Blues introduce new health reform compliant products

Blue Cross Blue Shield of Michigan and Blue Care Network are introducing a wide array of new health care products for individuals (those without health care coverage through an employer or other group) and small groups (with 50 or fewer full-time-equivalent employees). The new products are fully compliant with Patient Protection and Affordable Care Act regulations.

They are available for purchase starting Oct. 1, 2013, for coverage beginning Jan. 1, 2014 or later. The Blues’ individual products will be available Oct. 1 online at bcbsm.com. Oct. 1 is also the day we expect the Michigan Marketplace to open.

All of the new health care products cover the Affordable Care Act-mandated essential health benefits of the State of Michigan benchmark health care plan. For more information on essential health benefits, see the article titled "A look at essential health benefits" in the August issue of The Record.

All of the new health care products cover the same services, including:

• Office visits (including mental health and substance abuse treatment)
• Inpatient hospital days (including mental health and substance abuse treatment)
• Maternity care (pre- and postnatal, delivery and newborn care)
• Preventive services with no co-sharing, as required by the ACA
• Allergy testing and therapy
• Outpatient physical and occupational therapy is covered for a combined 30 visits per year. For BCBSM PPO plans, this includes spinal manipulation when performed by a chiropractor or osteopathic physician. BCN individual and small group products have a separate 30-visit limit per year for spinal manipulation when performed by a chiropractor or osteopathic physician.
• Outpatient speech therapy up to 30 visits per year
• Durable medical equipment, prosthetics and orthotics
• Home health care visits
• Pediatric dental benefits offered in a separate product for eligible members through the end of the plan year in which the member turns 19. Individuals and small groups need to have pediatric dental coverage. This coverage can be purchased as a separate plan from The Blues, purchased through another carrier, or the required pediatric coverage will be packaged with the medical plan.
• Pediatric vision coverage is included in all plans (for children through the end of the plan year in which the member turns 19)
• Bariatric surgery
• Sleep studies
• Additional coverage of preventive drugs
• Pharmacy coverage with additional tiers.

What differs between the new plans is:

• The amount of member cost-sharing (Higher cost-sharing results in lower premiums.)
• The provider network (HMO plans have smaller networks and can offer lower premiums.)
• Managed care (HMO plans offer lower premiums than PPO plans.)

The Blues are offering 18 new individual medical products. For small groups, we are offering a total of 46 new medical products, of which eight will be available on the Marketplace’s Small Business Health Options Program, also known as SHOP. Individuals and small groups can purchase benefits directly from the Blues, through health insurance agents, health plan advisors or through the Marketplace.

Government subsidies for qualified individuals and tax credits for small businesses are only available through the Marketplace. The Blues website has a calculator to help shoppers learn whether a subsidy or tax credit is available to them.

The new Blues individual and small group products span from lower premium, higher cost-sharing value plans up to higher premium, lower cost-sharing platinum options. We’re offering a broad array of plans so individual or small group purchasers can choose the best fit for their needs and budgets. We want you to be aware of the plans we have available so you can help your patients if they come to you for advice.

Marketplace metal levels

Five different Blues medical plans for individuals

• Blue Cross^® Multi-State, offered to Michigan residents only through the Marketplace website, has BCBSM’s PPO network with nationwide coverage. Member cost-sharing is lower when services are obtained within the network. These are the only Blues individual plans that provide medical, prescription, pediatric and adult dental and vision coverage all in one plan. Offered in silver and gold options.

• Blue Cross^® Premier has BCBSM’s PPO network with nationwide coverage. Member cost-sharing is lower when services are obtained within the network. Offered in four options: value, bronze, silver and gold.

• Blue Cross^® Preferred has BCN’s statewide HMO network. Care must be coordinated by a primary care physician. Offered in four options: value, bronze, silver and gold.

• Blue Cross^® Select has BCN’s PCP Focus HMO network. Care must be coordinated by a primary care physician. Offered in four options: value, bronze, silver and gold.

