Idea Transcript
Plan Overviews
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Section Summary In this section you’ll learn about the variety of health plans that Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue®, Inc. offer to meet our members’ healthcare needs. (For ease of reference, the term “BCBSMA” will be used throughout the blue book to refer to both Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.). In addition, you will learn how to identify BCBSMA members by their ID card and you’ll find summaries of specific plans for some of our largest accounts. These summaries contain a picture of the corresponding member ID card and the basic information you’ll need when a patient visits your office. The plan summaries reflect the most common features of each plan. There may be variations or exceptions because of choices made by individual accounts.
For Information about:
See page:
A Description of our Health Plans Health Maintenance Organization (HMO) ..........................................3 Indemnity ...............................................................................................3 Point-of-Service (POS) ..........................................................................4 Preferred Provider Organization (PPO) .................................................4 Exclusive Provider Organization (EPO) ................................................4 Medicare Advantage and Senior Health Plans......................................5 Identifying Your Patient’s Plan by ID Number Member ID card......................................................................................6 Determining Eligibility Typical ID card data................................................................................7 A special note about temporary member ID cards ................................7 Six ways to determine eligibility for BCBSMA members .....................7 About Referrals and Authorizations Five ways to determine eligibility for out-of-state BCBS members.......8 Information we’ll need from you ............................................................8 How to submit referrals ..........................................................................8 How to submit authorizations ................................................................9 Authorization fax numbers.....................................................................9 Plan Summaries HMO EPO PPO PPO PPO
Access Blue Plans........................................................................................11 Advantage Blue® ........................................................................................19 Blue Care® Elect (100/80 Option)..............................................................23 Blue Care® Elect Deductible PPO Options ................................................27 Blue Care® Elect Preferred .........................................................................33
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Plan Overview (continued) Type
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Plan
POS Blue Choice® Plan 1....................................................................................37 POS Blue Choice® New England Plan 1.............................................................41 POS Blue Health Plan for Kids ...........................................................................47 Indemnity Comprehensive Major Medical ..................................................................51 Indemnity Comprehensive Major Medical with Co-Pay Option ................................55 HMO HMO Basic Blue® Direct ............................................................................59 HMO HMO Blue® Deductible Plans.....................................................................63 HMO HMO Blue® Enhanced Value......................................................................67 HMO HMO Blue® New England ..........................................................................71 HMO HMO Blue® New England—$1,000 Deductible ........................................75 HMO HMO Blue®—Standard Plan ......................................................................79 HMO HMO Blue® Preferences..............................................................................83 HMO HMO Blue®—Value ....................................................................................87 HMO HMO Blue®—Value Plus ............................................................................91 Medicare Supplemental Managed Blue® for Seniors ........................................................................95 Indemnity Master Health Plus®´...................................................................................99 Indemnity Master Medical®´.........................................................................................103 Medicare Supplemental Medex®´ Core Plus—Direct Pay .................................................................107 Medicare Supplemental Medex®´ Gold—Direct Pay.........................................................................111 Medicare Supplemental Medex®´ Group (without OBRA and with drugs) .....................................115 Medicare Supplemental Medex®´ Group OBRA (with drugs) ..........................................................117 HMO Medical Security Program Network Blue Preferences ...............................119 Medicare Advantage Medicare HMO Blue® .................................................................................121 Medicare Advantage Medicare PPO BlueSM ..................................................................................125 PPO PPO Basic Blue Direct.................................................................................129 PPO PPO Blue Direct..........................................................................................133 Indemnity Vital Insurance Protection™(VIP) ..............................................................137 Account summaries PPO PPO Indemnity PPO POS PPO PPO PPO PPO HMO PPO POS POS POS HMO HMO POS Indemnity POS HMO
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Boston Scientific 100/80 PPO.....................................................................141 Boston Scientific 80/60 PPO.......................................................................145 City of Boston—Master Medical.................................................................149 Cumberland Farms.......................................................................................153 Federal Employees—Service Benefit Plan/Basic Option............................157 Federal Employees—Service Benefit Plan/Standard Option......................161 Gillette Company—Advantage Blue®........................................................ 167 Gillette Company PPO (100 Option).........................................................171 Liberty Mutual Blue Care® Elect Preferred 90/70 Plan...............................173 Lucent Technologies....................................................................................177 Osram Sylvania ............................................................................................181 Partners Plus................................................................................................ 185 Partners Value Plan......................................................................................189 Raytheon—Blue Choice® New England Plan 2..........................................193 Raytheon—Network Blue® New England...................................................197 TJX—Network Blue.................................................................................... 201 TJX—Option A Plus...................................................................................205 TJX—Option 400........................................................................................209 Verizon Health Care Network—Blue Choice® New England Plan 2........211 Verizon HMO Blue®....................................................................................215
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A Description of Our Health Plans
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BCBSMA offers a wide variety of health plans designed to meet all of our members’ needs, described below. In the specific plan summary pages that follow in this section, we classify each health plan according to the categories below: HMO, Indemnity, point-of-service (POS), exclusive provider organization (EPO), preferred provider organization (PPO), Medicare Supplemental or Medicare Advantage (formerly Medicare+Choice).
