Member benefit changes and clarifications for commercial members

Home

Administrative

Billing & Reimbursement

TitleWeb
Member benefit changes and clarifications for commercial members

November 16, 2018

Effective January 1, 2019, 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
Air ambulance transport	HMO POS/DPOS EPO PPO	Language for air ambulance transport has been updated to clarify that nonemergency air transport may be covered when medically necessary. In addition, the language about reasonable distance was removed.
Ambulatory surgical center	HMO POS/DPOS EPO PPO	The definition of ambulatory surgical center has been updated for consistency with the definition used by the Commonwealth of Pennsylvania and to distinguish ambulatory surgical center from outpatient hospital.
Consumable medical supplies	HMO POS/DPOS EPO PPO	Language has been updated to distinguish consumable medical supplies from durable medical equipment to more clearly explain the benefits. In addition, exclusion language has been updated to remove ACE bandages.
Emerging technology	HMO POS/DPOS EPO PPO	Language has been added to allow Independence to determine if a provider is eligible for reimbursement to perform covered services that are considered emerging technology.
Nutritional foods ? Additives	HMO POS/DPOS EPO PPO	Exclusion language for additives has been updated to list NeoSure, Scandishake, and oral probiotics as additives.
Oral surgery ? Dental	HMO POS/DPOS EPO PPO	Language has been added to clarify that when oral surgery services are paid for by Independence, but those services were available and should have been paid for by the member?s dental plan, Independence has the right to seek recovery from the provider.
Outpatient mental health	HMO POS/DPOS EPO PPO	The definition of the outpatient mental health benefit has been expanded to include telehealth.
Payments to out-of-network providers	PPO	Language has been added to state that Independence reserves the right to make payments directly to out-of-network providers.
Telemedicine services	HMO POS/DPOS EPO PPO	Language for telemedicine services has been updated to include primary care providers as eligible providers.
Termination of in-network hospital or skilled nursing facility	EPO PPO	Language has been clarified and updated to remove the statement that a hospital or skilled nursing facility would continue to provide services to a member if the provider?s contract was terminated.

Effective January 1, 2019, the following changes apply to members with an Independence prescription drug benefit:

Type of benefit/service	Plans affected	Change/clarification
Authorized generics	HMO POS/DPOS EPO PPO	The definitions of generic and brand-name drugs have been updated, and new language has been added to define authorized generic drugs and clarify that those drugs are excluded from the generic tier. Authorized generics are brand-name drugs that are marketed without the brand name on its label and sold by the brand-name drug company, or another company with the brand company?s permission. For cost-sharing purposes, authorized generics are treated as brand-name drugs.
Coordination of benefits	HMO EPO PPO	Language has been updated to remove the statement that coordination of benefits does not apply to pharmacy plans.
Out-of-pocket accumulations	HMO POS/DPOS EPO PPO	Language has been added to clarify that if a member uses a drug manufacturer?s coupon or patient assistance program to get a prescription at either no cost or a reduced cost, the dollar value covered by the manufacturer will not be applied to the member?s deductible (if applicable) or to the member?s out-of-pocket maximum.
Refill thresholds	HMO	Language has been updated to remove refill thresholds for prescription refills from the ?Prescription Drug Limitations? section.