Posted on NaviNet Plan Central page 3-3-08 MY DIRECT BLUE: HIGHMARK'S ACA PLAN FOR 08 In an increasingly challenging ACA market, Highmark continues to pursue options for keeping health insurance affordable for our ACA members. To accomplish this in 08 we are offering several ACA plans in western Pennsylvania using an ACA select network. Note: In some counties Highmark continues to offer an ACA PPO plan that uses our broad networks. Nationwide, ACA health plans are shifting to select network models as reflected in the 07 ACA plans, where more than 75 percent are using HMO or EPO models. By offering a select network of high-quality providers, Highmark is working to keep care local and provide quality outcomes at an affordable cost for our ACA members. The new ACA select network includes local physicians and hospitals and meets all state and federal access requirements. Depending on their county of residence, members will have either an HMO or an EPO plan available, with multiple options for deductibles, cost sharing, or out-of-pocket maximums. BlueCard and providers in other regions are excluded. Members will have access to out-of-network providers for emergency or urgent care only. Members do not have out-of-network benefits for nonemergency care. Members are liable for 00 percent of the cost of services rendered by out-of-network providers. Western Pennsylvania HMO EPO Network my Direct Blue EPO: Beaver, Butler counties ACA Select my Direct Blue HMO: Allegheny, Crawford, Erie, Washington, and counties my Direct Blue Conemaugh EPO: Blair, Cambria, and Somerset counties WHAT PROVIDERS NEED TO KNOW Beginning Nov. 5, 07, Highmark sent letters to providers to inform them of their participation status in the ACA select network. If you did not receive such notification, assume you are not in the ACA select network for 08. (Continued)
You can use NaviNet to confirm if you are participating in the ACA select network by accessing Provider File Management. Select the View group details link in the upper left corner of the screen. We identified the participating providers using criteria such as member access needs by geography, ownership of practice, specialty-required admitting privileges, and quality and efficiency. If a physician practice is employed by a hospital or health system in the network, the practice will participate. Likewise, if the practice is employed by a hospital or health system that is not in the network, the practice will also not participate. (See the map or chart below.) You can find an overview of our product changes for 08 on the Highmark 08 web page, which you can access through the Provider Resource Center. The Provider Resource Center is accessible through NaviNet or through our website, under Helpful Links. The new plans using the ACA select network were effective Jan., 08. Be sure to see the map, hospital list, and alpha prefixes, included below. REMINDER As always, we encourage you to use the convenient, self-service tools available to you and your staff. NaviNet offers quick and easy access to verify your participation status, member eligibility and benefits, allowances, request authorizations, and submit or research claims. In addition, the Provider Resource Center contains all of the reference materials you need in one convenient place, including manuals, medical policy, and 08 product information. (Continued)
HELP OUR MEMBERS STAY IN NETWORK For 08, please remember that our HMO and EPO ACA products will be supported by a select network. As a Highmark network provider, you can assist your patients by always referring them to other Highmark innetwork providers. Your referrals affect your patients' costs and quality of care. Members get the most from their health benefits when they receive services from in-network providers. Going out of network means my Direct Blue patients' claims will be denied, and those patients will be responsible for 00 percent of the cost of care. Be sure your my Direct Blue patients get the most from their health benefits by referring them to hospitals and providers within the ACA select network. To identify Highmark ACA select network providers, visit our online Provider Directory on the Provider Resource Center. You can access the Provider Resource Center through NaviNet. (Map, hospital list, alpha prefixes and sample ID cards follow below.)
