SelectBlue Three-Tier Options - Blue Cross Blue Shield of Nebraska

SelectBlue
Three-Tier Options
PLAN OPTIONS
Health Plans for Employer Groups
With 101+ Employees
EF F ECTI VE J A NUARY 1, 20 16
Choose the best
BLUE FOR YOU!
If you own a business, you already know the
challenges you face. It’s hard work. It’s a constant
juggling act. You don’t need us to tell you that.
What you do need from us is a way to offer your
employees health care coverage–affordably. Blue
Cross and Blue Shield of Nebraska offers unique
three-tier plan designs with a variety of benefit
options at affordable costs for groups in the Omaha
community with 101+ employees.
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The three tiers offer three levels of cost sharing:
NETWORK
CONSISTS OF
COST SHARING
(deductible/copayment/
coinsurance)
Select In-network
(Tier I)
Providers in the select health care
system
Lowest
In-network
(Tier II)
All other NEtwork BLUE providers
contracting as a Tier II provider, as
well as BlueCard providers
Moderate
Out-of-network
(Tier III)
Providers not contracting as Tier I
or Tier II network provider
Highest
NOTE: As of this printing, CHI Health is not participating as a Tier I or Tier II provider in our three-tier options.
In-network (Tier I and Tier II) and out-of-network deductible and out-of-pocket limits are separate and do
not cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate
between in-network and out-of-network, unless noted differently.
When members use Select BlueChoice providers they will get the advantages of using an in-network
provider, as well as the best benefits available under their health plan. The FIND A DOCTOR search tool
on nebraskablue.com helps members find Tier I and Tier II health care providers in the Select BlueChoice
network, or members may call our Member Services Department at the number shown on the back of
their BCBSNE member identification card.
Large Group Three-Tier Options
Blue Cross and Blue Shield of Nebraska
has teamed with several leading health
care systems to offer your employees a
unique three-tier plan design. This plan
design uses a select provider network
called Select BlueChoice. When a
Select BlueChoice provider is used, your
employees will receive Select In-network
(Tier I) benefits. These benefits provide
all the advantages of In-network (Tier II)
benefits, but with the addition of lower
deductibles, coinsurance, and copays.
You already know about health plans with
in-network and out-of-network benefits.
A three-tier plan is similar to that, but
a three-tier plan has an additional tier
(or level) that offers the lowest cost
sharing (or deductible, copayments, and
coinsurance) available in a plan. This tier
is called a Select In-network Tier.
Members may access any provider in
any of the tiers. However, if they use
providers in the Select In-network Tier,
members will receive all the advantages
of an in-network provider, as well as pay
the lowest deductible and copayment
or coinsurance amounts available under
their plan.
Both Tier I and Tier II providers are
considered in-network. In-network
providers have agreed to accept our
benefit payment for covered services as
payment in full, except for any deductibles, copayments, or coinsurance
amounts, as well as charges for noncovered services. In-network providers
can’t bill members for amounts over
our benefit allowance. Out-of-network
providers can bill patients for amounts
in excess of the amount payable under
the contract.
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About the Select BlueChoice Network
These leading health care systems, and other providers, are in the Select BlueChoice network:
Children’s Hospital & Medical Center
and Children’s Physicians
The leader in pediatric health
care, Children’s Hospital &
Medical Center offers unique
resources to children from
across a five-state region and
beyond. Children’s is home
to Nebraska’s only Level IV
regional Newborn Intensive
Care Unit and the state’s only Level II
Pediatric Trauma Center. A regional heart
center, it also provides expertise in pediatric
heart transplantation. Children’s is recognized as a 2015-16 Best Children’s Hospital
by U.S. News & World Report in cardiology
and heart surgery, gastroenterology and GI
surgery and orthopedics.
Nebraska Medicine – Nebraska Medical Center
Nebraska Medicine – Nebraska Medical
Center is Nebraska’s largest health care
facility with more than 5,300 employees and
over 1,000 physicians and 39 clinics. Patients
from all 50 states and six continents come
to Nebraska Medical Center for treatment.
The hospital is world-renowned in the
major service lines of oncology, solid
organ transplantation, cardiology, neurology
and trauma. It is also an international pioneer
in the treatment of lymphoma and leukemia.
Nebraska Medical Center and its teaching partner, The University
of Nebraska Medical Center, are embarking on a cooperative
effort to build a new $370 million cancer center on campus.
Nebraska Medicine – Bellevue
Nebraska Medicine – Bellevue is a full
service, acute care hospital offering
emergency, intensive care, radiology,
cardiology, pulmonary, pathology,
maternity, inpatient and outpatient
procedural, rehab and therapy, and
patient care services.
Nationally ranked among the
top ten hospitals for quality
and safety by University
HealthSystem Consortium.
