Frequently Asked Questions
For Members Covered Through a Small Employer
Below are frequently asked questions about Independence Blue Cross health insurance plans for members who are covered through a small employer (50 or fewer employees). Click on a topic below to view a list of related questions.
- Health Insurance Basics
- Covered Benefits
- Keystone HMO Proactive Plans with a Tiered Network
- Prescription Drug Benefits
- Dental Benefits
- Vision Benefits
- Tobacco Use
Health Insurance Basics
- What is a copay?
- What is coinsurance?
- What is a deductible?
- What is an out-of-pocket maximum?
- What is a primary care physician (PCP)?
- What is a specialist?
- What is a referral?
- How can I save money on costs related to my health insurance?
What is a copay?
A copayment, or copay, is the fee you pay when you see a doctor or get other services. You may pay a copay of $30 to see a doctor or $450 when you go to the emergency room.
What is coinsurance?
Coinsurance is the percentage you pay for some covered services. If your coinsurance is 20 percent, your health plan will pay 80 percent of the cost of covered services, and you will pay the remaining 20 percent. The amount you pay is typically not based on the full retail price of the service. It is based on a discounted rate negotiated by your health plan with heath care providers like doctors and hospitals.
What is a deductible?
A deductible is 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 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, if your plan has a $1,600 deductible, 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.
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. Single deductible applies when an individual is enrolled without dependents.
What is an out-of-pocket maximum?
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 Independence.
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. Single out-of-pocket maximum applies only when an individual is enrolled without any dependents.
What is a primary care physician (PCP)?
A PCP is the doctor you see for most of your health care needs. HMO plans require you to choose a PCP, who will refer you to a specialist when needed. PPOs do not require that you choose a primary care physician. To find a PCP, use our Find a Doctor tool.
What is a specialist?
A specialist provides medical care for certain conditions in addition to the treatment provided by your primary care physician (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, and spinal manipulations. Under our PPO plans, you never need a referral to see a specialist.
What is a referral?
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, and spinal manipulations.
How can I save money on costs related to my health insurance?
- 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 primary care physician (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 of 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.
- What services do all plans cover?
- Why is the cost for certain benefits different depending on where I receive care?
- Is coverage provided for the treatment of Autism Spectrum Disorders?
- Does my plan cover preventive care, such as colonoscopies?
- Does my plan include coverage for telemedicine visits?
- Does my plan cover gender reassignment surgery?
- Are there services that my plan does not cover?
What services do all plans cover?
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 ibxpress.com.
Essential Health Benefit
Preventive, wellness, and disease management services
Yearly physical, flu shot, gynecological exam, birth control
Treatment for broken bones, heart attacks, and more at a hospital emergency room
Minor surgeries, blood tests, X-rays
Treatment at a hospital for a condition that requires you to stay overnight or multiple days
Maternity and newborn services
Care through the course of a pregnancy, delivery of the baby, and checkups after the baby is born
Pediatric services, including dental and vision
Well visits, shots to prevent serious health conditions, teeth cleanings and exams, frames, lenses
High blood pressure medicine, insulin, antibiotics, birth control pills
Mental health and substance abuse services, including behavioral health treatment
Getting help to deal with conditions like depression, alcohol abuse, and drug abuse
Rehabilitation and habilitation services
Physical therapy, speech therapy, occupational therapy
Why is the cost for certain benefits different depending on where I receive care?
For services such as outpatient surgery, sleep studies, and laboratory 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. When you use an in-network ambulatory surgical center (ASC) for outpatient surgery, you will pay less out of pocket. 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 primary care physician’s (PCP’s) designated lab site. You should refer to your ID card for the lab site indicator or contact your PCP for this information.
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 ibxpress.com.
Is coverage provided for the treatment of Autism Spectrum Disorders?
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 ibxpress.com for a complete description of ASD benefits.
Does my plan cover preventive care, such as colonoscopies?
