Healthcare Reform Timeline

Frequently Asked Questions

 

Benefits/coverage

Starting with plan years beginning on or after January 1, 2014, plans that are not grandfathered will provide coverage for routine patient costs received by a member who is participating in an approved clinical trial. This change will expand the coverage currently provided. Coverage will include phase I clinical trials and expand the types of conditions beyond cancer. 

Plans will cover routine costs associated with a phase I, phase II, phase III, or phase IV clinical trial that is being done to prevent, detect, or treat cancer or a life-threatening disease or condition (a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted). Routine patient costs are considered the medically necessary services that would be otherwise covered by a health plan if the member was not a part of a clinical trial.

To qualify, a clinical trial must be at least one of the following:

  • Federally funded
  • Conducted under an investigational new drug application reviewed by the Food and Drug Administration
  • A drug trial that is exempt from having such an investigational new drug application

This information is subject to change based on new or revised laws or regulations, and additional coverage rules and limitations may apply. For more information on how these benefits may apply to your coverage, please check your subscriber agreement or call Customer Service.

Benefits/coverage

Health insurance issuers like Blue Cross are obligated to pay claims for covered services rendered during the first month of the grace period. During the second and third months of the grace period, health insurance carriers may pend claims until the member has either paid the premiums owed or the grace period has ended. At the end of the grace period, if the member has not paid their premiums, claims may be denied.

During the grace period, providers will be notified that their claims are pended because the member is in the grace period. In addition, we are working to ensure that when providers contact Blue Cross to confirm eligibility, they are informed that the member’s eligibility is pended as a result of the grace period. 

Members who may be eligible for this grace period will have a ZBN prefix on their ID card. It is important to note that not every member who purchases coverage through HealthSource RI in the individual market will be eligible for premium subsidies or for the grace period. 

For all other members enrolled through HealthSource RI or directly through Blue Cross, there will be a one-month grace period for members who are delinquent in paying their bills. Blue Cross will continue to pay claims during this one-month period.

Benefits/coverage

Beginning in January 2014, Blue Cross will be offering a variety of commercial plans through HealthSource RI to individuals and families as well as small businesses and their employees. These plans include VantageBlue, VantageBlue SelectRI, BlueSolutions for HSA, BlueCHiP for Healthy Options, and Blue Cross Dental Direct. These plans operate in the same way whether they are purchased directly from Blue Cross or through HealthSource RI. Providers should continue to follow current practices for eligibility, benefits, care management, and claims processing. Please note that Medicare plans are not available through HealthSource RI.  

Benefits/coverage

The mental health parity regulations now apply to plans sold in the individual and small group markets and will continue to apply to the large group market. Blue Cross has offered compliant plans in all commercial markets since mental health parity went into effect, and we will continue to ensure that our plans remain compliant with these regulations. 

Benefits/coverage

Health plans now provide full coverage for many preventive services with no cost sharing (deductibles, copays,  or coinsurances) when members visit in-network doctors. Preventive care is healthcare that is aimed at screening for and preventing disease, including:

  • Flu shots and other immunizations 
  • Blood tests 
  • Other screenings such as mammograms, Pap tests, and colonoscopies
  • Other preventive services covered under federal healthcare reform

When state law is more generous than the federal mandates for preventive services, we follow state law. For more information about preventive care services, please read this sheet.

Benefits/coverage

Provider responsibilities

Upon renewal, Blue Cross plans sold in the individual and small employer group market will need to include essential health benefits. All member cost sharing for an essential health benefit will apply to the member’s out-of-pocket maximum. This will include copayments for office visits that typically don’t apply to the member’s out-of-pocket maximum.

Once the out-of-pocket maximum is met, the member will have 100 percent coverage in network. It is more important than ever for providers to verify a member’s benefits and eligibility prior to rendering services as many changes will be implemented as groups renew in 2014 into ACA-compliant plans.

To determine whether a member’s plan has renewed, providers should check the effective date (under member coverage) on the Plan Summary page in the Eligibility section of BCBSRI.com. It is safe to assume that the member’s plan has not renewed if the effective date is prior to January 1, 2014.

Important note: Since groups will be renewing into plans that comply with several new healthcare reform regulations, it is very important for providers to remember to verify a member’s eligibility and benefits. 

Provider responsibilities

HealthSource RI is a health insurance marketplace (also called an exchange) where Rhode Island individuals, families and small employers can compare and buy health plans. Blue Cross will be offering some of our commercial plans through HealthSource RI, and providers will participate if their contract includes our commercial plans.

Provider responsibilities

Other

To help increase access to care, the Affordable Care Act includes investments in healthcare professionals, including:

  • Expanding the National Health Service Corps to repay student loans and provide scholarships for primary care physicians, physician assistants, and nurse practitioners willing to work in underserved areas (effective 2010).
  • Providing increased payment to rural healthcare providers to help them continue to serve their communities (effective 2010).
  • Establishing the Community First Choice Option, which allows states to offer home- and community-based services to disabled people through Medicaid rather than institutional care in nursing homes (effective 2011).
  • Increasing Medicaid Payments for primary care doctors. States must pay primary care physicians no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services (effective 2013).
Other