In partnership with Nebraska
Medicine – Nebraska Medical
Center, the Bellevue facility
also offers a full-service
outpatient hematology/
oncology clinic and infusion
center serving the residents
of Bellevue, Sarpy County
and the surrounding area.
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Nebraska Orthopaedic Hospital
Methodist Hospital
In the short time since opening in 2004, Nebraska Orthopaedic
Hospital has already established itself as a leader in orthopaedics
and health care. Commitment to the complete care and treatment
of the patient, as well as the dedication from physicians, administration and hospital staff, has earned the hospital both local and
national recognition.
Founded in 1891 by members of the Methodist Church
in Omaha, Nebraska Methodist Hospital, is a not-forprofit, licensed 430-bed acute care hospital serving
the metropolitan-Omaha area. With more than 2,000
full-time employees and over 400 physicians on active
staff, Methodist Hospital was ranked second-best in
Nebraska by the recent U.S. News & World Report Best
Hospitals rankings.
Nebraska Orthopaedic Hospital is Joint Commission accredited
— receiving Disease Specific Certification for both total hip and
total knee replacement.
Named as a 2015 Top 100 Hospital for
Joint Replacement by Healthgrades.
Named the #1 Orthopaedics Hospital in the
state of Nebraska, 47th in the Country
Named Top
100 Hospital
for Joint
Replacement
Nebraska Methodist Health System
Founded in 1982, Methodist Health System is the oldest not-forprofit health care system in the region and employs more than
5,000 people. The Health System is a regionally recognized leader
in the delivery of consumer-preferred, high-quality services in
cardiology, neurosurgery, women’s services, cancer care, gastroenterology, orthopedics and comprehensive diagnostic services.
Methodist Health System is the parent organization for
• Methodist Hospital
• Methodist Physicians Clinic, Inc.
• Methodist Women’s Hospital • Nebraska Methodist College • Methodist Jennie Edmundson
The Josie Harper Campus
Hospital
• Shared Service Systems
Methodist Women’s Hospital
Methodist Women’s Hospital is the region’s only hospital dedicated
to women’s health – more babies are delivered here than any other
hospital in Nebraska. Home to the area’s largest maternal-fetal
medicine group and a NICU that treats more babies than any
other, the 126-bed hospital in west Omaha also offers a full array
of surgical options for women, as well as emergency, imaging and
laboratory services for men, women and children.
Methodist Jennie Edmundson Hospital
Affiliated with Methodist Health System since 1994, Jennie
Edmundson Hospital in Council Bluffs was founded in 1886 by a
nondenominational group of women called the Faith Band. Jennie
Edmundson Hospital is a regional leader in wound care, emergency
angioplasty procedures, cancer care, obstetrics and newborn care,
sports medicine, occupational and behavioral health.
Fremont Health and participating local
physicians
Fremont Health is more than a community hospital. It’s
a healthcare system that includes a full-service medical
center, primary care and specialty clinics, as well as
specialized physicians and services. Fremont Health
provides the latest advances in medical practice and
technology, locally focused programs and services, and
a seamless continuum of care that lasts a lifetime.
SecureCare
SecureCare is an Independent Physicians Association
which includes a network of all the chiropractors in
Nebraska, and offers chiropractic care, primary care,
acupuncture, and other non-invasive therapeutic
services. In 2012, SecureCare received the nationally
recognized URAC accreditation in Provider Credentialing
and was reaccredited in 2015.
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access
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IN ALL
S TAT E S
Provider networks
Statewide, nationwide and around the world
A health plan is only as good as its provider network. Whatever three-tier health plan option you choose, your employees
have access to a large network of hospitals, doctors and
other health care providers. Select BlueChoice (Tier I) offers
a wide range of physicians and hospitals through Nebraska
Medicine – Nebraska Medical Center, Methodist Health
System, Children’s Hospital and Medical Center, Fremont
Health and other facilities. Our Tier II network is made up of
87% of Nebraska’s doctors, and 93% of the state’s hospitals.
That makes obtaining in-network care easy and convenient.
In-network providers have agreed to accept our benefit payment for covered services as payment in full, except for any
deductible, copays, coinsurance amounts and charges for
noncovered services, which are the member’s responsibility.
That means Select BlueChoice and Tier II providers, under
the terms of their contract with us, can’t bill your employees
for amounts over our contracted allowable amount. Out-ofnetwork providers can bill patients for amounts in excess of
the amount payable under the contract.
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Select BlueChoice and Tier II providers also file claims for
Blue Cross and Blue Shield of Nebraska members, meaning
your employees have less paperwork to worry about. And as
an additional time-saving convenience, we send our benefit
payment directly to Select BlueChoice and Tier II providers.
Have employees living in other states? Have employees with
dependents attending college out of state? The BlueCard®
Program makes obtaining in-network care easy.
