continue to verify member eligibility and benefits (including cost-sharing amounts) for plans purchased on the Marketplace through the NaviNet^? web portal. Be sure to obtain a copy of the member?s current ID card at every visit to ensure that you submit the most up-to-date information to IBC.

Q. What will the member ID cards look like if members purchase an IBC plan via the Marketplace?
A. Member ID cards for plans purchased on the Marketplace will contain the same information as ID cards for non-Marketplace plans, which includes member name, member ID number, provider network (i.e., Keystone Health Plan East, Personal Choice), coverage effective date, basic copayment information, and indicators for benefits such as vision and pharmacy. There are no differences in ID cards for plans purchased on or off the Marketplace.

Note: For our Keystone HMO Proactive plans, the member ID card will indicate "Gold Proactive" or "Silver Proactive," and copayment information will be listed by provider benefit tier level (i.e., Preferred, Enhanced, Standard).

Q. How does Keystone HMO Proactive differ in terms of pricing from other IBC plans being offered on the Marketplace?
A. Keystone HMO Proactive is a tiered network product being offered at both the Silver and Gold metallic tier levels. The 2014 premiums for Keystone HMO Proactive are priced approximately 15 percent lower than comparable HMO products within the Silver and Gold metallic tiers.

Resources available to you and your patients

Your patients, our members, may require more information to understand Health Care Reform. To help, we have created a comprehensive website devoted exclusively to the topic of Health Care Reform. We encourage you to visit this site if you or your patients have questions about Health Care Reform.

On this site, existing and prospective members can access a guide called Health Care Law & You, which includes the ABCs of health insurance, major changes for 2014, and information to help them better understand their health coverage options. If you would like a supply of our Health Care Law & You guide for display or distribution at your office/facility, please submit an online request or call the Provider Supply Line at 1-800-858-4728. A Spanish version of the guide is also available.

If you have specific questions about submitting claims for members with coverage under the new products listed in this article, please contact your Network Coordinator.

NaviNet^® is a registered trademark of NaviNet, Inc., an independent company.