Frequently asked questions for members covered through a small employer

The flat fee you pay when you see a doctor or receive other services. For example, $20 to see a doctor.

The percentage you pay for some covered services. If your coinsurance is 20 percent, your health insurance company will pay 80 percent of the cost of covered services; you will pay the remaining 20 percent (your costs are usually based on a discounted amount negotiated by your insurance company).

The amount you pay each year before your health plan starts paying for covered services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for the covered health care services you receive. Once you have paid this amount, your insurance will begin to pay a portion or all of your health care costs, depending on the health plan.

For HSA-qualified plans, the family deductible applies when an individual and one or more dependents are enrolled. The full family deductible must be met by one or several family members before claims are eligible to pay; however, no family member will contribute more than the individual out-of-pocket maximum amount. If an individual is enrolled without dependents, the individual deductible applies.

For all other plans, once an individual meets the individual deductible amount, claims for that individual will pay. Once the family deductible is met, claims for all individuals will pay. If an individual is enrolled without dependents, the individual deductible applies.

An out-of-pocket maximum is the most you will have to pay for your health care expenses during a plan period for covered services received from providers that participate in the plan’s network. No matter what, you will not pay more than this amount each year. Any care for covered services you get after you meet your out-of-pocket maximum will be covered 100 percent by the health insurer.

Family out-of-pocket maximum applies when an individual and one or more dependents are enrolled. Once an individual meets the individual out-of-pocket maximum, benefits for that individual are covered in full. Once the family out-of-pocket maximum is met, benefits for all family members are covered in full. The individual out-of-pocket maximum applies only when an individual is enrolled without any dependents.

Please note that only Essential Health Benefits accumulate toward the out-of-pocket maximum. For example, adult vision services are not considered an Essential Health Benefit and would not accumulate toward the out-of-pocket maximum. A list of Essential Health Benefits is provided below under “What services do all plans cover?”

For benefits that state “subject to deductible and copay”, you are responsible for the copay both before and after the deductible is reached. Below is an example of how your cost-share would apply for the HMO Silver Secure $5,000/$50/$100/$600 plan. In this example, it is assumed that nothing has been paid toward the plan deductible.

For this example, you have a three-day inpatient hospital stay. On day one of your inpatient stay, you would pay the daily copayment of $600/per day. Next, you would pay the allowed cost for the inpatient hospital bill, less the $600 copay. If the allowed cost was $4,000, you would pay $3,400 toward your deductible (which is $4,000 minus $600.) On day two, you will again pay a $600 copayment, but will only be required to pay $1,600 toward the hospital bill to satisfy your $5,000 plan deductible ($3,400 from day 1 + $1,600 from day 2 = $5,000.) As the deductible is now satisfied, on day three, you would then only be responsible for the copayment of $600. You would have no additional out-of-pocket costs for this three-day hospital admission.

A PCP is the doctor you see for most of your health care needs. HMO and DPOS plans require you to choose a PCP, who will refer you to a specialist when needed. PPOs and EPOs do not require that you choose a primary care physician. To find a PCP, use our Find a Doctor tool.

A specialist provides medical care for certain conditions in addition to the treatment provided by your PCP. For example, you may need to see an allergist for allergies or an orthopedic surgeon for a knee injury. Under an HMO plan, you need to obtain a referral from your PCP to receive benefits for care provided by a specialist. For DPOS plans, your PCP will write you a referral for radiology services, physical/occupational therapy, spinal manipulations, and acupuncture services. Under our PPO and EPO plans, you never need a referral to see a specialist.

If you have an HMO plan, your family doctor (or PCP) will need to write you a referral before you see other network providers, such as a dermatologist. No need to pick up a piece of paper, our referrals are done electronically, so in most cases you can get a referral simply by calling your PCP’s office. For DPOS plans, your PCP will write you a referral for radiology services, physical/occupational therapy, spinal manipulations, and acupuncture services.

