1 1 2 3 4 5 BCNprovidernews 6 7 NOVEMBER–DECEMBER 2014 8 Cover Story 9 The Blues to offer a variety 10 11 of individual products for 2015 12 Network Operations 13 When the Health Insurance Marketplace opens Nov. 15, Blue Care Network 14 and Blue Cross Blue Shield of Michigan will have many new products available 15 for coverage beginning Jan. 1, 2015, or later. 16 BCN Advantage 17 Blue Cross and BCN are offering 41 individual products; 24 of them are BCN 18 HMO plans and 17 are Blue Cross PPO plans. All of the products sold on the 19 Blue Cross Complete Marketplace will be sold with Blue Cross names. (Please see the article on 20 Page 8 for some tips to identify Blue Cross and BCN plans by their names.) 21 22 Blue Care of Michigan's Personal PlusSM will remain open in 2015, but it will 23 Patient Care not be open to new contracts. Some changes to Personal Plus were made 24 to comply with certain Federal and State mandates. For example, elective 25 26 abortion was added as a rider and, for the applied behavioral analysis Inside this issue… 27 Behavioral Health benefit for autism, the line therapy hour limit to treat autism spectrum 28 disorders will be removed effective January 2015. 29 n Blue Cross Metro Detroit HMO Some plans are discontinuing. 30 provides new low-cost coverage to 31 Quality Counts • BCBSM’s Keep FitSM will no longer be offered. Keep Fit members will individuals in Southeast Michigan ..... Page 3 32 need to have purchased another individual plan that becomes effective 33 January 2015. 34 n Blue Care Network provides 35 Pharmacy News • Blue Cross Partnered Value and Blue Cross Preferred Value plans are office staff incentives for tobacco 36 discontinued effective Dec. 31, 2014. cessation campaign .........................Page 12 37 38 New plans will be offered for 2015: 39 Billing Bulletin • Blue Cross® Metro Detroit HMO – a local network HMO in three counties n BCN Advantage introduces 40 offered by Blue Care Network. Members must reside in Wayne, Oakland ConnectedCare HMO 41 or Macomb counties. (More information on Page 3.) local network ................................. Page 20 42 43 ® Referral Roundup • Blue Cross Metro Detroit EPO – an exclusive provider organization in 44 six counties offered by Blue Cross. (More information is on Page 5.) n From the medical director: 45 Help Blue Care Network reduce • New “Extra” plans – these plans include a basic individual product benefit 46 childhood obesity ....................... Page 30 47 Index design plus the following: 48 - The plan pays the first four specialist office visits per member before the 49 deductible (copayments will apply) 50 - The plan pays Tier 1A and Tier 1B generic prescription drugs before the 51 deductible (copays will apply.) 52 Feedback | Subscribe BCN Provider News User Guide PDF Blue Care Network of Michigan is a nonprofit corporation and Please see Blues products, continued on Page 2 independent licensee of the Blue Cross and Blue Shield Association. network operations 2 1 2 3 Blues products, continued from Page 1 4 5 Highlights of cost sharing changes for the BCN Extra New Medicare Advantage product 6 plans include: 7 BCN Advantage ConnectedCare HMO is a new individual 8 Cover Story • Simplified cost sharing by removing copays for imaging Medicare Advantage HMO product with an exclusive 9 services, such as CTs, PET scans or MRIs. provider network developed primarily around Southeast 10 Michigan and Kalamazoo County. Open enrollment for 11 • Removed copays for mental health and substance abuse Medicare Advantage began on Oct. 1, 2014 for a Jan. 1, 12 Network Operations 13 outpatient services. 2015 effective date. (For details about BCN Advantage 14 • Inpatient copay – No $500 copay for a stay in a hospital, ConnectedCare HMO, see the article on Page 20.) 15 mental health, substance abuse and skilled nursing 16 BCN Advantage facility. Also no copay for delivery and all inpatient Check member eligibility and benefits 17 maternity services. Coinsurance will continue to apply. Providers should be sure to check eligibility and benefits 18 19 before providing services. It’s important to check both the • Office visits – Primary care physician office copay 20 Blue Cross Complete plan name and the network associated with the plan. For reduced to $20 for Silver and Gold Extra plans. 21 local plans, such as the Metro Detroit HMO, providers 22 For Bronze Extra plans the PCP office copay is $40 and need to refer within the local network. For information 23 the specialist office copay is $75. (Applies to Blue Care about how to find the Blues plans you are contracted to 24 Patient Care Network only.) provide services for, see the PDF below. 