Working with Anthem® Subject Specific Webinar Series Special Session New 2014 Anthem Products
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New 2014 Anthem Products – Health Insurance Marketplace (Exchange) Agenda • • • • • • • • • • •
Housekeeping & Announcements Affordable Care Act (ACA) Health Insurance Marketplace Qualified Health Plan On and Off Exchange Grandfathering 2014 Insurance Options On Exchange Coverage Levels Essential Health Benefits 2014 Products and Networks Referrals & More Information 22
Housekeeping & Announcements • Housekeeping • Handouts & Navigation Click here for handouts 1. Select items by checking the boxes
2. Select a destination on your computer
3. Press OK to download
Control your view Full Screen 33
Affordable Care Act (ACA) • Comprehensive health care reform law enacted in March 2010, in two parts: o The Patient Protection and Affordable Care Act – enacted on March 23, 2010 o The Health Care and Education Reconciliations Act –enacted on March 30, 2010 (amended the Patient Protection and Affordable Care Act)
• The name, “Affordable Care Act” is used to refer to the final, amended version of the law. One of the provisions of the Affordable Care Act requires all individuals to have health insurance as of January 1, 2014 or pay a penalty. 44
Health Insurance Marketplace • Commonly called Exchange • Online marketplace where individuals and small businesses can do the following: o Shop for insurance and compare health plans o Get answers to questions o Find out if they are eligible for tax credits for private insurance o Enroll in a health plan that meets their needs
• Exchanges began to offer health plans to individuals and small businesses on October 1, 2013, with a coverage effective date of January 1, 2014 • Exchange website - www.Healthcare.gov
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Qualified Health Plan • Health plan that meets the requirements to be sold in an exchange. o Certified by the Health Insurance Marketplace o Provides essential health benefits o Follows established limits on cost-sharing
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On and Off Exchange • On Exchange o Individual qualified health plans purchased through the Health Insurance Marketplace
• Off Exchange o Individual or Small Group health plans purchased outside of the Health Insurance Marketplace (broker, sales agent, private exchange, or directly through health insurance company)
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Grandfathering • Grandfathered health plan o A plan in effect on or before March 23, 2010 o No changes since March 23, 2010 to materially reduce benefits or employer contributions o Exempt from many changes required under the Affordable Care Act
• Nongrandfathered health plan o Purchased after March 23, 2010; or o Had changes after March 23, 2010 that caused it to lose grandfathered status o Must be ACA compliant beginning January 1, 2014 88
2014 Insurance Options • Continue to obtain insurance through an employer if available • Buy an individual plan through the exchange or the traditional individual market • Enroll in a government sponsored plan, if eligible • Go uninsured and pay a penalty (unless the consumer qualifies for an exemption) o The penalty amount will start at $95 or 1% of taxable income (whichever is greater), and increase over the years with annual adjustments through 2017 and beyond.
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2014 Insurance Options • Members may select a new health plan that is supported by a different Anthem provider network than their previous plan. o Providers can identify the network that supports the new plan by the network name field indicated on the member’s new ID card. • Members transitioning to new policies may have new member ID numbers and new prefixes. • Benefits under new plans may be different than the benefits offered under previous plans. o Anthem plans may not have out-of-network benefits for services that are not urgent or emergent.
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2014 Insurance Options • New plans may utilize a different drug list than previous plans o The National Drug List Broad list of covered drugs offered with large group, national accounts and some small group health plans Link: Anthem National Drug List o Select Drug List Drugs that include a select number of medications in all therapeutic categories and classes, while meeting the requirements of the Affordable Care Act (ACA). May be tiered differently than the National Drug List Multi-source brand drugs (drugs that have a generic equivalent) are not included Link: Anthem Select Drug List
• More information Health Exchange Information Page: Important drug list information for plans purchased on and off Exchange 1111
On Exchange Coverage Levels Four levels of tiered plans offered in the Exchange Marketplace, referred to as “metal levels.” • Bronze – highest cost shares, lowest premium • Silver • Gold • Platinum – lowest cost shares, highest premium
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Essential Health Benefits Plans available in the exchange marketplace must offer what are called “essential health benefits.” Essential health benefits include the following services: Ambulatory services
Emergency services
Hospitalization
Laboratory services
Preventive/Wellness services
Maternity/Newborn care
Rehabilitative/habilitative services
Mental/Behavioral Health
Prescription drugs
Chronic Disease Management
Pediatric services, including oral and vision care
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New 2014 Anthem Products Type
Alpha Prefix
Anthem (Bronze/Silver/Gold) Direct Access
Individual
VZE
Blue Priority X-WI
On
Anthem (Bronze/Silver/Gold) Direct Access
Individual
VZH
Blue Priority X-WI
On
Anthem (Essential/Core/Preferred) Direct Access
Individual
VZS
Blue Priority – WI
Off
Anthem (Essential/Core/Preferred) Direct Access
Small Group
VZU
Blue Priority – WI
Off
Anthem (Essential/Core/Preferred) Direct Access
Small Group
VZC
Blue Preferred
Off
Anthem (Essential/Core/Preferred) Direct Access
Small Group
VZB
Blue Access
Off
Product
Network
Exchange
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New 2014 Anthem Products •Sample Member Identification Card -WI Individual On Exchange 1. Product name includes “Metal” level 2. Unique member alpha prefixes 3. Individual and Family In and Out-of Network Cost Shares 4. Network Name 5. Limited Benefit Disclaimer 6. Pediatric Dental
Test – Card Front
Test – Card Back 1515
New 2014 Anthem Products •Sample Member Identification Card -WI Individual Off Exchange 1. Product name 2. Unique member alpha prefixes 3. Individual and Family In Network Cost Shares 4. Network Name 5. Limited Benefit Disclaimer 6. Pediatric Dental