Health Maintenance Organization (HMO) An HMO is a managed care network of doctors and hospitals dedicated to providing high-quality, affordable health care. With an HMO, a primary care physician (PCP) coordinates the member’s care and, if necessary, refers the member to an in-network specialist. Our range of HMO plans offer these benefits: • routine office visits and screenings • annual check-ups • annual OB/GYN visits for women • routine wellness visits • immunizations for infants and children • a pharmacy benefit that provides prescription drug coverage.
Indemnity Indemnity products offer full coverage for most services after the member pays a co-payment or a deductible. Some indemnity products also share the cost with the member through co-insurance for certain services, with some products having limits on the amount of co-insurance a member or family must pay in a given year. Members may choose from any participating provider (there is no primary care physician who coordinates care) and no referrals are required.
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A Description of Our Health Plans (continued) Point-of-Service (POS) Our point-of-service (POS) plans offer reliable managed care networks but also give the member the freedom to seek out-of-network care. BCBSMA POS plans offer: • a PCP to coordinate all in-network care • the flexibility for the member to self-refer to any Blue Cross Blue Shield participating indemnity provider (at a higher out-of-pocket cost) • access to a complete range of services • a pharmacy benefit that provides prescription drug coverage. Balanced between HMOs and Indemnity plans, POS plans are often considered the best of both worlds.
Preferred Provider Organization (PPO) PPOs allow a member to choose a primary care physician (PCP) to coordinate in-network care, but do not require them to do so. These plans offer in- and out-ofnetwork benefits and give the member the flexibility to coordinate his or her own care. Our PPO plans offer: • access to a preferred provider network that spans the United States and extends abroad • access to a complete range of services • a pharmacy benefit that provides prescription drug coverage.
Exclusive Provider Organization (EPO) Advantage Blue® is our Exclusive Provider Organization (EPO) product that offers a solution for self-insured companies with employees across the country who want a national managed network product. EPOs feature an open-access network plan. Advantage Blue members use our PPO network and are not required to choose a PCP, but are encouraged to do so. Advantage Blue also uses BlueCard® PPO for national claims processing. There are no referral requirements.
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A Description of Our Health Plans (continued) Medicare Advantage and Senior Health Plans We have a wide selection of plans for seniors. Based on the Medicare Modernization Act of 2003, BCBSMA also offers seniors prescription drug coverage. Our plans include: • Medicare PPO BlueSM, a Medicare Advantage plan. This plan is available to Medicare beneficiaries in all Massachusetts counties except Berkshire, Dukes, and Nantucket. The plan is offered with and without prescription drug coverage, and such prescription drug coverage is offered at two levels—basic and enhanced. The Medicare Advantage formulary covers generic drugs, and preferred and non-preferred brand-name drugs, and is administered via Express Scripts, Inc. (ESI). • Medicare HMO Blue® (a Medicare Advantage plan previously known as Blue Care® 65). This plan manages all Medicare-covered health services. A PCP coordinates the member’s care. It is offered with and without prescription drug coverage, and such coverage is offered at two levels—basic and enhanced. The formulary for this plan, administered by ESI, is the same as that of Medicare PPO Blue and can be found at www.bluecrossma.com/forseniors. • Blue MedicareRx. Together with Anthem Blue Cross and Blue Shield in Connecticut, Blue Cross Blue Shield of Rhode Island, and Blue Cross Blue Shield of Vermont, BCBSMA offers a new regional Medicare Part D prescription drug plan (PDP) to all Medicare beneficiaries regardless of income level, pre-existing conditions, or current prescription expenses. Beneficiaries can purchase Blue MedicareRx as a stand-alone product, or as supplemental coverage to our Medex®´ plans, such as Medex Bronze and Medex Core. Members can choose from three different design options. Each offers a three-tier prescription benefit, with co-payment for generic, preferred, and non-preferred drugs, and co-insurance for injectable medications. Blue MedicareRx has its own formulary at www.bluecrossma.com/forseniors/our_plans/blue_medicare_rx.htm. Anthem