Effective January 1, 2019, we will make a number of changes to our commercial HMO and PPO, Medicare Advantage, and Medex® plans. Because of these changes, it is important to always check your patient’s Blue Cross member ID card and to verify eligibility and benefits. We recommend you use Online Services to verify member eligibility and benefits.
Effective January 1, 2019 on renewal, we will expand the types of programs that qualify for fitness and weight loss reimbursement. These changes will be effective for all products, except for the Federal Employee Program.
We are expanding our fitness benefit to include coverage for stand-alone fitness studio classes. A qualified fitness program is a full-service health club where members use cardiovascular and strength-training equipment for fitness, including individual health clubs and fitness centers, YMCAs, YWCAs, Jewish Community Centers, Council on Aging sites, municipal fitness centers, or a fitness studio with instructor-led group classes for cardiovascular and strength-training, such as yoga, pilates, zumba, kickboxing, cross-fit, and indoor cycling and spinning.
We are expanding the types of programs that qualify for our weight loss reimbursement. Starting in 2019, qualifying weight loss programs include both hospital-based programs and Weight Watchers®´ in-person, Weight Watchers online, and other non-hospital programs (in-person or online) that combine healthy eating, exercise, and coaching sessions with certified health professionals such as nutritionists, registered dietitians, or exercise physiologists.
We will change copayment, deductible amounts, and out-of-pocket maximums for many of our individual and small group plans. An out-of-pocket maximum is the maximum amount a member will pay for covered services in a plan year before their health plan coverage begins. Always check the patient’s benefits and eligibility for the most up-to-date information.
The following two co-payment changes will take effect starting January 1, 2019 on plan renewal for individual and small-group plans either directly or through the Connector.
Split office visit co-payment
Affected PPO members will have a lower copayment when they receive services from a family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, limited services clinic, or multi-specialty provider group; or by a physician assistant or nurse practitioner. The higher copayment will apply to any other covered provider.
Split-level cost sharing for diagnostic tests and imaging. For affected members, we will introduce two different cost shares for Outpatient lab tests, X-rays, and high-tech radiology. Members will pay the higher cost share when services performed at a general hospital or hospital-owned outpatient center. When these services are performed by independent clinical lab or freestanding imaging providers, the lower cost share will apply.
On October 1, we distributed a News Alert, Medication Coverage Changes, with information about changes to medication coverage for 2019. To read the News Alert, log in and go to News>Clinical & Pharmacy.
We also want to remind prescribers that we’re excluding proton pump inhibitors from coverage, and won’t make any formulary exceptions.
We are making several benefit enhancements to our Medicare HMO BlueSM and PPO BlueSM products starting January 1, 2019. Here are highlights:
New Medicare HMO Blue SaverRx plan
We are introducing a new health plan called the Medicare HMO Blue SaverRx - $0 premium HMO plan. This plan is similar to our other Standard Medicare HMO Blue plan with the same referral and authorization requirements and the same supplemental benefits, but with a slightly different cost-share model.
Value-Based Insurance Design still offered
In 2019 we will continue to offer our newest benefit designed called the Medicare Advantage Value-Based Insurance Design. This program is for Medicare Advantage members enrolled in our individual direct pay plans. Under the program, members don’t have a cost-share for medications commonly used to treat hypertension in tiers 1, 2, and 3 of our formulary.
Key features for value-based eligible medications
The Centers for Medicare & Medicaid Services (CMS) developed this program to decrease cost of care, so patients can take better control of their health and enjoy an improved quality of life. If members have questions about the program, encourage them to call the number on the back of their ID card.
Prior authorization requirements
We are removing the prior authorization requirement for the following services for all Medicare Advantage plans:
|Service||This resource will be updated January 1, 2019 to reflect this change|
|Outpatient psychiatric services|
|Medical nutrition therapy|
We are adding a requirement for prior authorization for certain Medicare Part B gene therapy prescription drugs as well.
For all Medicare Advantage plans, members will have a lower copay for Medicare-covered vision exams when performed by their primary care provider or physician of choice. And for our Medicare PPO Value, HMO Value, and HMO Flex members, we are lowering the copay for routine vision exams.
Emergency care (including Worldwide emergency, urgent and transportation services)
We are increasing the emergency room copay to $90 for the Medicare PPO Saver/Value and Medicare HMO/Value/Flex products to align with other health plans’ Medicare Advantage plans. We are reissuing ID cards, so please be sure to check members’ ID cards for the appropriate copayment amount.
Lowered copay for outpatient x-rays, labs and other diagnostic tests
We are lowering the copayment for outpatient procedures, tests, labs, and X-rays to $10 per day per category of test for our Medicare PPO Saver/Value and Medicare HMO Value/Flex products. Now all of our Medicare Advantage plans will have this same copay.
We previously communicated other changes to our Medicare products, that will be effective January 1, 2019 including changes to prescription drug coverage.