This article is for all providers caring for our members
Beginning January 1, 2022, we will make changes to our health plans and benefits. Because of these changes, it is important to always check your patient’s Blue Cross ID card and to verify their eligibility and benefits. You can do this using ConnectCenterTM, which will replace Online Services starting in January 2022, or you can use another similar technology.
As we communicated in August, we plan to make changes to our telehealth payment policies in April 2022 and will notify you of these changes via a News Alert in January. Until then, please continue to reference the COVID-19 Temporary payment policy, and follow the guidance in that policy.
As a reminder, effective July 1, 2021, member cost share was reinstated for non-COVID telehealth services. We reinstated member copayments, co-insurance, and deductibles for non-COVID telehealth visits, including all mental and behavioral health services. Note: These changes do not apply to our Medicare Advantage members. We are following guidelines from the Blue Cross Blue Shield Association regarding coverage for Federal Employee Program members. For more details, please see fepblue.org.
For COVID-related visits, please continue to bill members for their cost share once the claim has processed. When you are checking eligibility, Online Services (soon to be ConnectCenter) will show the standard telehealth cost share. The system will not distinguish between a COVID visit and a non-COVID visit; therefore, we recommend that you bill the member for the applicable cost share once the claim has processed to ensure you do not have to reimburse the member.
Large employers can choose to offer their employees $0 cost share* for a set number of visits. (They can opt to have the first one, three, or six outpatient visits per member, per plan year at $0 cost share before regular cost share begins to apply.) This is an option for the following outpatient visits that are rendered in person or via telehealth:
- Acupuncture
- Chiropractic care
- Mental health and substance use therapy visits (including outpatient psychiatric evaluation and management services; outpatient psychotherapy services such as individual therapy, group therapy, and family therapy; and monitoring and medication management for members taking psychiatric drugs)
- Non-preventive care visits with a PCP
- For members enrolled in a PPO plan that have PCP non-preventive visits, the following provider types are eligible: a family or general practitioner, internist, pediatrician, geriatric specialist, or multi-specialty provider group, OB/GYN physician, nurse midwife, limited services clinic, physician assistant or nurse practitioner designated by the health plan as primary care
- Physical therapy and occupational therapy
*For Health Savings Account qualified high-deductible health plans (Saver plans), the deductible must be met up-front, then any copayment or co-insurance will be waived for the rest of the year.
We’re expanding our fitness-related benefits and promoting healthier lifestyles with a variety of new offerings:
- Fitness program: The existing fitness program benefit will now include reimbursement for home fitness equipment items such as stationary bikes, weights, exercise bands, treadmills, and fitness machines (this includes Peloton®´ reimbursable as an online or virtual program).
- Mind and Body program: The Mind and Body program will reimburse up to $300 per family per calendar year for the following covered expenses: massage therapy, hypnosis, qi gong, tai chi, and meditation (in-person sessions) as well as meditation or breathing apps (defined as digital applications focused on breathing and meditation mind therapy, like Headspace®´ , Calm, or BreathetoRelax).
Certain large, self-funded accounts may purchase a benefit that will provide independent second opinions through a vendor called 2nd.MD. With this benefit, members can get a second opinion from a 2nd.MD physician. After the consult, the vendor will:
- Connect with the member’s local doctor
- Help the member coordinate care with local specialists, transfer records, and set up appointments
Please respond promptly to medical record requests you may receive from 2nd.MD for your patients.
We’re continuing to review guidance from the federal government on the Consolidated Appropriations Act (CAA) and other federal transparency initiatives. We’ll notify you of any impacts or changes as we learn of them.
Starting January 1, we will offer our members BlueFit, the next generation proactive health plan. BlueFit guides members to lower annual costs and helps boost their Health Savings Account (HSA) over time, avoid cost surprises, and invest in their future health care.
Here’s a highlight of what BlueFit offers to our members:
- HMO or PPO plan paired with a built-in HSA
- Comprehensive pharmacy benefits with PillPack for over-the-counter (OTC) drugs
- Accident and critical illness coverage automatically paid to members
- Digital offerings such as mental health programs and dental consults
- Up to $600 in incentives and rewards deposited into their HSA
BlueFit HMO plan members can use any provider in the HMO Blue New England network. Primary care provider (PCP) referrals are not needed to see a specialist.
BlueFit PPO plan members have extensive nationwide access to the entire Blue Cross Blue Shield network, including access to providers outside of the network, for a higher cost. PCPs and referrals are not needed.
Please follow the same procedures to file claims, and check eligibility and benefits as you would for any of our members.
We’ve recently increased our membership in plans that use our newest national limited network, the Blue High Performance NetworkSM (BlueHPNSM). In Massachusetts, we’re enrolling members in Advantage Blue Performance plans that pair with the BlueHPN limited network. Read here for more information to help you recognize these members.
To help our Medicare members with out-of-pocket costs, we’re introducing a new Medicare Advantage plan option: Medicare PPO Blue FreedomRx Option. This plan offers coverage for all Medicare-covered medical services, both in- and out-of-network, with a $0 member cost share and includes extra benefits such as fitness and weight loss reimbursements, routine vision, hearing, and dental. These members will use the Medicare Advantage formulary.
To recognize Medicare PPO Blue FreedomRx patients, look for the OV and ER copays of $0 on the front of the member’s Blue Cross ID card (shown below).
Three of our Medicare Advantage plans— Medicare HMO Blue PlusRx, Medicare PPO Blue ValueRx, and Medicare PPO Blue SaverRx—will have a $0 member copay for primary care visits. Medicare PPO PlusRx will have a $5 primary care visit copay. The three remaining direct pay Medicare Advantage plans will continue with a $10 copay.
All of our direct pay Medicare Advantage plans will have lower copays ranging from $10 to $30 per visit for outpatient mental health visits.
We are expanding coverage to include virtual fitness programs and home exercise equipment. This includes virtual fitness memberships, subscriptions, programs, or classes that provide cardiovascular and strength-training using a digital platform. We’ll also cover home fitness equipment like stationary bikes, weights, exercise bands, treadmills, and fitness machines. Members have a yearly allowance of between $150 to $250 towards membership fees, in-person and virtual class fees, and home fitness equipment.
We have expanded the eligibility for our meals benefit. In addition to post-discharge after an inpatient stay at a hospital, members who are post-outpatient day surgery may be eligible for up to eight weeks of meals delivered to their home, at no cost, while they recover from their illness or injury.
This benefit is managed by our Care Management team who will work with you to coordinate medically tailored meals. To refer a member for this program, please send an email to MedAdvCMReferrals@bcbsma.com.
In an October 1 News Alert, we announced changes to our members’ benefits and coverage for their medications. These include:
- Formulary changes (moving medications to non-covered status, tier changes, quality care dosing changes)
- Pharmacy medical policy changes
- Medical benefit changes (applies to Medicare Advantage)
- New offerings (6-tier benefit, $0 copayments, 90-day retail benefit)
To access our News Alert, log in and go to News. Look for the News Alert (indicated with an exclamation mark) dated October 1, 2021, called "Medication coverage changes starting Jan 1."
We’ll begin applying prior authorization to services listed in our medical policies for EPO, PPO, and Medicare Advantage members, including:
- Continuous glucose monitors
- Spine surgeries (does not apply to Medicare Advantage)
- Other services (refer to list of codes that was included with our News Alert)
To see the complete list of services, access our September 1 News Alert by logging in and going to News. Look for the News Alert (indicated with an exclamation mark) called, "Expanding authorizations to EPO, PPO, Medicare Advantage members."
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