25 26 Blue Cross will continue to offer the Premier and Multi-State 27 Behavioral Health PPO. The plan gives members a broad choice of doctors 28 and hospitals in the Blue Cross statewide PPO network, Finding your 29 including nationwide coverage. Members may receive Blues plans PDF 30 services from hospitals or doctors outside the network, but 31 Quality Counts 32 will pay less if they use in-network providers. 33 34 35 Pharmacy News 36 37 Provider Communications Market Communications Editor Elizabeth Donoghue Colvin 38 Cindy Palese Catherine Vera-Burgos, Jennifer Fry Publications 39 Billing Bulletin [email protected] Manager Tracy Petipren Cathy Rauckis 40 41 42 Contributors: 43 Belinda Bolton; Terri Brady; Richard Cook; Laura Cornish; Jeniene Edwards; Mary Ellison; Moira Horne; Mary McFarlane; Dani Sokoloski; Referral Roundup 44 Michelle Smith 45 46 47 BCBSM and BCN maintain BCBSM.com, hcbo.com and theunadvertisedbrand.com. The Blues do not control any other websites referenced in this publication or endorse their Index 48 general content. 49 References to “Blue Care Network” and “BCN” in this publication refer to all Blue Care Network of Michigan, Blue Care of Michigan, Inc., BCN Services Company and Blue Cross 50 Complete of Michigan products, except where noted otherwise. Clinical information in this issue is consistent with BCN Clinical Practice Guidelines and applies to the care of BCNprovidernews BCN and BCN subsidiary/affiliate corporation members regardless of product. More information is available in the BCN Provider Manual on web-DENIS. Specific benefit information 51 NOVEMBER–DECEMBER 2014 is available on web-DENIS, CAREN or by calling Provider Inquiry. 52 No portion of this publication may be copied without the express written permission of Blue Care Network of Michigan, except that BCN-participating health care providers may make Feedback copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCN. network operations 3 1 2 3 Blue Cross Metro Detroit HMO provides new low-cost 4 5 coverage to individuals in Southeast Michigan 6 7 Blue Care Network is offering a new, affordable HMO The new Blue Cross Metro Detroit HMO product is priced 8 Cover Story 9 individual coverage option for 2015, Blue Cross® Metro to appeal to people in the three counties seeking affordable 10 Detroit HMO. The product will be offered to individuals health insurance and care coordinated through local doctors 11 residing in three counties – Oakland, Macomb and Wayne and hospitals. Metro Detroit HMO has a local network that 12 Network Operations – with gold, silver and bronze options. The HMO product is a subset of the larger BCN provider network. The local 13 will be offered both on and off the Health Insurance network includes primary care physicians from the medical 14 Marketplace. Individuals can purchase the product during care groups listed below. Members must select a PCP 15 16 BCN Advantage open enrollment, Nov. 15, 2014 through Feb. 15, 2015, contracted within the local network. The PCP will coordinate 17 with coverage beginning Jan. 1, 2015, or later depending care with local network specialists and hospitals. 18 on the date of purchase. 19 Blue Cross Complete 20 The Metro Detroit HMO local network includes PCPs from these medical care groups: 21 22 • Accountable Healthcare Advantage • Oakwood Accountable Care Organization 23 Patient Care • Macomb St. Clair Primary Physicians Group • Providence Partners in Mission 24 • Medical Network One • St. John Macomb PHO 25 26 • Midwest Medical Center, P.C. • St. John Physician Hospital Organization 27 Behavioral Health • Oakland General Associates • St. John River District 28 • Oakland Southfield Physicians Group • United Physicians 29 30 31 Quality Counts 32 33 34 35 Pharmacy News 36 37 38 39 Billing Bulletin 40 41 42 43 Referral Roundup 44 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback Please see Metro Detroit HMO, continued on Page 4 network operations 4 1 2 3 Metro Detroit HMO, continued from Page 3 4 5 6 The Metro Detroit HMO local network includes these When Metro Detroit HMO members are referred for 7 hospital systems and hospitals: services within the Metro Detroit HMO local network, 8 Cover Story 9 • St. John Providence Health/Ascension standard BCN referral and clinical review requirements 10 apply. Services performed outside the Metro Detroit 11 - St. John Hospital and Medical Center (Detroit) HMO local network require authorization by BCN, even 12 Network Operations - Providence Hospital (Southfield) if the providers are in the larger BCN network. The only 13 - St. John Macomb – Oakland Hospital Macomb Center exception to this is for urgent and emergent services. 14 15 - St. John Macomb – Oakland Hospital Oakland Center 16 BCN Advantage Women are required to use obstetrician-gynecologist - St. John River District Hospital (East China) providers in the network. If they wish to visit an OB-GYN 17 18 • Oakwood Healthcare System outside the network, services require clinical review.