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Direct Pay Changes

Important Changes
New Rules affecting Direct Pay (non-group) Insurance

Summary of Benefits and Coverage
Under the federal Affordable Care Act, health insurers and group health plans are required to provide a Summary of Benefits and Coverage to those who have private insurance. This regulation is intended to give members clear and consistent information about their health plan. This will help you better understand and evaluate your choices.

Since September 23, 2012, we’ve been providing a Summary of Benefits and Coverage to you upon renewal, request, and when material changes occur, at no additional charge. We've also provided an online glossary to help you understand common health care terms.

Summary of Benefits and Coverage to Replace Current Summary of Benefits
We no longer create the benefit summaries that you may have received from us in the past. Instead, we will provide the new Summary of Benefits and Coverage.

We do not provide a Summary of Benefits and Coverage for the following plans:

  • Managed Blue for Seniors
  • Medicare Advantage
  • Medex
  • Dental and vision plans

We will continue to provide current benefit summaries for the plans listed above.

Summary of Benefits and Coverage Services—As of September 23, 2012

  • You can find the Summary of Benefits and Coverage on our website. You will receive a new Summary of Benefits and Coverage every time your plan renews.
  • You can request a Summary of Benefits and Coverage from Member Service by calling the number on the front of your ID card. Within 7 business days of receiving your request, we will provide one copy of the Summary of Benefits and Coverage to you in electronic (PDF) format.
  • If there are changes to your Blue Cross Blue Shield of Massachusetts plan(s) that require updating the Summary of Benefits and Coverage, we'll provide a new one within 30 days.
  • Printed copies of the Summary of Benefits and Coverage are available upon request.

Learn More
Please visit www.bluecrossma.com/national-health-care-reform to access the health care glossary and get updates as they become available. If you have any questions, please call Member Service at the number on the front of your ID card.

Eligibility Requirements
Beginning October 1, 2010, Massachusetts residents who are eligible for coverage through an employer-sponsored (group) plan will be ineligible for coverage in the individual (non-group) market.

Massachusetts residents must establish that they are ineligible for coverage through an employer-sponsored plan that meets MCC guidelines to be eligible for coverage in the individual market.

Enrollment Requirements
Beginning December 1, 2010, Massachusetts residents will only be able to enroll in a plan in the individual market during the annual Open Enrollment period, unless they meet certain criteria.

Massachusetts residents may only obtain individual coverage outside of an Open Enrollment period if they establish that they requested non-group coverage within 63 days of termination of prior creditable coverage held for 18 or more months under a group health plan, governmental plan, or church plan. Additional restrictions may apply.

Any coverage issued based on your completed application today will be effective the first of the month following the receipt of your completed application.