Test – Card Front
Test – Card Back 1616
New 2014 Anthem Products Eligibility and Benefits – 270/271 Transactions • Individual On Exchange Test Example
Metal Level Abbreviations: Bronze=BRZ Silver=SLV Gold=GLD 1717
New 2014 Anthem Products Eligibility and Benefits – Availity® • Individual On Exchange Test Example Individual On Exchange Member - Preliminary Test Results Plan Product Information Status:
Active Coverage
Coverage Level: Individual Service Type:
Health Benefit Coverage
Plan/Product:
BRZ DIRAC CD
Translation - Anthem Bronze Direct Access w/Child Dental
Insurance Type: Point of Service (POS) - Not Confirmed Status: Service Type:
Active Coverage Professional (Physician) Visit - Office
Benefit:
01/01/2014-12/31/2014
Message:
Specialist
Status:
Active Coverage
Metal Level Abbreviations: Bronze=BRZ Silver=SLV Gold=GLD
Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on
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New 2014 Anthem Products Eligibility and Benefits – Availity® • Individual Off Exchange Test Example Individual Off Exchange Member - Preliminary Test Results Plan Product Information Status:
Active Coverage
Coverage Level: Individual Service Type:
Health Benefit Coverage
Plan/Product:
COR DIRAC CD
Translation – Anthem Core Direct Access w/Child Dental
Insurance Type: Point of Service (POS) - Not Confirmed Status:
Active Coverage
Service Type:
Professional (Physician) Visit - Office
Benefit:
01/01/2014-12/31/2014
Message:
Specialist
Status:
Active Coverage
Product Level Abbreviations: Essential=ESS CORE=COR Preferred=PRF
Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on
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Blue Priority Service Area Blue Priority Network • • • • •
23 hospitals Over 190 clinics More than 2,400 doctors Serves more than 30 counties Comprised of 3 of the top rated systems for efficiency & quality in the state – – – – –
Aspirus Health System Aurora Health Care Children’s Health Systems ThedaCare Broad base of Ancillary Providers 2020
Referrals & More Information PCP, Referrals and Precertification • New Anthem Direct Access Products o PCP selection is not required o Referrals are not required o Precertification requirements that apply to commercial lines of business will apply to exchange products Refer to Anthem’s precertification (prior authorization) guidelines located on the Provider Home page at www.anthem.com • Products supported by Blue Priority X-WI and Blue Priority WI networks o Out of network benefits limited to urgent or emergent services
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Referrals & More Information Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy. • 3 month grace period applies after the individual has paid at least one month’s premium • Premium non-payment o Anthem will process claims for services received during the first month o Anthem will pend claims for services received during the second and third months of the grace period, until the full premium is received Providers notified on their remittance advice that the claim cannot be paid until the premium is received
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Referrals & More Information Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy • Premium non-payment continued o After the third month, if the premium is not received, the member’s health plan will be terminated and the claims for services received during the second and third month will be denied o Providers will be notified of denied claims on their remittance advice o The member will be responsible for payment of services
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Referrals & More Information Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy • Premium non-payment continued o 271 Eligibility Transactional Response First Month of Grace Period • 2110 C – EB01 = 1 (ACTIVE) • 2100 C – DTP01 = 291 (PLAN) • 2100 C – DTP02 = RD8 • 2100 C – Plan Date Time Period • 2100 C – DTP01 = 343 (Premium Paid to Date) • 2100 C – DTP03 = Date for which the premium is paid through • 2110 C – DTP01 = 193 (Period Start) • 2110 C – DTP03 = First day of the grace period and MSG*HIX GRACE PERIOD~ • 2110 C – DTP01 =194 (Period End) • 2110 C – DTP03 = Last day of grace period and MSG*HIX GRACE PERIOD~ • Return normal requested Service Types and required patient liabilities
Second and Third Month of Grace Period • 2110 C – EB01 = 5 (ACTIVE Pending Investigation) • 2100 C – DTP01 = 291 (PLAN) • 2100 C – DTP02 = RD8 • 2100 C – Plan Date Time Period • 2100 C – DTP01 = 343 (Premium Paid to Date) • 2100 C – DTP03 = Date for which the premium is paid through • 2110 C – DTP01 = 193 (Period Start) • 2110 C – DTP03 = First day of the grace period and MSG*HIX GRACE PERIOD~ • 2110 C – DTP01 =194 (Period End) • 2110 C – DTP03 = Last day of grace period and MSG*HIX GRACE PERIOD~ • Return normal requested Service Types and required patient liabilities
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Referrals & More Information Grace period for individual health plans purchased on Exchange that are eligible for a governmental premium subsidy • Premium non-payment continued o ANSI 835 Codes passed on 835 Electronic Remittance Advice Claim Adjustment Reason Code (CARC) 133 – The disposition of the claim service is pending further review (Use only with Group Code OA) Start: 02/28/1997|Last modified : 01/20/2013 Remittance Advice Remark Code (RARC) N617 – This enrollee is in the second or third month of the advanced premium tax credit grace period Start: 07/15/2013 o Paper Remittance Advice remark code information See our “Grace period for individual health plans purchased on the Exchange” article on our Health Exchange Information Page
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Referrals & More Information Provider Service & More Information • Online Eligibility, Benefits, Claim Status Inquiry – Availity® • Claims Submission o Same as any other Anthem claim (Electronic Submission is preferred) • Remittance Advice o Same as any other Anthem business via electronic or paper • Updated Ready Reference Guide under “Contact Us” • Health Exchange Information from the Provider Home Page on our public provider website: Health Exchange Information • Contact your local Network Relations Consultant
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New 2014 Anthem Products – Health Insurance Marketplace (Exchange)
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Working with Anthem®
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• Thank you for attending
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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