• Use health care providers in your plan’s network.
  You can save money on health insurance costs by choosing in-network health care providers. You can use the Find a Doctor tool to find out if your current PCP, health care specialists, and facilities are in the network.
• Choose generic prescription drugs.
  You can also make your health care more affordable by choosing generic prescription drugs over name-brand prescription drugs. Generic drugs offer the same benefits as name-brand drugs, but at a lower cost.
• Take advantage of preventive care.
  You can save money and prevent some serious illnesses by actively maintaining your health and scheduling regular preventive care appointments. The Affordable Care Act (ACA) requires health insurance plans to cover preventive care without charging a copayment or coinsurance, even if you have not yet met your plan’s annual deductible. View a full list of free preventive health services.

All health plans offered by a small employer (50 or fewer employees) must include a core set of Essential Health Benefits, which are shown in the chart below. For specific details about your plan and the out-of-pocket costs for covered services, view your Summary of Benefits and Coverage at ibx.com.

For the following services, your plan may offer the opportunity to lower your out-of-pocket costs by choosing to have your services provided at a lower cost place of service.

• Outpatient surgery
• Sleep studies
• Outpatient laboratory services
• Physical and occupational therapy
• Radiology (routine and complex)
• Biotech/Specialty drugs and administration/infusion
• Virtual care visits

For example, when you use an in-network ambulatory surgical center (ASC) for outpatient surgery, you will pay less out of pocket than if you have the procedure at a hospital. Some common outpatient surgical procedures performed at ASCs include tonsil removal, hernia repairs, and cataract surgeries.

When you need blood work or other covered laboratory services, certain plans offer $0 cost-sharing when you use a freestanding lab in our network. If you choose to use a hospital-based lab, you will pay your plan’s designated cost-sharing amount for this covered service.

If you are enrolled in an HMO or Direct POS plan, in-network lab services are always covered at 100 percent when you use your PCP’s designated lab site. You should refer to your ID card for the lab site indicator or contact your PCP for this information.

If you are enrolled in a PPO (non-HSA/HRA) plan, and you use a freestanding facility for physical therapy/occupational therapy or radiology services, your out-of-pocket costs will be lower than if you go to a hospital-based facility.

If you receive injections of biotech/specialty drugs, your cost-share will be lower for both the drug and the administration/infusion of the drug if you receive the infusion in the home or office setting rather than an outpatient setting.

You should consult your doctor to determine the most appropriate settings to receive covered services.

To learn more about how you can save money when you receive care, review the Schedule of Covered Services in your benefits booklet, which is available at ibx.com.

All of our health plans include coverage for autism spectrum disorders (ASD). Autism is defined by a certain set of behaviors and is a “spectrum disorder,” meaning it affects individuals differently and to varying degrees.

Benefits include assessments and tests deemed medically necessary to diagnose ASD, and coverage for applied behavioral analysis. View your benefits booklet at ibx.com for a complete description of ASD benefits.

Colon cancer is preventable, and if it’s caught early enough, it’s treatable. Your plan includes a Preventive Plus benefit with $0 member cost-sharing (no copayment, deductible, or coinsurance) when a member receives a preventive colonoscopy to screen for colorectal cancer at a Preventive Plus (P+) facility and it is performed by an in-network professional (a gastroenterologist or a colon and rectal surgeon). To find participating Preventive Plus (P+) facilities and in-network professionals, use our Find a Doctor tool. Facilities are designated via the Preventive Plus icon (+).

Effective September 1, 2021, IBX will cover colorectal cancer screenings as a preventive service for individuals starting at 45 years of age at no cost–share. This change is in response to the U.S. Preventive Services Task Force’s (USPSTF) updated colorectal cancer screening recommendation released on May 18, 2021.

For $0 member cost–sharing to apply, in addition to seeking services from Preventive Plus providers, colonoscopy screenings must meet the USPSTF’s guidelines.

