Blue Cross customers can opt for reference-based benefit designs

As part of our ongoing commitment to helping our customers and members better manage the cost of their health care, Blue Cross Blue Shield of Michigan is launching reference-based benefit designs.

These benefit designs, sometimes referred to as RBB, can be chosen by customers to supplement their current plans. They encourage members to gain as much information about certain services as possible, allowing them to take a more active role in their health care decisions.

Jan. 1, 2017, is the start date for the first customer group that has chosen this new option.
Here’s how it works:

1. Employers select certain services and “reference prices” for those services. These prices are the costs established for an episode of care based on claims data received by Blue Cross from their providers.
2. Information about these services and reference prices is shared with the employees of a particular group (the Blue Cross member).
3. When members need a service that is selected for RBB, they’ll use a vendor tool that helps them understand the cost involved and then go to a health care provider for the service.
4. Health care providers charge for the service the same way they do today.
5. Blue Cross pays up to a certain amount for the service.
6. If the health care provider offers the service at or below the reference price, Blue Cross pays the allowed amount plus any member liability.
7. If the health care provider charges an amount that exceeds the reference price, the member is responsible for the difference between the selected reference price and additional amount, plus any existing liability.

It’s important to note that RBB doesn’t modify rates or change the amount that health care providers charge for their services. Health care providers can expect to receive contracted rates on all procedures. It does, however, affect member cost share.

Example: If a member has a reference cost of $500 for an MRI of the spine and the allowable amount is $700, then Blue Cross pays up to $500 for the procedure and the member is responsible for $200.

Members with RBB will know the amount they owe by using consumer transparency tools that are part of the RBB. Providers will know the member cost share by checking web-DENIS.

As customer groups choose RBB for their members, we’ll include this information in the monthly billing chart in The Record, and we’ll also include the information in Benefit Explainer. In addition, we’ll post an RBB presentation on web-DENIS in mid-November and provide you with more details in the December Record.

Frequently asked questions about RBB

How are reference costs established?

Reference costs are established for a specific episode of care based on claims data received by Blue Cross from their providers.

How will I get paid?

Reference-based benefits won’t modify the current contract amount. Providers can expect to receive their contract rate on all procedures where reference-based benefits apply.

How will I know if a member is covered under reference-based benefits?

You can check the member’s benefits and eligibility on web-DENIS.

Do reference-based benefits apply to emergency services?

No. Reference-based benefits aren’t applicable to any service that is urgent or emergent.

How does the member identify services that are at or below the reference cost?

This information will be provided to members by their employer group. Members with reference-based benefits will be given access to consumer transparency tools to determine the cost of services.

What if members covered under reference-based benefits ask me for additional information about their benefits?

You can direct members to the transparency tools provided by their employer. Members who enroll in reference-based benefits will receive a welcome packet that gives them the tools they need to determine the cost of a particular episode of care.