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2009 Plan Updates

Product Portfolio and Benefit Design Updates
As part of our ongoing effort to improve the quality and affordability of the health care that our members receive, effective October 1, 2009, we are instituting several changes to our standard plan designs and have introduced one new plan option.

Please review the pdf Product Portfolio and Benefit Design Update brochure and the pdf Standard Plan Design Changes chart for a detailed overview of the changes.

Emergency Room Copayment Changes
When members use hospital emergency rooms for non-urgent care, it has a negative effect on both the quality and cost of health care. To encourage members to use emergency departments only when they urgently need care, beginning October 1, 2009, emergency room copayments will be increased in many of our plans. The copayment amounts for emergency room services will be increased to $100, $150, or $200, depending on the premium level and out-of-pocket cost of the plan.

High-Tech Radiology Benefit Change
Changes are being made to our plan designs that include a copayment for certain outpatient radiology diagnostic tests (MRI, CT, and PET scans). Effective October 1, 2009 (or on anniversary for renewing customers), the high-tech radiology copayment will be waived when the test is delivered in association with an emergency room visit or surgical day procedure. In addition, we will be applying the outpatient radiology diagnostic test copayment to a fourth category of test: nuclear cardiac imaging.

Plans Changing to Plan-Year Accumulation for Deductible and Out-of-Pocket Maximums
The following plan designs will change from a calendar-year deductible and out-of-pocket maximum accumulation to a plan-year deductible and out-of-pocket maximum accumulation. The plans that are changing are:

  • HMO Blue® Premier Value
  • HMO Blue New EnglandSM Premier Value
  • Network Blue® Premier Value
  • Network Blue New England Premier Value
  • Access Blue BasicSM

Mental Health Benefit Changes
Mental health conditions are classified as either biologically based conditions or non-biologically based conditions under Blue Cross Blue Shield of Massachusetts products. Effective July 1, 2009, four categories of non-biological conditions are being reclassified as biologically based conditions. These categories are substance abuse, eating disorders, post-traumatic stress disorder (PTSD), and autism.

Effective July 1, 2009, the benefits that are provided for these four conditions will be the same as benefits provided for biologically based conditions. For example, a benefit limit such as the 24-outpatient-visit limit would no longer apply for substance abuse, eating disorders, PTSD, or autism.

The federal Emergency Economic Stabilization Act of 2008 (Mental Health Parity Act) was passed in October 2008. The Act requires that group health plans and group health insurers that provide physical and mental health/substance use disorder benefits ensure that the financial requirements and treatment limitations that apply to mental health and substance use disorder benefits are no more restrictive than the financial requirements and treatment limitations on physical benefits.

Coverage of these mental health benefits will apply to group health plans, except group accounts with fewer than 50 employees, Medex®' plans, Medicare Advantage plans, dental and vision plans, non-group plans, student health plans offered by schools, and Federal Employee Program (FEP) plans. These changes will become effective on October 1, 2009 (or upon account renewal).

Options Product Re-Tiering
Our family of tiered-network products provides members with information about provider quality and cost, and financial incentives for choosing Enhanced Benefits Tier providers. These plans include: HMO Blue New England Options, HMO Blue Options, Network Blue New England OptionsSM, Network Blue Options, Blue Precision®, Preferred Blue PPOSM Options, and PPO Blue OptionsSM.

Providers are placed in one of three provider tiers (Enhanced, Basic, or Standard Benefit Tiers) depending on their performance on cost and quality-of-care measures. We will be updating the provider tiers in a manner that is consistent with well-accepted principles for performance measurement, including those recommended by local and national physician leaders and measurement experts. Hospital quality and cost data will become available to members of all plans so you can consider whether a tiered-network plan is right for you.

Midwife/Home Birth Coverage Clarification
In response to requests by our members, we are clarifying our position on care given by certified professional midwives and other types of midwives. Home births are not the standard practice of care in Massachusetts, and therefore, our benefits are specific to certified nurse midwives (CNMs), and cover only the services that these clinicians provide.

In addition, any home births taking place in Massachusetts on or after October 1, 2009, will only be covered when the delivery is made in the home in an emergency or unplanned situation and when rendered by a network provider (i.e., CNM, obstetrician).

Unplanned births are those in which circumstances prevent the mother from delivering at a hospital or birthing center. To seek care in such a situation, the mother should call 911 if appropriate, and/or her certified nurse midwife or obstetrician (or their covering provider).

Infertility Changes
Effective October 1, 2009, the following changes will be made to coverage for infertility treatments:

1. We will cover infertility services according to our medical policy for women over the age of 35 who have been unable to conceive for six months.

2. We will cover one in vitro fertilization (IVF) cycle for women who will receive treatment for cancer that will make them unable to conceive. The IVF cycle will be made available prior to the treatment that will cause them to become infertile.

PPO and HMO Plan Coverage for Non-Participating Radiology, Anesthesiology, Pathology, and Emergency Medicine Providers
The following applies to services received for hospital-based radiologists, anesthesiologists, pathologists, and emergency medicine specialists who do not participate in our PPO and/or HMO networks and whose billing is not handled through a participating group. Effective January 1, 2009, when a member receives a covered service from one of these non-participating providers, Blue Cross and Blue Shield will pay the subscriber directly for these services. It is the responsibility of the subscriber to pay the provider. The provider is responsible for collecting payment from the subscriber. Refer to the chart below to see which hospitals, provider types, and networks are affected. A box marked with an X indicates that the provider does not participate in this plan network.

 

Affected Hospitals Radiology Anesthesiology Pathology Emergency
HMO PPO HMO PPO HMO PPO HMO PPO
Anna Jaques Hospital                
Berkshire Medical Center x x     x      
Beverly Hospital         x      
Cape Cod Hospital     x   x x x x
Caritas Carney Hospital         x x    
Caritas Good Samaritan Medical Center           x    
Caritas Norwood Hospital     x x x x    
Cooley Dickinson Hospital x x x x x      
Falmouth Hospital     x          
Jordan Hospital                
Mercy Hospital                
Morton Hospital and Medical Center                

x = Provider not in network

 

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