5 ACA Select Network In-Network Hospitals Key ACA Select Network Product Counties NEPA Region Network Product Counties Limited Participation Counties 3 Erie 9 Warren McKean Potter Tioga Bradford Susquehanna Non-Compete Region Crawford 6 Mercer Lawrence Beaver 8 7 Washington 3 5 3 6 Butler Venango Clarion Armstrong Forest Jefferson Indiana Elk 4 Clearfield Cameron Centre Clinton Lycoming Union Snyder 5Allegheny Cambria Dauphin 7 4 Blair Perry 3 6 0 3 Huntington Greene 37 3 8 Fayette 40 39 Somerset 34 Bedford 4 Franklin 5 8 Adams 9 Sullivan Columbia Montour York Lebanon Lancaster Wyoming Luzerne 8 Schuylkill Carbon Lackawanna Wayne Monroe 3 Lehigh 3 Berks 0 Ch 3 0 Pike Northampton Bucks Montgomery # Name County # Name County # Name County # Name County Allegheny General Hospital Allegheny Nason Hospital Blair Corry Memorial Hospital Erie 3 Lehigh Valley Hospital - Muhlenberg Northampton Allegheny Valley Hospital Allegheny Butler Memorial Hospital Butler Millcreek Community Hospital Erie 3 Schuylkill Medical Crt East Norwegian St Schuylkill 3 Childrens Hospital of Pittsburgh Allegheny 3 Conemaugh Memorial Medical Center Cambria 3 Saint Vincent Health Center Erie 33 Schuylkill Medical Ctr South Jackson Street Schuylkill 4 Forbes Regional Hospital Allegheny 4 Conemaugh Miners Medical Center Cambria 4 Chambersburg Hospital Franklin 34 Conemaugh Meyersdale Medical Center Somerset 5 Heritage Valley Sewickley Allegheny 5 Blue Mountain Hospital (all hospitals) Carbon 5 Waynesboro Hospital Franklin 35 Advanced Surgical Hospital, LLC Washington 6 Jefferson Regional Medical Center Allegheny 6 Meadville Medical Center Crawford 6 Lancaster General Hospital Lancaster 36 Canonsburg General Hospital Washington 7 The Western Pennsylvania Hospital Allegheny 7 Titusville Area Hospital Crawford 7 Sacred Heart Hospital Lehigh 37 Monongahela Valley Hospital, Inc. Washington 8 Heritage Valley Beaver Beaver 8 Carlisle Regional Medical Center Cumberland 8 Lehigh Valley Hospital-Hazleton Luzerne 38 Excela Frick Hospital 9 Lehigh Valley Hospital Lehigh 9 Holy Spirit Hospital Cumberland 9 Bradford Regional Medical Center McKean 39 Excela Latrobe Hospital 0 St Joseph Medical Center Berks 0 Milton S Hershey Medical Center Dauphin 30 Lehigh Valley Pocono Monroe 40 Excela Hospital Last Updated: 09/7/7 Confidential and Proprietary 0
ACA Select Network In-Network Hospitals (detail) page of Name Region ACA Select Network System City County Allegheny General Hospital WPA In AHN Pittsburgh Allegheny Allegheny Valley Hospital WPA In AHN Natrona Heights Allegheny Childrens Hospital of Pittsburgh WPA In UPMC Pittsburgh Allegheny Forbes Regional Hospital WPA In AHN Monroeville Allegheny Heritage Valley Sewickley WPA In Heritage Sewickley Allegheny Jefferson Regional Medical Center WPA In AHN Jefferson Hills Allegheny The Western Pennsylvania Hospital WPA In AHN Pittsburgh Allegheny Heritage Valley Beaver WPA In Heritage Beaver Beaver St Joseph Medical Center CPA In Independent Reading Berks Nason Hospital WPA In Conemaugh Roaring Spring Blair Butler Memorial Hospital WPA In Independent Butler Butler Dlp Conemaugh Memorial Medical Center, LLC WPA In Conemaugh Johnstown Cambria Dlp Conemaugh Miners Medical Center, LLC WPA In Conemaugh Hastings Cambria Blue Mountain Hospital CPA In Blue Mountain Palmerton Carbon Blue Mountain Hospital Gnaden Campus CPA In Blue Mountain Lehighton Carbon Blue Mountain Hospital Palmerton Campus CPA In Blue Mountain Palmerton Carbon Meadville Medical Center WPA In Independent Meadville Crawford Titusville Area Hospital WPA In Independent Titusville Crawford Carlisle Regional Medical Center CPA In Pinnacle/UPMC Carlisle Cumberland Holy Spirit Hospital CPA In Independent Camp Hill Cumberland Milton S Hershey Medical Center CPA In Hershey Hershey Dauphin Corry Memorial Hospital WPA In Independent Corry Erie Millcreek Community Hospital WPA In Independent Erie Erie Saint Vincent Health Center WPA In AHN Erie Erie Chambersburg Hospital CPA In Independent Chambersburg Franklin Waynesboro Hospital CPA In Independent Waynesboro Franklin Last Updated: 09/7/7 Confidential and Proprietary