• Blue Cross^® Partnered for residents of Kent, Muskegon and Oceana counties who agree to receive care within the Mercy Health network, following BCN HMO policies, with care coordinated by a Mercy Health primary care physician. Care within BCN’s entire HMO network, but outside the Mercy Health network, requires plan authorization. More information about BCN’s Mercy Health partnership is available in the Sept.-Oct. 2013 BCN Provider News. Offered in four options: value, bronze, silver and gold.

Blues medical plans for small groups
There are many options available for small group purchase. Most are similar to products offered by the Blues in 2013, with adjustments to meet essential health benefits and other health care reform requirements. Options include familiar plans like Community Blue PPO^SM and Blue Care Network’s standard HMO, along with consumer-directed health plans such as health reimbursement arrangement options and health savings accounts, and wellness products like BCN’s Healthy Blue LivingSM and a new BCBSM Healthy Blue Achieve PPO^SM.

Features applying to the new plans Copays
The new plans have tiered copays offering lower out-of-pocket costs for office visits with a primary care physician and higher costs for specialist visits and facility care. In some cases, government subsidies can result in no copays for individual (non-group) silver plans. Cost-sharing subsidies do not apply to small group employer plans.

Coinsurance
Plans that include coinsurance have percentage cost-sharing that ranges from 10 to 60 percent. Plans that offer an out-of-network benefit include higher coinsurance costs for seeking care outside the provider network. Note that government subsidies can lower coinsurance requirements for specific members enrolled in the individual silver plans. Government subsidies do not apply to small group employer plans.

Integrated deductible for individual plans
These new individual plans have deductibles that include all medical and prescription drug expenses. This is different from most current plans, with the exception of high-deductible health plans, which have integrated deductibles today. Small group plans do not have an integrated deductible, except for the high-deductible health plans.

Out-of-pocket maximum
The new plans all have an out-of-pocket maximum. The out-of-pocket maximums include all medical and prescription drug deductibles, coinsurance and copays. Once the member reaches the out-of-pocket maximum, the member pays no further cost-sharing for the remainder of the year for covered services – including no further copays for medical services or prescription medications. Cost-sharing for dental and adult vision services is not included in the out-of-pocket maximum. There is no cost-sharing for pediatric vision. Note that government subsidies can lower coinsurance requirements for specific members enrolled in the individual silver plans. Government subsidies do not apply to small group employer plans.

Two current individual plans will stay around through 2014
Members who have a current Blues individual health care plan must move to one of the new health reform compliant plans as of Jan. 1, 2014, with two exceptions. The following two Blues individual plans are open for new enrollment until Dec. 1, 2013, and members in these non-health care reform compliant plans can remain in their plans until the end of 2014:

• BCBSM’s Keep Fit^SM
• Blue Care of Michigan’s Personal Plus^SM

These two plans keep their current benefits and cost-sharing levels through the end of 2014.

Group changes happen on the group’s 2014 plan renewal date
All group coverage must become health care reform compliant at the group’s 2014 plan year, which is typically aligned with the renewal date. Many groups renew in January, but plan years happen throughout the year so at least some non-health care reform compliant plans will be active throughout 2014.

What does this mean to health care providers?
Make sure you always check eligibility and benefits before providing services. When checking benefits, you should also check to see if patients have reached their out-of-pocket maximums. If an out-of-pocket maximum applies, it will be noted on the Medical Benefits screen on web-DENIS. If you see an out-of-pocket maximum listed on web-DENIS, it is a health care compliant out-of-pocket maximum and includes all member cost-sharing (copays, coinsurance and deductibles for both medical and pharmacy) unless otherwise noted.

When you see an out-of-pocket maximum listed, make sure you check the member’s accumulators before charging cost-sharing for services. Here’s how to do this on web-DENIS:

• Click on Subscriber Info.
• Click on Deductible/Copay and input the member’s contract number.
• Select the member’s line of business and click on Enter.
• Click on the member’s name.

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice.