2017 ACA Product Training

65 Pages·2016·2.21 MB·English

RETAIL MARKETS
ACA - 2017 PRODUCT TRAINING
BLUE CROSS AND BLUE SHIELD OF ILLINOIS
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
DO NOT USE WITHOUT PERMISSION. an Independent Licensee of the Blue Cross and Blue Shield Association
Disclaimer
The content contained within this guide is proprietary information. Proprietary Information
is not for use/disclosure outside of Blue Cross and Blue Shield of Illinois and its affiliated
companies. This guide is for training purposes only. All changes to material must be
approved by Blue Cross and Blue Shield of Illinois.
© Copyright 2016. Health Care Service Corporation. All Rights Reserved.
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 2
Training Requirement to Sell Individual
In order for a producer to sell Health Insurance Marketplace plans (and receive
compensation) in Illinois, a producer must register as an agent/broker with the Federally
Facilitated Marketplace. This process is managed by the Centers for Medicare and
Medicaid Services (CMS).
1. Producers who are CMS-certified in the Individual Marketplace can sell and receive
compensation for both Marketplace retail plans and non-Marketplace retail plans.
2. Producers who are NOT CMS-certified in the Individual Marketplace can only sell and
receive compensation for non-Marketplace retail plans.
3. To receive renewal compensation for Marketplace policies, producers must also be
CMS-certified.
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 3
Training Topics
2017 Illinois Updates Dental/ Ancillary Products
• Virtual Visits • Dental Benefits
• Hospital vs. Freestanding Outpatient Facility • Pediatric Vision Benefits
• Mental Health / Substance Abuse Office Visits
• Lower Urgent Care Copays Pharmacy Benefits
• Preferred Pharmacy Network
Products Overview • Benefit Structure
• Naming Structure • How to Read Drug List
• Plan Design Components
Rules Affecting Rates and Pricing
Network Information 1. Age Bands
• Network Coverage 2. Family Demographics
• New Blue FocusCare network 3. Benefit Design
4. Tobacco Use
Major Medical Products 5. Geographic Rating Areas
• Changes at a Glance
• Marketplace Plans Comparison Charts Retail Shopping Cart (RSC)
• Non-Marketplace Plans Comparison Charts • Marketplace Shopping
• Catastrophic Plans • Non-Marketplace Shopping
• Retail Shopping Cart Videos
Out-of-pocket Costs
• Deductibles ACA Updates and Reminders
• Out-of-Pocket Limits • Tax penalties
• Required training
• Resources and tools
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 4
2017 ILLINOIS UPDATES
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 5
Virtual Visits
• What is a Virtual Visit?
– Virtual Visits allow members to visit with a doctor virtually for simple, non-emergency medical and
behavioral health care needs via phone, video or mobile app. Electronic prescriptions, when
appropriate, can be sent to the members pharmacy of choice.
• How does it work?
– Non-emergency medical consults available by phone and/or video 24/7/365 and behavioral health
consults available by video and by appointment
– Copay will mirror the plan office visit copay
• Behavioral health virtual visits will mirror the plan behavioral health cost share
– Plans with no copay, in-network deductible/coinsurance will apply
– Virtual Visits are considered an additional site of treatment
– Virtual Visits will utilize MDLIVE’s network of physicians
– MDLIVE will have both English and Spanish speaking physicians available
• All other languages will be available via a translation services
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 6
Virtual Visits
How will Virtual Visits be accessed?
– Single sign-on to the MDLIVE portal from Blue Access for MembersSM (BAMSM) and
Blue Access Mobile℠
– Integration with BCBS transparency products – Provider Finder®/MLE
– Warm transfers from Blue Cross Blue Shield of Illinois Customer Advocates to
MDLIVE for questions or technical issues
How to interact with a provider?
• Illinois—Phone and video
– PPO only
– EXCEPTION: IL HMO members will work through medical group
to obtain telemedicine benefits
• *All Behavioral Health Visits are Video
• Services not available on Grandfathered or Grandmothered plans
MDLIVE, an independent company, that provides virtual visit services for Blue Cross and Blue Shield of Illinois. MDLIVE operatesand administers the
virtual visit program and is solely responsible for its operations and that of its contracted providers. MDLIVE and the MDLIVE logo are registered
trademarks of MDLIVE, Inc. and may not be used without written permission. MDLIVE is not an insurance product nor a prescriptionfulfillment
warehouse. MDLIVE operates subject to state regulations and may not be available in certain states. MDLIVE does not guaranteethat a prescription
will be written. MDLIVE does not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of
their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services
*Disclaimer: Access to certain transparency products may not be available for all plans.
Note: Virtual Visits, powered by MDLIVE may NOT be marketed in IL, OK and TX until DOI approval.
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 7
When to Use Virtual Visits
Non-emergency Medical Overview:
Common Medical
Provider Types Medical Services
Issues
• Sinusitis
• Family Medicine
• Non-Emergency Medical for Adults • Allergies
• Internal Medicine
• Non-Emergency Medical for Children • Cold and flu
• Pediatrics
• ePrescribing • Ear ache
• ER Physicians
• Fever
• Pink eye
Behavioral Health Overview:
BH Provider Types BH Services Common BH Needs
• Depression and anxiety
• Psychologists • Diagnostic Assessment
• Marital problems
• Psychiatrists • Ongoing Counseling
• Child behavior and learning issues
• Licensed Professional Counselors • ePrescribing
• Financial hardship
• Licensed Marriage/Family Therapists • Ongoing Med Management
• Coping with loss and grief
• Licensed Clinical Social Workers • Care Coordination
• Stresses and challenges of everyday
• Alcohol/Drug/Addiction Counselors
life
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 8
Hospital vs. Freestanding Outpatient Facility
• What is a freestanding outpatient facility?
– Facility that provides health care services and is neither integrated with, nor department of, a hospital*
• What you need to know?
– Introducing cost share differential to encourage members to go to lower cost facilities for certain services
• EXCEPTIONS -100% coinsurance plans (where deductible amount equals out of pocket maximum) or new CMS standardized plans
– Cost share differential will apply to either the copay, per occurrence deductible, or coinsurance level, depending on
plan design
• Why is this important?
– Use of freestanding outpatient facility reduces medical costs (claims are typically less than hospital setting, resulting
in lower out of pocket costs and lower overall medical costs)
• What does it mean to the member?
– Members will have higher out-of-pocket costs when going to a hospital facility for certain services
• Applies to: Outpatient surgery, X-Rays and Diagnostic Imaging, Laboratory Services, Imaging (CT/PET/MRI)
• No longer applies to Outpatient Infusion Therapy (2016 concept)
*This definition is derived from https://definedterm.com/a/definition/52998
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 9
Cost Share Differential Example
• What you can do to help?
– Encourage members to use Provider Finder’s dropdown section “Freestanding Outpatient Facilities”
– Remember: A member may not understand that the type of facility where they have their service
performed will ultimately cost them more money out of their pocket
In-Network
Freestanding In-Network Hospital Out-of-Network
Outpatient Facility
$400 Per Occurrence $400 Per Occurrence
Deductible and 20% Deductible and 40%
member coinsurance member coinsurance
Cost-sharing 50% coinsurance after
after deductible after deductible
for MRI deductible
OR OR
$400 copay $800 copay
PROPRIETARY INFORMATION. PROPERTY OF BLUE CROSS AND BLUE SHIELD OF ILLINOIS
DO NOT USE WITHOUT PERMISSION. 10