Change in Tiered Network Benefits For Some Serious Conditions
Our tiered network plans now include a new benefit for certain members with a serious health condition, such as cancer or cystic fibrosis.
The benefit only applies to employer-sponsored plans with fewer than 50 employees or people who purchase health coverage directly from Blue Cross Blue Shield of Massachusetts.
With this new benefit, which is due to a change in Massachusetts' insurance law, members who qualify can receive care at certain higher-cost facilities and pay a lower cost share for up to one year. That way, their care isn't disrupted.
We are notifying subscribers of the new benefit via letter.
Details of Benefit
Members can qualify for this protection if they started active treatment before they enrolled in a tiered-network plan and they meet all of the conditions listed below:
- They have been receiving treatment for a serious health condition at one of the following: Dana Farber Cancer Institute; Children's Hospital; Shriners Hospital in Boston or Springfield; Floating Hospital for Children at Tufts Medical Center; Nashoba Valley Medical Center; or Massachusetts Eye and Ear Infirmary.
- They would normally pay the highest cost share amount for the above-mentioned hospital's services, or their hospital is not part of your network.
- Their active course of treatment, if disrupted, would cause them undue hardship. This means, for example, it could endanger their life, cause suffering or pain, result in a substantial change to their treatment plan, or they would have to obtain their care from multiple providers in a way that would significantly worsen their condition.
- The services are medically necessary and covered.
In addition, this benefit varies based on when the member started getting care:
- If they started active treatment before May 1, 2012, they'll pay a lower cost share for covered services that are part of that course of treatment through April 30, 2013.
- If the member started active treatment on or after May 1, 2012, your company must have only offered the subscriber the tiered-network plan in which his or her hospital had the highest cost share (most expensive for the member), or his or her hospital is not part of the network and the treatment is not available from another provider in the network. If that's the case, the member will pay the lower cost share for covered services that are part of that course of treatment for a 12-month period, starting when the subscriber first enrolled in a tiered-network plan.
To apply for the benefits, member and his or her doctor will need to fill out the Continuity of Care Form for Plans That Include a Tiered-Provider Network form. When we receive the member's completed form, we will review it to determine if the member's care qualifies for the reduced cost share. If the member does not qualify for the reduced cost share and he or she receives care at one of the listed hospitals, he or she will have to pay the cost share amounts that normally apply for that hospital under the tiered-network plan.