If your employees or their dependents live or travel outside
Nebraska, they can still obtain covered services at the
in-network (Tier II) level through the BlueCard Program.
To access benefits wherever they are, all your employees
have to do is use hospitals and doctors in the local Blue Cross
and Blue Shield Plan’s BlueCard PPO network. When they do,
they will also enjoy the discount and claim filing agreements
Blue Cross and Blue Shield Plans across the country have
negotiated with the BlueCard network hospitals and doctors
in their area.
Remember, when your employees
use a Select BlueChoice provider,
they receive Select In-network (Tier I)
benefits. These benefits provide all
the advantages of In-network (Tier II)
benefits, but with the addition of lower
deductibles, coinsurance, and copays.
Choosing a plan
Fully-insured and self-funded employers
Employers may select their own cost share amounts, such as
deductibles, coinsurance percentages, out-of-pocket limits and
copayment amounts, while following cost share differential
guidelines. See pages 8-11 for more information.
When creating a three-tier plan design for your group the first
time, the Select in-network deductible should be closest to
the current plan’s in-network deductible amount. The Select
in-network deductible should not be lower than the current
in-network deductible.
For employees living outside the three-tier service area
When offering a three-tier design to groups who have employees
residing outside of the three-tier service area, employers can
offer a two-tier plan. In-network benefits on the two-tier plans can
be designed with an actuarial equivalent to the three-tier design
based on the hospital tier usage.
If you have questions, please contact a member of your Blue
Cross and Blue Shield of Nebraska sales or account service team.
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Structured Three-Tier Plan Options
Employers can chose from four base coverage options and two office copay options and determine the cost share amounts.
Cost shares are variable for deductible, coinsurance percentage, copayment amounts, and out-of-pocket limits.
Coverage Options
Option A
Option B
Option C
Option D
Deductible, then Coinsurance
Deductible, then Coinsurance
Deductible, then Coinsurance
Deductible, then Coinsurance
Physician Office Copayment
Physician Office Copayment
Physician Office Copayment
Urgent Care Copayment
Urgent Care Copayment
Emergency Room (Care) Copayment
Emergency Room (Care) Copayment
Manipulation Copayment
Emergency care copayments
(services received in a hospital emergency room setting)
• Facility Services: Copayment, then coinsurance (deductible waived)
• Professional Services: Coinsurance only, deductible waived
• Out-of-Network will be paid at the Tier I Select In-network level of benefits
Physician Office Copayment Options
Office Services Copayment
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Office Visit Copayment
Office copayment applies each time services are rendered at the doctor’s
office, even if an office visit is not billed
Office visit copayment applies to the physician’s office visit only. Other
services in the physician’s office: Coinsurance only, deductible waived
Allergy injections and serum (in the physician’s office)
•Tier I: $10
•Tier II: $15
•Tier III: Deductible, then coinsurance
Allergy injections and serum (in the physician’s office)
•Tier I: Coinsurance only
•Tier II: Coinsurance only
•Tier III: Deductible, then coinsurance
Cost Share Differential Guidelines
The following charts represent the minimum cost share differentials. Differential
guidelines are shown in red. Boxes that are gray do not change. If an existing plan
option is too rich this logic may not apply, and the starting point for differential
spread may need to be adjusted.
When selecting a standard plan option or creating a plan design, the Select
In-network deductible should be closest to the current plan’s in-network individual
deductible amount. The starting point (individual Select In-network deductible)
should not be lower than the current in-network deductible.
Deductible Options - Starting Point of $500 (up to $1,000)
Deductible (calendar year)
Individual
Family
Type of Deductible
Coinsurance for covered services
Percentage the covered person pays
Out-of-pocket limit (calendar year)
Individual
Family
Select In-network (Tier I)
In-network (Tier II)
Out-of-network (Tier III)
Starting Point
2.5 X Tier I Deductible
2X Tier II Deductible
2X Individual Deductible
2X Individual Deductible
2X Individual Deductible
Embedded
Embedded
Embedded
Percentage Starting Point
20% differential from Tier I
20% differential from Tier II
2.5X Individual Deductible
2.5X Individual Deductible
2X Individual Deductible
2X Individual Out-of-pocket
2X Individual Out-of-pocket
2X Individual Out-of-pocket
Tier I and Tier II deductible and out-of-pocket limit cross accumulate to each
other; does not cross accumulate to the out-of-network (Tier III)
Preventive healthcare services
Preventive care services
Physician office services
Primary care physician
Specialist
Plan Pays 100%
Plan Pays 100%
Deductible and Coinsurance
Copay Starting Point
$XX Copay = 2.5 X Tier I
Deductible and Coinsurance
Copay Starting Point
$XX Copay = 2.5 X Tier I
Deductible and Coinsurance
Copay Starting Point
$XX Copay = 2.5 X Tier I
Deductible and Coinsurance
Copay then Coinsurance
Tier I Level of Benefits
Tier I Level of Benefits
Coinsurance
Tier I Level of Benefits
Tier I Level of Benefits
Urgent care & emergency care facility services
Urgent care facility services
Emergency care services facility
Emergency care services
professional
Does not cross accumulate to
In-network (Tier I or II)
When calculating 2.5X, round up to the nearest $5.