ACA Select Network In-Network Hospitals (detail) page of Name Region ACA Select Network System City County Lancaster General Hospital CPA In Lancaster General Lancaster Lancaster Lancaster General Women's and Babies Hospital CPA In Lancaster General Lancaster Lancaster Lehigh Valley Hospital CPA In Lehigh Allentown Lehigh Sacred Heart Hospital CPA In Independent Allentown Lehigh Lehigh Valley Hospital-Hazleton CPA In Lehigh Hazleton Luzerne Bradford Regional Medical Center WPA In Independent Bradford McKean Lehigh Valley Hospital - Pocono CPA In Lehigh East Stroudsburg Monroe Lehigh Valley Hospital - Muhlenberg CPA In Lehigh Bethlehem Northampton Schuylkill Medical Crt East Norwegian St CPA In Independent Pottsville Schuylkill Schuylkill Medical Ctr South Jackson Street CPA In Independent Pottsville Schuylkill Dlp Conemaugh Meyersdale Medical Center, LLC WPA In Conemaugh Meyersdale Somerset Advanced Surgical Hospital, LLC WPA In Independent Washington Washington Canonsburg General Hospital WPA In AHN Canonsburg Washington Monongahela Valley Hospital, Inc. WPA In Independent Monongahela Washington Excela Frick Hospital WPA In Excela Mount Pleasant Excela Latrobe Hospital WPA In Excela Latrobe Excela Hospital WPA In Excela Greensburg Last Updated: 09/7/7 Confidential and Proprietary
Alpha Prefixes (Look for these alpha prefixes in the member ID number to identify the patients who will use the ACA select network. These are valid until /3/8. For the most up-to-date listing of alpha prefixes and product names, please refer to NaviNet.) Region Offered 08 Plan Name Alpha Prefix Counties Offered WPA my Direct Blue Conemaugh EPO 000G IFI Blair, Cambria, Somerset WPA my Direct Blue Conemaugh EPO 000G IFH Blair, Cambria, Somerset WPA my Direct Blue EPO 000G IFO Beaver, Butler WPA my Direct Blue EPO 000G IFN Beaver, Butler WPA my Direct Blue HMO 000G IFK Allegheny, Crawford, Erie, Washington, WPA my Direct Blue HMO 000G IFJ Allegheny, Crawford, Erie, Washington, WPA my Direct Blue Conemaugh EPO 3750S IFH Blair, Cambria, Somerset WPA my Direct Blue EPO 3750S IFN Beaver, Butler WPA my Direct Blue HMO 3750S IFJ Allegheny, Crawford, Erie, Washington, WPA my Direct Blue Conemaugh EPO 750S IFI Blair, Cambria, Somerset WPA my Direct Blue Conemaugh EPO 750S IFH Blair, Cambria, Somerset WPA my Direct Blue EPO 750S IFO Beaver, Butler WPA my Direct Blue EPO 750S IFN Beaver, Butler WPA my Direct Blue HMO 750S IFK Allegheny, Crawford, Erie, Washington, WPA my Direct Blue HMO 750S IFJ Allegheny, Crawford, Erie, Washington, WPA my Direct Blue Conemaugh EPO 850SQE IFH Blair, Cambria, Somerset WPA my Direct Blue EPO 850SQE IFN Beaver, Butler WPA my Direct Blue HMO 850SQE IFJ Allegheny, Crawford, Erie, Washington, WPA my Direct Blue Conemaugh EPO 7000B IFI Blair, Cambria, Somerset WPA my Direct Blue Conemaugh EPO 7000B IFH Blair, Cambria, Somerset WPA my Direct Blue EPO 7000B IFO Beaver, Butler WPA my Direct Blue EPO 7000B IFN Beaver, Butler WPA my Direct Blue HMO 7000B IFK Allegheny, Crawford, Erie, Washington, WPA my Direct Blue HMO 7000B IFJ Allegheny, Crawford, Erie, Washington, WPA my Direct Blue Conemaugh EPO 6950B IFI Blair, Cambria, Somerset WPA my Direct Blue Conemaugh EPO 6950B IFH Blair, Cambria, Somerset WPA my Direct Blue EPO 6950B IFO Beaver, Butler WPA my Direct Blue EPO 6950B IFN Beaver, Butler WPA my Direct Blue HMO 6950B IFK Allegheny, Crawford, Erie, Washington, WPA my Direct Blue HMO 6950B IFJ Allegheny, Crawford, Erie, Washington,
Sample ID Card WPA HHC - my Direct Blue HMO - ONX