• Screenings should begin at age 45 and continue through age 75.
• Screenings will be covered as preventive once every 10 years.

The Preventive Plus benefit does not apply if you reside or travel outside our service area and access care through the BlueCard^® Program or the Away From Home Care^® Guest Membership Program. If this applies to you, a preventive colonoscopy to screen for colorectal cancer will be covered at no cost when you use an in-network provider. However, if you choose to visit an out–of–network provider, cost-sharing for your plan’s out–of–network benefit applies, and your out–of–pocket costs may be significantly higher.

Colorectal cancer screening tests prior to age 45 will continue to be subject to medical necessity review and the plan’s outpatient surgery cost–sharing. This includes colorectal cancer screenings for members in high-risk categories before age 45 and screenings given more often than the USPSTF–recommended frequency. For members in high–risk categories, colorectal cancer screenings before age 45 and screenings performed more frequently than the USPSTF–recommended frequency are covered but will be subject to the cost-sharing provision of the plan’s outpatient surgery benefit.

Please note that diagnostic colonoscopies are subject to the cost–sharing provision of the plan’s outpatient surgery benefit.

All Blue Solutions small employer plans include coverage for telemedicine. Members can receive telemedicine, telebehavioral health, and teledermatology services through Teladoc Health (Teladoc)¹, as well as telebehavioral health services through a network provider, all for a $0 cost-share.²  To register for Teladoc, members can download the Teladoc mobile app or visit teladochealth.com. To find a telebehavioral health provider, members can call the phone number on the back of their ID card, or access the Find a Doctor tool on ibx.com.

If available, members may also receive telemedicine services through their primary care physician or specialist and pay a reduced cost-share. Members in most plans will pay less for a virtual visit with their primary care doctor or specialist than for an in-person office visit.

During a telemedicine visit, doctors can typically diagnose, provide treatment plans, and prescribe medications for conditions that are not emergencies, such as colds and flu, allergies, ear and sinus infections, pink eye, and rashes.

Members now have access to coverage for gender reassignment surgeries and related services without annual or lifetime dollar limits; coverage will be based on medical necessity and in accordance with all medical policies.

Below are some of the services not covered by your health plan. For a complete list, members should consult their member handbooks.

• Services not medically necessary
• Services or supplies that are experimental or investigative, except routine costs associated with qualifying clinical trials
• Hearing aids, hearing examinations/tests for the prescription/fitting of hearing aids, and cochlear electromagnetic hearing devices
• Assisted fertilization techniques, such as in-vitro fertilization, GIFT, and ZIFT
• Reversal of voluntary sterilization
• Expenses related to organ donation for non-employee recipients
• Music therapy, equestrian therapy, and hippotherapy
• Sex therapy or other forms of counseling for treatment of the sexual dysfunction when performed by a non-licensed sex therapist
• Routine foot care, unless medically necessary or associated with the treatment of diabetes
• Foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes
• Cranial prosthesis, including wigs intended to replace hair loss
• Alternative therapies/complementary medicine such as hypnotherapy
• Routine physical exams for non-preventive purposes, such as insurance or employment applications, college, or premarital examinations
• Immunizations for travel or employment
• Services or supplies payable under workers’ compensation, motor vehicle insurance, or other legislation of similar purpose
• Cosmetic services/supplies
• Bariatric or obesity surgery
• Outpatient private duty nursing

Our Keystone HMO Proactive plans include the full Keystone Health Plan East HMO network of providers. However, with our Proactive plans, doctors, hospitals, and other types of providers in the Keystone Health Plan East HMO network have been assigned to one of three benefit tiers. For most services, you can save money when you visit providers in lower tiers.

There are some services, such as preventive care, emergency room care, physical therapy, occupational therapy, and mental health, which have the same cost-sharing regardless of the provider’s assigned tier.

Keystone HMO Proactive plans work just like a typical HMO. You can visit any doctors and hospitals in the network, and you select a primary care physician who refers to you specialists in any tiers. But now you can save on your out-of-pocket costs when you visit certain health care providers.