Prescription Management administers the formulary for this stand-alone benefit. • Managed Blue for Seniors (a Medicare Supplemental group HMO plan.) This is a group plan offered only through employers; a PCP coordinates the member’s care, including hospital services and specialist referrals. • Medex®´ (a Medicare Supplemental “Medigap” plan): The following Medex®´ plans are available and offer a range of benefits to supplement Medicare Part A and Part B benefits: Medex®´ Core and Medex®´ Bronze with prescription drug coverage. As required by the Medicare Modernization Act, we closed Medex®´Core Plus and Medex®´Gold to new members in 2005. Members already enrolled in these plans may continue to purchase coverage after January 1, 2006, and members who do not have prescription coverage may purchase the stand-alone Blue MedicareRx plan. Employer-sponsored Medex®´ is also available. Also, through the Seniorlink program, we offer a 20 percent discount on phone consultations, home assessments, ongoing care management, and referral services for seniors. Seniorlink is an independent eldercare management company focused on supporting families concerned about the health and safety of seniors. For more information, call Seniorlink at 1-866-500-5444, or visit their website at www.seniorlink.com. 2006 blue book
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Identifying Your Patient’s Plan by ID Number Member ID card We issue every BCBSMA member his or her own ID (in the case of a managed care plan, each member will receive a card) with a non-Social Security-based number. Medicare Advantage members have separate prescription plan ID cards along with their member ID cards. The ID card contains much of the information you’ll need to submit claims and coordinate your patients’ care. Each time a patient visits, perform an eligibility check to ensure the ID number is active. It is also important that you: • Always ask all of your Blue Cross Blue Shield (BCBS) patients, both local and out-ofstate, for their most current BCBS ID card. Photocopy the front and back of the card for your files and pass this key information on to your billing staff. • A three-character alpha prefix is part of all BCBS member ID numbers and should always be used in filing claims. After the three-character prefix, the ID card may include any combination of alpha/numeric characters (letters or numbers) for a maximum length of 17 characters. Federal Employee Program member cards begin with an “R” followed by eight numbers. Other plans may have different alpha/numeric combinations. Blue Cross Blue Shield Association rules prohibits BCBSMA from publishing or describing other Blue Cross Blue Shield plans’ three letter alpha prefix. • BCBSMA member IDs have a three-letter prefix with a nine-digit ID number followed by a two-digit suffix. The numeric portion of the number will, in most cases, begin with either a 98 or 96 (example: XXH981234567 01). Some cards may begin with a 94. • If a claim processes under an old Social Security ID number and you request a claim adjustment, your Provider Detail Advisories/Provider Payment Advisories will display the adjusted claim under the old number. • Be sure to submit claims using the same ID number you used when you recorded the patient’s visit. See sample ID card on next page.
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Determining Eligibility
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Typical ID card data While our ID cards differ from plan to plan, there are some standard elements common to all cards. This diagram will help you find and interpret the information we print on ID cards: The Blue Cross Blue Shield of Massachusetts logo is always here. The phone number for members to call if they have questions is here. This is the member’s ID number. When submitting claims to BCBSMA, please report the ID number just as it appears on the member’s card, including the alpha prefix and all following digits. The alpha prefix is an integral part of the successful completion of electronic interactive transactions for BCBSMA as well as out-of-state members. The member’s name and (for some plans) the medical record number appear here.
For managed care plans, this is the member’s enrollee number or suffix. For many of the BCBSMA electronic interactive transactions, the use of this two-digit code bypasses the need to enter the member’s date of birth. This suitcase logo indicates that the member belongs to the BlueCard® Program (see the BlueCard section of this manual).
PLAN CODE 200
CUSTOMER SERVICE #: 1-800-999-9999
XXX961234567
This area of the card shows which plan the member has. The name and logo of any applicable pharmacy program appears here.
