Flexible Network FAQs

Transcription

1 Flexible Network FAQs A tiered PPO network for self-insured national accounts Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is working with other Blue Cross and Blue Shield Plans (Blue Plans) to develop a Flexible Network for national accounts, which will become available in North Carolina s Charlotte region in This Flexible Network will offer self-insured National Accounts a new tiered benefit design for their employees (non-emergency) acute care hospital and ambulatory surgical center services when services are obtained as in-network through the BlueCard program. In its design, the Flexible Network allows national accounts to help decide facility tiers based upon and quality performance groupings, and to customize benefit plans to differentiate employees -for-care based upon those groupings. As example, if a facility s specific and quality performance grouping on a scale of one to ten is a five, the employer can decide if five is considered a tier-one or tier-two for its employees benefits. Cost and quality performance groupings begin with a comprehensive evaluation of facilities (i.e. acute care hospitals and ambulatory surgical centers). Facilities must meet a baseline set of nationally-consistent, industry-recognized quality measures. Facilities are then assessed and grouped based on s and benchmarked against their peers. After facility groupings are finalized, national employer accounts will develop benefit differentials based on their unique employee population and specific goals. Flexible Network + Utilizes Blue Cross NC s existing PPO (preferred provider organization) network for commercially offered, under age-65 products. + Available only to self-insured national accounts electing Flexible Network PPO benefit plans. + Keeps access open within the BlueCard PPO network. + Members have the ability to seek care from any facility participating in Blue Cross NC s PPO network for commercial products. + Members with this benefit design will have the lowest out-of-pocket when they choose or are referred to a tier-one facility in the Charlotte region, when facility services are needed. + Members with Flexible Network tiered benefit designs can obtain urgent and emergent care at any in-network PPO hospital emergency room. However, if admitted to the hospital from the emergency room, the member s out-of-pocket s for the inpatient hospital stay will be determined by the hospital s tier associated with the member s benefit.

2 Flexible Network starts in the Charlotte region, January 1, 2019 Acute care hospitals and ambulatory surgical centers in the Charlotte region will be included in the Flexible Network for National Accounts, beginning January 1, At this time 40 facilities are anticipated to be grouped within the Flexible Network s tiered benefit design: + 18 acute care hospitals, and + 22 ambulatory surgical centers Acute care hospitals and ambulatory These include Zip Codes that begin with surgical centers outside of the Charlotte the first-three numeric characters of: region will not be grouped as part of the Flexible Network s tiered benefit (280) (281) (282) (297) design, and can provide in-network services if participating in Blue Cross NC s PPO network for commercially offered, under age-65 products. Blue Plans will sell the Flexible Network to self-insured national account employers outside of North Carolina. If those employers have employees using Blue Cross NC s PPO network for commercially offered, under age-65 products, you may see members with Flexible Network benefits starting in How providers in the Flexible Network are grouped Working with the Blue Cross and Blue Shield (BCBS) Association, Blue Plans are evaluating acute care hospitals and ambulatory surgical centers within the national BlueCard PPO network. These facilities are first grouped using a set of nationwide, industry-recognized quality measures. Then the facilities are grouped by the of care. A facility s inclusion in the Flexible Network requires a baseline set of nationallyconsistent quality measures be met. The facility is then assessed and grouped based on benchmarks and against peers. + Grouping 1-10 indicates a facility met quality and measures for inclusion. + indicates a facility did not meet quality criteria. The included facilities have been selected based upon their Zip Code locations within the Charlotte region. + indicates insufficient quality data was available on a specific facility, or the quality threshold was met but there is insufficient data. Group 1 10 $-$$$ Met overall quality benchmark and grouped based on with group (1) having the lowest out-of-pocket for the member [ ] [ ] [ ] Did not meet overall quality benchmark (??? ) Ungrouped BlueCard network facility not grouped typically due to insufficient data