All Keystone Health Plan East HMO providers have been grouped into three tiers based on cost and, in many cases, quality measures. While all of the doctors and hospitals in our network must meet high quality standards, some are able to offer more cost-effective care. If they cost less, then you will pay less. It’s that simple. You can use our Find a Doctor tool to check what tier a doctor is in.

For some services, like surgery, you pay out-of-pocket costs for both the facility and the performing doctor. To save the most money, you’ll want to make sure both are in Tier 1 – Preferred.

With an HMO tiered network plan, the network is divided into three groups that we call tiers. All three tiers have high quality doctors and hospitals. But don’t think that high quality has to equal high cost. These tiers help you find providers that offer you the best value on care. Our HMO tiered network plan is called Keystone HMO Proactive and gives you access to the full HMO network of more than 46,000 doctors and 160 hospitals, unlike a limited network that gives you access to a smaller portion of a network.

All doctors, hospitals, and other health care providers from the Keystone Health Plan East HMO network are assigned a tier; however, there are some services that have the same cost-sharing across all tiers. Examples include preventive care, emergency room care, physical therapy, occupational therapy, and mental health. View your Summary of Benefits and Coverage at ibx.com for more details.

We’ve assigned our HMO network providers to one of three tiers. These tier assignments were based on relative cost, quality (if available), and the tier of the facilities to which your PCP typically refers IBX patients for hospital and outpatient surgical services. While all of the doctors in our network must meet high quality standards, many offer the same services at a lower cost.

More than 50 percent of doctors and hospitals are in Tier 1 – Preferred, so you have plenty of options for where you receive care. And you don’t have to stay within one tier. For example, you can visit Tier 2 – Enhanced providers for some services and Tier 3 – Standard providers for other services.

Doctors can be assigned to more than one tier since tiers are assigned by office location, rather than by individual doctor. For example, Dr. Smith’s office in the city may be assigned to Tier 1 – Preferred while their office in the suburbs may be assigned Tier 2 – Enhanced. What you pay when you see Dr. Smith will be based on the tier of the office you visit for your appointment. This tier assignment will be displayed in our Find a Doctor tool.

IBX will re-evaluate provider tier assignments annually. Tier assignments are effective on January 1 every year.

You can use our Find a Doctor tool to see which tiers your doctors and hospitals are assigned to. Select “Keystone HMO Proactive” as your plan.

There are some services that have the same cost-sharing across all tiers. Examples include preventive care, emergency room care, physical therapy, occupational therapy, and mental health. Only certain provider types will have cost-sharing that varies based on the tier assignment. View your Summary of Benefits and Coverage at ibx.com for more details.

Many covered services will cost the same amount to you no matter the tier level of the provider or facility you visit. These are:

If you have an emergency, you should always visit the nearest hospital. Emergency room services, in addition to a few other services (see previous question), have the same cost-sharing across all tiers. Please note that if you are admitted to an in-network hospital from the emergency room, the cost-sharing for inpatient hospital care, including medical care provided by a participating professional provider, will apply based on the tier of the in-network hospital or participating professional provider. If you are admitted to an out-of-network hospital following an emergency room admission, the Tier 3 – Standard level of benefits (highest cost-sharing) will apply.

Emergency room fees are the same no matter which tier of hospital you choose. However, if you are admitted to an in-network hospital from the emergency room, the cost-sharing for your inpatient hospital care will apply based on the tier of the in-network hospital. If you are admitted to an out-of-network hospital following an emergency room admission, the Tier 3 – Standard level of benefits will apply. For non-emergency care, you must use in-network providers.

You can speak with your doctor about why he or she referred you to that specialist. You can explain to your doctor that you have a tiered network plan and that you prefer to see a Tier 1 – Preferred specialist if possible.

