Inter-Plan Arrangements
Model Simplified Member Benefit Booklet Disclosure Language
HMO/PPO/POS/EPO/Traditional
Out-of-Area Services
Overview
We have a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area we serve (the “[Anthem] Service Area”), the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below.
When you receive care outside of the [Anthem] Service Area, you will receive it from one of two kinds of Providers. Most Providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some Providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of Providers. [Insert for plans that have limited out of network coverage: [The Plan] covers only limited healthcare services received outside of the [Anthem] Service Area. For example, Emergency [or Urgent Care] obtained outside the [Anthem] Service Area is always covered. Any other services will not be covered when processed through any Inter-Plan Arrangements {, unless authorized by [Anthem]}.
Inter-Plan Arrangements Eligibility – Claim Types
Most claim types are eligible to be processed through Inter-Plan Arrangements, as described above. Examples of claims that are not included are prescription drugs that you obtain from a pharmacy and most dental or vision benefits.
A. BlueCard® Program
Under the BlueCard® Program, when you receive Covered Services within the geographic area served by a Host Blue, [Anthem] will still fulfill [Our] contractual obligations. But, the Host Blue is responsible for: (a) contracting with its Providers; and (b) handling its interactions with those Providers.
When you receive [Covered Services] outside the [Anthem] Service Area and the claim is processed through the Blue Card Program, the amount you pay is calculated based on the lower of:
- The billed charges for [Covered Services] or
- The negotiated price that the Host Blue makes available to Us.
Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to the Provider. Sometimes, it is an estimated price that takes into account special arrangements with that Provider. Sometimes, such an arrangement may be an average price, based on a discount that results in expected average savings for services provided by similar types of Providers. Estimated and average pricing arrangements may also involve types of settlements, incentive payments and/or other credits or charges.
Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price We used for your claim because they will not be applied after a claim has already been paid.
B. Negotiated (non–BlueCard Program) Arrangements
With respect to one or more Host Blues, instead of using the BlueCard Program, Anthem may process your claims for [Covered Services] through negotiated arrangements for national accounts.
The amount you pay for [Covered Services] under this arrangement will be calculated based on the lower of either billed charges for [Covered Services] or the negotiated price (refer to the description of negotiated price under Section A, BlueCard Program) made available to [Anthem] by the Host Blue.
C. Special Cases: Value-Based Programs
BlueCard® Program
If you receive Covered Services under a value-based program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or care coordinator fees that are a part of such an arrangement, except when a Host Blue passes these fees to Anthem through average pricing or fee schedule adjustments.
If Anthem has entered into a negotiated arrangement with a Host Blue to provide value-based programs to the [Plan] on your behalf, [Anthem] will follow the same procedures for value-based programs administration and care coordinator fees as noted above for the BlueCard Program.
D. Nonparticipating Providers Outside [Anthem] Service Area
Option 1 (use if plan uses InterPlan Program pricing):
- Allowed Amounts and Member Liability Calculation
When Covered Services are provided outside of [Anthem]’s Service Area by non-participating providers, [the Plan] may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law. In these situations, the amount you pay for such services as deductible, copayment or coinsurance will be based on that allowed amount Also, you may be responsible for the difference between the amount that the non-participating provider bills and the payment [the Plan] will make for the Covered Services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out-of-network emergency services. - Exceptions
In certain situations, [the Plan] may use other pricing methods, such as [billed charges the pricing it would use if the healthcare services had been obtained within the [Anthem] Service Area, or a special negotiated price to determine the amount [the Plan] will pay for services provided by nonparticipating providers. In these situations, you may be liable for the difference between the amount that the nonparticipating provider bills and the payment [the Plan] makes for the Covered Services as set forth in this paragraph.
Option 2 (use if group picks another methodology to calculate the allowed amount for nonparticipating provider claims (e.g., % of Medicare) or has another section of the plan that would also describe the use of InterPlan pricing)
The pricing method used for nonparticipating provider claims is described in (insert description of Section of booklet).
E. BlueCard Worldwide® Program
If you plan to travel outside the United States, call customer service to find out your BlueCard Worldwide benefits. Benefits for services received outside of the United States may be different from services received in the United States. [Insert if applicable: The plan only covers Emergency, including ambulance, {and Urgent Care} outside of the United States.] Remember to take an up to date health ID card with you.
When you are traveling abroad and need medical care, you can call the BlueCard Worldwide Service Center any time. They are available 24 hours a day, seven days a week. The toll free number is 800-810-2583. Or you can call them collect at 804-673-1177.
[Delete if only covering emergency care: If you need inpatient hospital care, you or someone on your behalf, should contact us for preauthorization.] Keep in mind, if you need emergency medical care, go to the nearest hospital. There is no need to call before you receive care.
How claims are paid with BlueCard Worldwide
In most cases, when you arrange inpatient hospital care with BlueCard Worldwide, claims will be filed for you. The only amounts that you may need to pay up front are any copayment, coinsurance or deductible amounts that may apply.
You will typically need to pay for the following services up front:
- Doctors services
- Inpatient hospital care not arranged through BlueCard Worldwide; and
- Outpatient services.
You will need to file a claim form for any payments made up front.
When you need BlueCard Worldwide claim forms you can get international claims forms in the following ways:
- Call the BlueCard Worldwide Service Center at the numbers above or
- Online at www.bluecardworldwide.com.
You will find the address for mailing the claim on the form.
Drafting notes: Terms that are [bracketed] can be replaced with any defined terms used by the Plan (e.g., “Covered Services” may not be defined, in which case it could be changed to “covered services”). Additionally, if the plan is not drafted to use “you” and instead refers to Members or Participants, this language can be updated to reflect the style used in the Plan/SPD.
Any sections that are totally bracketed can be deleted if not applicable. These sections generally relate to EPO/HMO type plans that only cover urgent/emergent care outside of the plan’s service area.
Section D requires a choice between Option 1 or 2.
