The benefits and the impacts
The Affordable Care Act (ACA) prescribed a vast number of regulations that carriers must comply with when offering ACA-compliant products. Understanding new coverage can create confusion for providers. This is an introduction of Wellmark’s new products, along with an overview of how the benefits and cost-sharing amounts offered under these new products could impact your day-to-day business.
Changes in out-of-pocket maximums (OPMs)
The ACA regulation is a cap placed on the out-of-pocket maximum (OPM) for non-grandfathered plans and is expected to have the greatest impact on when and how much you bill patients. EFFECTIVE JAN. 1, 2014, the new OPM limits cannot exceed those set for Health Savings Accounts. Generally, this means in 2014, the single OPM cannot be more than $6,350, and a family OPM cannot exceed $12,700. Also, all amounts patients pay out of their own pocket, including copayments, will apply toward the OPM. This means that patients will likely reach their OPM sooner.
Once a patient’s OPM amount is satisfied, you can no longer collect any deductible, coinsurance or copayment amounts from that patient. Thus, it will become more important than ever to check Wellmark’s Eligibility Verification and Benefit Inquiry (EVBI) tool at every visit. Doing so will allow you to review how much of the OPM has been satisfied.
Name change for Wellmark provider networks
Are you familiar with the Alliance SelectSM network in Iowa and Blue SelectSM network in South Dakota? These networks will not change; however, for the new plans, both networks will now be referred to as Wellmark Blue PPOSM. The Wellmark Health Plan of Iowa network will be referred to as Wellmark Blue HMOSM. While this change does not impact the service you provide, you should be aware of the name changes, as they will appear on Wellmark ID cards for ACA-compliant plans beginning Jan. 1, 2014.
In the small group market (employers with 50 or fewer employees), Wellmark will also offer plans that are part of the Point of Service (POS) network. POS plans combine elements of both HMO and PPO networks. Benefit levels vary, depending on whether the employee receives care from providers in- or out-of-network. As with a PPO plan, employees may receive care from out-of-network providers, but with greater out-of-pocket costs.
New Wellmark products
New Wellmark products were developed to meet the health insurance needs of those who purchase their own coverage, and for small groups (employers with 50 or fewer employees). The plans are available through Wellmark Blue Cross and Blue Shield of Iowa and South Dakota and to the members of Farm Bureau. Each plan is ACA-compliant, non-grandfathered, and covers the 10 categories of “essential health benefits.”
BEGINNING JAN. 1, 2014, patients coming through your doors could have coverage under one of Wellmark’s new plans. Below is an overview of each category of plans:
These plans are very similar to plans Wellmark offers today. You may collect office visit copayment amounts at time of service. Remember, you can only collect copayments from a patient if his/ her OPM is not satisfied, so be sure to verify Eligibility and Benefits on our secure web page.
Below is the in-network range of cost-sharing for new Wellmark ACA-compliant copay plans designed for small groups, individuals, and families:
These plans are very similar to plans Wellmark offers today. Coinsurance amounts can be collected at time of service. Remember, you can only collect coinsurance amounts from patients if their OPM has not been satisfied, so be sure to verify Eligibility and Benefits.
In the next column you’ll see the in-network range of cost-sharing for new Wellmark ACA-compliant coinsurance plans designed for small groups, individuals and families:
Wellmark’s four new “Max” plans offer maximum streamlining for provider processing. The concept is simple: there are just two numbers to compare. When your patient (our member) reaches his or her annual deductible, the out-of-pocket maximum (OPM) is also met. At that point, your business office will no longer need to collect cost-sharing amounts from the patient.
Below is the in-network range of cost-sharing for new Wellmark ACA-compliant Max plans designed for small groups, individuals and families:
Wellmark designed a unique ACA-compliant health care plan in Iowa called CompleteBlue 50/50. The name says it all. It is a “split the bill,” no-deductible approach to payment of allowed (insurer-provider contracted) charges for medical services.
The plan is available to individuals and families who purchase their own coverage and are residents of Iowa. At this point, the plan is not available to small groups or residents of South Dakota.
Below are the in-network cost-sharing amounts for the new Wellmark ACA-compliant 50/50 plan:
These plans are very similar to the HSA plans Wellmark offers today. Cost-sharing amounts can be collected at time of service. Remember, you can only collect cost-sharing amounts from patients if their OPM has not been satisfied, so be sure to verify Eligibility and Benefits.
Below is the in-network range of cost-sharing for new Wellmark ACA-compliant HSA plans designed for small groups, individuals and families:
Wellmark understands the pressure providers are under to comply with and adapt to the changes brought on by the Affordable Care Act. We are here to inform, assist and support you through these changes. For more information on the ACA, visit WeKnowReform.com — Wellmark’s single source for health care reform news and information.