Employees must reside in either the Pennsylvania five-county area or a contiguous county to be eligible to enroll in a Proactive plan. Employees residing in a non-contiguous county are not eligible to enroll in Proactive plans.

If you choose to purchase a brand drug that is available in a generic form (either at your request or your physician’s request), you will be responsible for paying the dispensing pharmacy the difference between the negotiated discount price for the generic drug and the brand drug, plus the appropriate cost-sharing for the brand drug. The Mandatory Generic Program is included in all HMO Proactive plans and all Silver and Bronze plans.

The formulary is designed to include all therapeutic categories and provide physicians with prescribing options. Drugs designated as non-formulary are drugs that are not covered. Non-formulary drugs have covered equivalents and/or alternatives used to treat the same condition in a more cost-effective manner. Physicians may request coverage of a non-formulary drug by submitting a medical necessity request. Visit ibx.com/formularyexceptionspolicy for details about the formulary exception process.

Note: If a member’s prescription drug benefit includes the mandatory generic benefit and the formulary exception is approved for a brand name drug that has a generic equivalent, the member will be responsible for paying the dispensing pharmacy the difference between the negotiated discount prices for the generic drug and the brand drug plus the appropriate member cost-sharing for a brand drug.

Our health plans are designed to make it easy for you to access lower-cost generic medications. Lower-cost generic drugs are as safe and effective as brand-name drugs. What you pay for generic drugs at retail pharmacies may vary depending on your plan.

Members in all small group plans⁴ have access to low-cost generics.

HSA-qualified and HRA plans apply copays for low-cost generics and generic drugs after the plan’s deductible has been met.

Reference your benefit booklet at ibx.com to view your cost-share for generic medications.

The Preferred Pharmacy network is a smaller version of our full pharmacy network. There are over 58,000 pharmacies in the Preferred Pharmacy network, including CVS, Walmart, and Target in addition to independent pharmacies.

Please note that Walgreens is not part of the Preferred Pharmacy network. If you fill a prescription at Walgreens, it will process as an out-of-network claim. You will be responsible for the total upfront cost of your prescription at the pharmacy and must submit a paper claim for partial reimbursement after purchase.

The Preferred Pharmacy network is included in HMO Proactive plans and all Silver and Bronze plans. Log in at ibx.com to find a participating pharmacy.

Specialty drugs are used to treat complex conditions or chronic diseases — such as rheumatoid arthritis, hepatitis C, and certain cancers — and typically require special handling, administration, and monitoring. All Blue Solutions plans include specific cost-sharing for these medications. You will pay the cost-share applicable for your plan’s specialty drugs tier, which can be found in your benefits booklet.

For all Blue Solutions plans, members should search the 5-Tier Formulary to determine if their drug is on the specialty drug list.

When using the OptumRx specialty pharmacy, members receive expert, personalized 24/7 support from pharmacists and nurses experienced in treating rare, complex, and chronic diseases.

Members benefit from a hands-on approach including:

• Video consultations. Real-time, face-to-face video consultations with an expert clinical or patient care coordinator from a secure online patient portal.
• Side effect management. Free therapy support kits help patients manage their condition and any treatment side effects.
• Condition, clinical, and lifestyle support. Patients receive tailored videos based on their condition and treatment regimen by email and can now view them on any device. Emails are sent throughout the course of treatment to provide continued encouragement and answer common questions a patient might have while taking the medication.

If your employer purchased your health plan directly from IBX, it includes pediatric dental benefits for your covered dependents up to age 19. View your Summary of Benefits and Coverage and benefits booklet at ibx.com for details about your plan’s pediatric dental benefits.

IBX offers several options to add comprehensive, cost-effective dental coverage for members age 19 and older. Members should contact their employers to determine if this coverage is available.

All of our small employer health plans include in-network coverage for adult and pediatric vision exams and glasses or contacts.

