BCBS - New Copay Plus Deductible Health Plans

Effective Jan. 1, 2015, Florida Blue and its affiliate Florida Blue HMO (Health Options, Inc.)
Are offering individual consumers certain Affordable Care Act plans with a new benefit design that
features a copay plus deductible cost share for most services. For these plans, the copay and
deductible are both due at the time services are rendered (for all services), except services
received from a primary care physician or when the copay amount shown is $0. After the
deductible is met, just the copay will be due at the time of service. The new cost share will apply
to the following plans on Jan. 1, 2015:

• BlueOptions-plans 1410,1410A, 1410O and 1410P
• BlueSelect -plans 1443,1443A, 1443O and 1443P
• BlueCare HMO -plans 1477, 1477A, 1477O and 1477P

It’s important to understand how much you can collect from a member who is enrolled in one of
these new plans. A couple of scenarios are provided below.

Scenario 1
Jason is enrolled in the Silver Everyday Health Copay & Deductible plan and needs to visit his
local urgent care center. The total bill is $550 and the plan allowance is $300.

Since Jason has not met any of his calendar year deductible, he is responsible for the $100
copay to the urgent care center and for paying his remaining deductible up to the allowed
amount of $300.

Jason Pays :
Copay $100
Deductible  $200
Total Out – of – Pocket $300 (Total amount you can collect)

Scenario 2
Mary is enrolled in a BlueOptions 1410 copay plus deductible plan and needs to visit a
specialist. She is told that the total bill is $100 and the plan allowance is $75. Her specialist
copay is $85 and she has not met her deductible. Important: In this scenario, the provider may
only collect $75(the allowed amount) as members should never pay more than the allowed amount
even if the copay and remaining deductible amounts are greater.

Mary Pays:
Total Out-of Pocket$75 (Total amount you can collect)

Follow the tips below to identify members enrolled in the new copay plus deductible plans and to
Determine how much you can collect upfront:
• Verify eligibility and benefits electronically through Availity and be sure to check the Plan/Product Information section to determine a member’s plan name and number.
• Use CareCalc, to obtain an estimate of a patient’s financial responsibility for a treatment or service based on the member’s benefits in real-time. You can access CareCalc through Availity; select Eligibility & Benefits, then Inquiry Option. You can find information about Florida Blue’s CareCalc requirements in the online Manual for Physicians and Providers on our website at floridablue.com.

• Ask members for a copy of their ID card at each visit. The plan number for copay plus deductible health plans will appear in the lower right corner of the ID card.