3 Flexible Network development The Flexible Network offers National Account employers and members greater opportunity to help self-manage their health care spending The Flexible Network is being developed as a solution within the Blue Distinction High-Performance Network portfolio, and is designed to serve the evolving needs of our National Accounts. Employers are looking for new ways to improve their employees health while managing their health care s. At the same time, members are looking for tools to help them make choices about where they get their care. With the Flexible Network, Blue Plans can offer members access to the broader national BlueCard PPO network, while also giving them a choice in options about facility-based services and making decisions Assess Quality [ ][ ] [ ] Evaluate Cost Performance For facilities meeting overall quality benchmarks $ Group 1 Design Benefit Differentials Sample designs [ Employer A ] Groups 1-5 Groups 6-10 Lowest member Acute Care Hospital Ambulatory Surgical Facility BlueCard PPO Network Group 10 $$$ COST EVALUATION Did not meet quality Insufficient data Out-of-network Groups 1-4 Lower member Highest member [ Employer B ] Lowest member Groups 5-10 Employers decide sharing groupings to create benefit designs for employees, and each employer can customize the groupings. Did not meet quality Insufficient data Out-of-network Lower Member Cost Highest member

4 About the Flexible Network Members can seek services from any BlueCard PPO, in-network facility or provider National Account, BlueCard eligible members having the Flexible Network tiered benefit design will be able to access services from any health care facility or provider participating in Blue Cross NC s PPO network for our commercially offered products. Facilities and providers must be in Blue Cross NC s PPO network for commercially offered, under age-65 products, for eligibility to provide in-network services. Facilities and providers participating in Blue Cross NC s Medicare Advantage PPO network but not in the commercial PPO network will be considered out-of-network for these members. Members pay less out-of-pocket when they obtain facility services at tier-one facilities National Account members with this benefit design will have the lowest out-of-pocket when they choose or are referred to tier-one facilities in the Charlotte region (when facility services are needed). + To support National Account members in understanding how their choice in different facilities will result in different out-of-pocket s, the benefit designs will be communicated to members through their employer groups, and Blue Plan transparency tools and call centers. + Members with Flexible Network benefits will be able to find facility tier information, applicable to their specific benefit plan and their facility of choice, by using the Blue Cross Blue and Shield Association s National Doctor & Hospital Finder tool, and also by accessing their own member account information available through their home-blue Plan s website for members. Verify members benefits and eligibility the same way you do for other BlueCard patients National Account members with this benefit design are also BlueCard members, so there s no change to how you obtain a member s benefits and eligibility information. Member applicable benefit tiers will also be available as part of the benefits and eligibility verification process. When checking a member s benefits and eligibility, you ll also be able to see that member s benefit tiers and what they should expect to pay out-of-pocket for their facility services. Tiers do not apply to emergency room services National Account members with Flexible Network tiered benefit designs can access urgent and emergent care at any in-network PPO hospital emergency room. However, if admitted to the hospital from the emergency room, the member s out-ofpocket s for the inpatient hospital stay will be determined by the hospital s tier associated with the member s benefit.

5 About the Flexible Network Not all National Account members will have the Flexible Network tiered benefit design Blue Plans are offering National Accounts the Flexible Network tiered benefit design, as an option for their employees. Blue Plans will also continue to offer National Accounts the same types of benefit plan options they have today. Most National Account members will not have the Flexible Network tiered benefit design in Later this year, we ll know more about how many National Account members may be enrolled in the Flexible Network tiered benefit design for 2019, and we ll provide an update when we have this information. Facility reimbursement rates are not changing as part of the Flexible Network design Blue Cross NC s negotiated rates and fees for services provided by acute care hospitals and ambulatory surgical centers are not affected by the Flexible Network design. Cost and quality information will be provided to facilities in the Charlotte region in March 2018 Early next month, acute care hospitals and ambulatory surgery centers in the Charlotte region will receive written notifications containing additional details about their individual and quality performance groupings within the Flexible Network. Also included, will be information about how and quality data is collected. Information will additionally include instructions about how to request an appeal if your facility doesn t agree with its grouping for the Flexible Network. Cost and quality data will be reviewed annually Working with the BCBS Association, Blue Plans will review and quality data every year, as necessary, to ensure alignment with up-to-date quality and performance information. The BLUE CROSS and BLUE SHIELD names and symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.