Member Suffix: 00
JANE DOE MRN 123456789 CO-PAYS: RX10/20/35 OV10/20 MH10 ER50
For managed care plans, we list all of the co-pay amounts here. Where there are two office visit co-pay amounts given, the first is for children under 12, the second for all others. The abbreviations mean: RX - prescription co-payment OV - office visit co-payment MH - mental health visit co-payment ER - emergency room co-payment
On the back of the card we print information specific to the member’s plan, such as utilization management procedures, where to call for mental health services, and a space to write in the PCP’s name.
A special note about temporary member ID cards Plastic replacement cards issued to members on an emergency basis do not have an “embossed” name and identification number like our regularly issued cards. Although the name and membership number are flat, the card still contains the same information and can be “swiped” through the point-of-service device. And, you can still verify benefits and eligibility information as you normally do. Please honor these Blue Cross Blue Shield cards as you would the more familiar, embossed membership card.
Six ways to determine eligibility for BCBSMA members You can get eligibility information about BCBSMA members in six ways: • Using Online Services (Emdeon Office). To sign-up, call 1-877-469-3263. • Using the Provider Terminal Network (PTN). • Using a POS device (a “swipe” box). • Establishing a direct ANSI 270/271 connection with BCBSMA through Emdeon. • Calling InfoDial®´ (1-800-443-6657 or 617-956-2374) available 24 hours, seven days a week. • Calling Provider Services: - Professional Provider Services - Ancillary Provider Services - Institutional Provider Services
1-800-882-2060 1-800-451-8124 1-800-451-8123
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About Referrals and Authorizations
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Five ways to determine eligibility for out-of-state BCBS members Before you treat a member from another BCBS plan, we recommend that you verify the patient’s eligibility and benefits. You can determine eligibility for out-ofstate BCBS members in one of the following ways: • Using Online Services (Emdeon Office) • Using the Provider Terminal Network (PTN) • Using a POS device (a “swipe” box) • Establishing a direct ANSI 270/271 connection with BCBSMA through Emdeon Business Services. • Calling BlueCard EligibilitySM at 1-800-676-BLUE (2583).
Information we’ll need from you We recommend that you use the electronic network to get eligibility information about BCBS patients. It’s the fastest way to get eligibility information directly from the member enrollment system. No matter which electronic method you choose to get eligibility information, you should have the following information available for this transaction: • The patient’s complete BCBS ID, including alpha prefix and all the digits and characters that follow • The patient’s date of birth • For out-of-state members, you may be required to enter the subscriber’s first and last name. • The provider’s or facility’s BCBS provider number. Throughout these plan overview pages, you will see reference to those services that require referrals and authorizations. Please use these instructions below to submit referrals and authorizations.
How to submit referrals You may submit all referral requests electronically via Online Services (through Emdeon Office), the POS device, InfoDial, or via Direct 278 connection.
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About Referrals and Authorizations
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How to submit authorizations For BCBSMA members, you can: • Submit electronically via Online Services (through Emdeon Office), PTN, the POS device, InfoDial, or via Direct 278 connection • Call Clinical Coordination at 1-800-327-6716 • Fax request to the appropriate Clinical Coordination fax number listed below. For out-of-state managed care members, you can submit authorization requests electronically via the technologies listed in the first bullet above or you can call BlueCard EligibilitySM at 1-800-676-BLUE (2583).
Authorization fax numbers To send information for:
Fax to:
Additional requested clinical information
1-888-282-1321
Appeals
(617) 246-4225
Appeals for Medicare HMO Blue members
(617) 246-5118
BCBSMA & EDS employee authorizations and referrals
(617) 246-4299
Behavioral health/substance abuse authorizations and referrals
1-888-641-5199
Medicare HMO Blue member authorizations and referrals
1-800-447-2994
Case Management
1-888-282-0780
Federal Employee Program member authorizations and referrals
1-888-282-1315
IVF services
1-800-836-1112
Medex®´ member authorizations and referrals
(617) 246-4210
Medical and surgical inpatient and outpatient authorizations and referrals (including OT, PT, ST, outpatient hospice)
1-888-282-0780
Pharmacy authorizations
1-800-583-6289
Pharmacy home infusion therapy authorizations
1-888-641-5355
Skilled nursing facility, rehab hospital, inpatient hospice and respite, medical policy authorizations
1-888-641-5330
(To respond to our requests for additional information)
(Use this number only for members whose behavioral health benefit is managed by BCBSMA)
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