On Exchange Product Training for 2014
This presentation is a high-level summary and for general informational purposes only. The information in this presentation is not
comprehensive and does not constitute legal, tax, compliance or other advice or guidance.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Our Mission
To promote the health and wellness
of our members and communities through
accessible, cost-effective, quality health care.
We are a customer-owned organization and
our accountability is clear.
Our promise to our members is to
make insurance
Simple. Affordable. Accessible.
Plan Design Components
Name
Ded
OPX
Coins
OV/SPC
ER
RX
Blue PPO
Gold 002
$1,500
$3,500
80%
$10/$60
$400
$0/$10/$35/$75/$150
Plan Designs Components
• Essential Health Benefits
• Deductible and Out-of-
What goes towards the
Deductible and OPX?
Deductible*
OPX*
(In-Network)
(In-Network)
• Deductible
Pocket Maximum (OPX)
• Per-Occurrence Deductible
• Out-of-Network Benefits
• Copays
• Rx Tiers
All Medical expenses
excluding copays and
Per-Occurrence
Deductibles
• Per-Occurrence
Deductible
• Copays (incl. Rx)
• Coinsurance
*Excluded from both: Premiums, Claims for Uncovered Services,
and Preauthorization Penalties
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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How do Claims Pay Towards OPX and
Deductible in the New ACA World?
• Copays and Per-Occurrence Deductibles do not feed into the
deductible
– These costs go directly to the Out of Pocket Maximums (OPX)
• All other eligible expenses go towards the annual deductible
• Cost sharing feeds into the OPX
– Includes Rx Copays
– Includes Office and Hospital Copays
– Includes Per-Occurrence Deductibles
In 2014, the OPX could be more critical
to the average consumer than their deductible.
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How Do Per-Occurrence Deductibles Work?
• Per-Occurrence Deductible Includes:
– Emergency Room
– Inpatient Hospital Admission
– Outpatient Surgery
• When a Per-Occurrence Deductible Is Paid:
– The amount is subtracted from the claim
– The balance of the claim is subject to the annual deductible and coinsurance
– The Per-Occurrence Deductible is credited towards the OPX
In-Network:
Member Responsibility
In-Network OPX
$200
$200
In-Network Annual Deductible - $1,500
$1,500
$1,700
Co-Insurance Amount - 20% of $1,300
$260
- $1,960 Met
Out-Patient Surgery Claim: $3,000*
Per-Occurrence Deductible - $200
*Example Only – Based on In-Network Level of Benefits
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Family Deductible and OPX Summary
•
If one person meets the individual deductible, the remaining
deductible can be met by the rest of the family members.
•
The one person that meets the individual deductible will start to
receive benefits and the coinsurance will begin to be applied
towards that person’s OPX.
•
If the one person that meets the individual deductible meets
the individual OPX, he will receive 100% coverage even if the
family deductible and OPX has not been met.
•
The remaining family members can contribute to the balance of
the family OPX.
•
•
Once the family OPX is met, then all family members will
receive 100% coverage.
One person cannot meet the entire family deductible and OPX.
Once the deductible is met, coinsurance will be applied.
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Copays
• Office Visit copay will cover everything billed as part of office visit
(if performed in the same office on the same day)
• Exceptions:
• Surgery
• Physical, Occupational and Speech therapy
• Chiropractic and Osteopathic manipulation
•
If services are performed in a separate office or facility and billed separately,
then coinsurance and deductible apply
• Mental Health and Substance Abuse will be covered the same as any
medical service
•
Inpatient covered at the in-patient per admission rate
•
Outpatient covered at primary care provider (PCP) rate
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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Rx Benefits Structure
• Benefit Structures
•
Drug Card
•
Coinsurance after Medical Deductible
• Formulary
•
Standard Formulary on PPO Network
•
Generics Plus formulary on narrow
networks
•
Generics Plus is a leaner version of the
standard formulary and includes nonspecialty and specialty drugs for all major
therapeutic categories
Rx Tier
Cost
Preferred Generic
$0
Non-Preferred Generic
$10
Formulary Brand Name
$35
Non-Formulary Brand Name
$75
Specialty
$150
• 5-Tier Drug Copays (2-tier Generics)
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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Out-of-Network Benefits for PPO and HMO
•
Out of Network Benefits for PPO plans
•
Out-of-network office visits (primary and specialist) are
subject to deductible and coinsurance, no copays are applied
•
Inpatient Admission Copay and Outpatient Surgery Copays:
$100 increase over In Network copay, per occurrence copay in
addition to deductible and coinsurance
•
All other Out-of-Network services are subject to deductible
and coinsurance
•
Deductible: 2x In-Network up to $25,400
•
Out of Pocket: 2x In-Network up to $25,400
•
Coinsurance: 20% differential from In-Network level with a
floor of 50%
•
Emergency room services will be the same as In-Network
•
HMO plans do not include Out of Network benefits
•
HMO plans do not include ‘Away From Home’ benefits, only
BlueCard Worldwide® for emergency and urgent care
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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Provider Networks and Plan Designs
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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2014 Retail Provider Networks
Provider Networks In New Mexico
PPO Provider Network
Blue Community HMO
Narrow HMO
Blue Advantage HMO
Narrowest HMO
Statewide
On and Off Exchange
Statewide
On Exchange Only
ALBQ Rating Area
On and Off Exchange
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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PPO Provider Network
Blue Community HMO
Blue Advantage HMO
New Mexico Provider Network Service Areas
New or Modified Network
PROPRIETARY INFORMATION. PROPERTY OF HEALTH CARE SERVICE CORPORATION. DO NOT USE WITHOUT PERMISSION.
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Why Choose Blue
•
•
•
•
•
Brand Recognition
•
•
•
•
•
New Mexico PPO Provider Network – 12,000 Providers
Network Strength
Claims Paying Capability
Website Strength – Direct Enrollment
Choices of Plans
– PPO
– HMO
– Catastrophic
Blue Community HMO NetworkSM – 5,000 Providers
Blue Advantage HMO NetworkSM – 2,800 Providers
Value Added Benefits
BlueCard Worldwide®
We are part of the community!
•
•
•
•
CareVan Program
Blue Bear Outreach
Healthy Kids, Healthy Families®
Blue Corps Team
This presentation is a high-level summary and for general informational purposes only. The information in this presentation is not comprehensive and does not
constitute legal, tax, compliance or other advice or guidance.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
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