Your health plan includes up to a $180 allowance for glasses for adults age 19 and older when you purchase your glasses from a Visionworks store, and up to $130 when visiting other Davis Vision participating locations. If you prefer contact lenses in lieu of glasses, your plan includes up to a $130 allowance. For covered dependents up to age 19, all plans include in-network coverage for glasses or contacts.

Members enrolled in an IBX health plan with pediatric and adult vision benefits can visit ibx.com/visionprovider to look up an in-network vision provider.

Members can access their policies online via ibx.com or have copies of their IBX Adult Vision policy mailed to them by calling 1-800-ASK-BLUE (1-800-275-2583, TTY:711) from 8 a.m. to 6 p.m. EST, Monday through Friday.

No, small employer health plans do not require a separate card and bill.

You may download a vision claim reimbursement form from ibx.com.

With the rewards program, subscribers can earn a $300 reward for completing program activities like getting preventive care and opting into digital messaging. Once you complete the program activities, you can redeem your $300 reward for an e-gift card. You can click on Achieve Well-being Rewards under Rewards & Incentives on the member portal at ibx.com for more details.

Only the subscriber (not dependents) can earn this reward.

You must complete the program activities and redeem your rewards within your Program Period, as outlined within your Program Description on the member portal. Some activities might require self-reporting. You must self-report the completion of these activities prior to the end of your Program Period to be eligible to redeem your rewards. If you do not self-report these activities by the end of the Program Period, you will not be eligible to redeem your rewards. Visit the Rewards & Incentives section of the member portal to self-report these activities.

The Program Period is based upon your 12-month medical plan year which will be referred to as the Program Period. For example, if your medical plan year starts on July 1, the Program Period ends on June 30 of the following year, and only those activities that you complete and self-report by June 30 will receive credit for rewards.

You will automatically receive credit for some of the activities you complete during the Program Period. There are some activities that require self-reporting. Visit the Rewards & Incentives section of the member portal to see which activities require self-reporting.

If you do not complete all of the program activities in the Program Period, you will not be eligible to redeem your rewards for the Program Period. You may begin to earn rewards when the new Program Period begins.

You will automatically receive credit for certain activities that carry over into your new plan year (such as member portal registration and opting in to IBX Wire).

Completed activities will show with a checkmark on the Rewards & Incentives section of the member portal.

Once you complete the program activities and are eligible to redeem your rewards for an e-gift card(s), you will see the Redeem Now button on the Rewards & Incentives section of the member portal. Click Redeem Now to see the selection of e-gift cards. Please ensure that you have a valid email address registered in the member portal.

You can choose e-gift cards from Amazon, Dunkin, Best Buy, and many more retailers. You will have the ability to choose from a combination of e-gift cards not to exceed $300.

If you do not receive the e-gift card or you have questions about your e-gift card, please contact the Gift Card Customer Service department at 1-844-227-3226 or email support@newoceanhealth.com.

If you have redeemed for an e-gift card(s), you can check the status of your order by contacting Customer Service at 1-844-227-3226 or email support@newoceanhealth.com.

No, there is no expiration date on your rewards once you’ve redeemed them. Once you redeem your rewards and choose a specific e-gift card, there may be expiration dates set forth by that particular store or card sponsor. Please review the Terms & Conditions when going through the redemption process.

Rewards may be considered taxable income. IBX recommends that you consult a tax professional for further guidance.

You may speak to a customer service representative at 1-800-ASK-BLUE (1-800-275-2583).

Under the rules of the Affordable Care Act, tobacco use is one of the factors health insurers can use to determine how much someone will pay for a health plan. If you are a tobacco user, you may pay a higher premium.

If you initially indicated that you are a “tobacco user” when you enrolled in your IBX health plan but you are now in a tobacco cessation program, you may call 1-800-ASK-BLUE (1-800-275-2583).

IBX will reimburse you for participating in an approved tobacco cessation program. Call 1-800-ASK-BLUE (1-800-275-2583) or go to reimbursements.ibx.com for more information.