Out-of-pocket limits include deductible and coinsurance amounts
and any applicable copayments, including prescription drug.
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Deductible Options - $1,250 and above
Deductible (calendar year)
Individual
Family
Type of Deductible
Coinsurance for covered services
Percentage the covered person pays
Out-of-pocket limit (calendar year)
Individual
Family
Select In-network (Tier I)
In-network (Tier II)
Out-of-network (Tier III)
Starting Point
$1,500 difference Tier I
2X Tier II Deductible
2X Individual Deductible
2X Individual Deductible
2X Individual Deductible
Embedded
Embedded
Embedded
Percentage Starting Point
20% differential from Tier I
20% differential from Tier II
Plus $1,500 Individual Deductible
Maximum Individual Out-of-Pocket
2X Tier II Out-of-Pocket
2X Individual Out-of-pocket
Maximum Family Out-of-Pocket
2X Individual Out-of-Pocket
Tier I and Tier II deductible and out-of-pocket limit cross accumulate to each other;
does not cross accumulate to the out-of-network (Tier III)
Physician office services
Primary care physician
Specialist
Copay Starting Point
$XX Copay = 2.5 X Tier I
Deductible and Coinsurance
Copay Starting Point
$XX Copay = 2.5 X Tier I
Deductible and Coinsurance
Copay Starting Point
$XX Copay = 2.5 X Tier I
Deductible and Coinsurance
Copay then Coinsurance
Tier I Level of Benefits
Tier I Level of Benefits
Coinsurance
Tier I Level of Benefits
Tier I Level of Benefits
Urgent care & emergency care facility services
Urgent care facility services
Emergency care services facility
Emergency care services
professional
Out-of-pocket limits include deductible and coinsurance amounts and
any applicable copayments, including prescription drug.
The in-network annual out-of-pocket limit cannot exceed the amounts
published in Affordable Care Act regulations.
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Does not cross accumulate to
In-network (Tier I or II)
HSA-Eligible Design Options - Starting point cannot be less than the minimum individual deductible
as shown in Internal Revenue Code Section 223(c)(A)(ii). For embedded plan designs, the minimum individual deductible must be equal to or greater than the minimum family deductible.
Deductible (calendar year)
Individual
Family
Type of Deductible
Coinsurance for covered services
Percentage the covered person pays
Out-of-pocket limit (calendar year)
Individual
Family
Select In-network (Tier I)
In-network (Tier II)
Out-of-network (Tier III)
Starting Point
$1,500 difference Tier I
2X tier II Deductible
2X Individual Deductible
2X Individual Deductible
2X Individual Deductible
Embedded
Embedded
Embedded
Percentage Starting Point
20% differential from Tier I
20% differential from Tier II
Plus $1,500 Individual Deductible
Maximum Individual Out-of-Pocket
2X Tier II Out-of-Pocket
2X Individual Out-of-pocket
Maximum Family Out-of-Pocket
2X Individual Out-of-Pocket
Tier I and Tier II deductible and out-of-pocket limit cross accumulate to each other;
does not cross accumulate to the out-of-network (Tier III)
Physician office services
Primary care physician
Does not cross accumulate to
In-network (Tier I or II)
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Urgent care & emergency care facility services
Urgent care facility services
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Tier I Level of Benefits
Tier I Level of Benefits
Deductible and Coinsurance
Tier I Level of Benefits
Tier I Level of Benefits
Specialist
Emergency care services facility
Emergency care services
professional
Out-of-pocket limits include deductible and coinsurance amounts and
any applicable copayments, including prescription drug.
The in-network annual out-of-pocket limit cannot exceed the amounts
published in Affordable Care Act regulations. In addition, for health
savings account-eligible plans, the annual out-of-pocket limit cannot
exceed the Internal Revenue Code Section 223(c)(A)(ii).
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This document is a brief overview of three-tier health plan options for groups with 101+ employees. It is not a
contract. It is a general overview only. It does not provide all the details of the coverage, including benefits, limitations
and contract exclusions. In the event there are discrepancies between this document and the contract, the terms
and conditions of the contract will govern. For more information regarding benefits, limitations, exclusions and other
provisions, refer to the master group contract.
Blue Cross and Blue Shield of Nebraska is an independent
licensee of the Blue Cross and Blue Shield Association.
36-180 (06-08-15)