Does the hospital tiering apply to all hospitals in Massachusetts?
The hospital tiering only applies to acute care/general hospitals in Massachusetts. The Blue Options plans also tier primary care providers.
If a member is admitted to a hospital through the emergency room (ER) the ER copayment is waived and he/she will be responsible for the Enhanced Benefit Tier cost-share level for the inpatient admission up to their out-of-pocket maximum.
What's the difference between an ambulatory surgical facility and surgical day care unit?
A surgical day care unit is part of a hospital and bills as a hospital. An ambulatory surgical facility can be a freestanding surgical facility, not associated with a hospital.
`The member is responsible for the Basic Benefits Tier deductible and inpatient copayment, up to their out-of-pocket maximum. The member is not responsible for any additional Standard Benefits Tier cost-share (deductible and/or copayment) because this was a transfer and not a separate admission.
If a member is admitted to an Enhanced Benefits Tier hospital but is then transferred to a Basic Benefits Tier hospital, what is the member's cost-share responsibility?
The member is responsible for the Enhanced Benefits Tier inpatient copayment (there is no deductible on Enhanced Benefits Tier admissions). The member is not responsible for the Basic Benefits Tier cost-share (deductible and/or copayment) because this was a transfer and not a separate admission.
What happens when a member is re-admitted to a facility?
The member is not responsible for a new inpatient admission cost-share (deductible and/or copayment) if he/she is re-admitted to the same facility within seven days from being discharged from the hospital for the same or related DRG.
What happens when a newborn baby with a medical condition is transferred from one facility to another facility?
For well newborns, the inpatient admission cost-share is satisfied through the mother's admission. A newborn baby with a medical condition who is transferred from the birth location to another facility is not responsible for an inpatient admission cost-share (deductible and/or copayment).
Why do the new Blue Options deductible plans have an out-of-pocket (OOP) maximum and the existing Options plans (copays only) do not?
According to minimum credible coverage (MCC) standards, if a health benefit plan includes deductibles or co-insurance for in-network core services, the plan must set out-of-pocket maximums for in-network covered services that do not exceed $5,000 for an individual and $10,000 for a family. Our new Blue Options deductible plans, meet this definition, and therefore, the $5,000/$10,000 out-of-pocket maximum applies. Our existing Options plans do not require the $5,000/$10,000 out-of-pocket maximum in order to meet MCC standards.