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 provider — which are providers that are not hospital-based — and it is performed by a Preventive Plus professional (a gastroenterologist or a colon and rectal surgeon). To find participating Preventive Plus providers, use our Find a Doctor tool and look for the Preventive Plus icon.
For $0 member cost-sharing to apply, in addition to seeking services from Preventive Plus providers, colonoscopy screenings must meet the United States Preventive Services Task Force’s (USPSTF) recommendations.
- Screenings should begin at age 50 and continue through age 75.
- Screenings will be covered as preventive once every 10 years.
Colorectal cancer screening tests that are not included in the USPSTF recommendations will be subject to medical necessity and member cost-sharing. This includes colorectal cancer screenings for members in high-risk categories before age 50 and screenings given more often than the USPSTF-recommended frequency. For members in high-risk categories, colorectal cancer screenings before age 50 and screenings given more frequently than the USPSTF-recommended frequency are covered but will be subject to the cost-sharing provisions of your benefit plan.
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.
Does my plan include coverage for telemedicine visits?
Beginning on your coverage renewal or effective date in 2017, all Blue Solutions small employer plans include coverage for telemedicine from MDLIVE*. 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. For all Blue Solutions plans, members will be responsible for a $40 fee per occurrence. For more information or to connect via web video, you can login at mdlive.com/ibx.
Does my plan cover gender reassignment surgery?
Beginning with renewal/effective dates in 2017, the exclusion for gender reassignment surgery has been removed from all Blue Solutions plans. Members will 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.
Are there services that my plan does not cover?
Below are some of the services not covered by your health plan. For a complete list, members should consult their member handbook.
- 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
- Treatment of sexual dysfunction not related to organic disease except for sexual dysfunction relating to an injury
- Routine foot care, unless medically necessary or associated with 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 acupuncture
- 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
Keystone HMO Proactive Plans with a Tiered Network
- What is unique about the Keystone HMO Proactive plans?
- What is a tiered network?
- What is the difference between a tiered network and a limited network?
- Are all the providers from the Keystone Health Plan East HMO network assigned a tier?
- How do you determine which tier providers are assigned to?
- What percentage of providers are in Tier 1 – Preferred?
- Can a doctor be assigned to more than one tier?
- How often will providers change tiers?
- How can I find out which tiers my doctors and hospitals are in?
- Will my cost-sharing always vary based on the provider and tier I choose?
- Are certain services covered at the same cost-sharing amount regardless of tier level?
- Do I need to worry about tiers in the event of an emergency?
- What happens if I am admitted to a Tier 2 – Enhanced or Tier 3 – Standard hospital through their Emergency Room?
- If my doctor refers me to a specialist in Tier 2 – Enhanced or Tier 3 – Standard, is there anything I can do? Standard, is there anything I can do?
What is unique about the Keystone HMO Proactive plans?
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 and emergency room, physical therapy, occupational therapy, and mental health, which have the same cost-sharing regardless of the provider’s assigned tier.
What is a tiered network?
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-pockets 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 most 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.
Tier 1 – Preferred
Tier 2 – Enhanced
Tier 3 – Standard
What is the difference between a tiered network and a limited network?
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 choose 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.
Are all the providers from the Keystone Health Plan East HMO network assigned a tier?
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 and emergency room, physical therapy, occupational therapy, and mental health. View your Summary of Benefits and Coverage at ibxpress.com for more details.
How do you determine which tier providers are assigned to?
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 in which your primary care physician (PCP) typically refers Independence Blue Cross 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.
What percentage of providers are in Tier 1 – Preferred?
More than 50 percent of doctors and hospitals are in Tier 1 – Preferred, so you have plenty of choices for where you receive care. And you don’t have to stay within one tier. For example, you can choose to see Tier 2 – Enhanced providers for some services and Tier 3 – Standard providers for other services.
Can a doctor be assigned to more than one tier?
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 the 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.
How often will providers change tiers?
Independence Blue Cross will re-evaluate provider tier assignments annually. Tier assignments are effective on January 1 every year.
How can I find out which tiers my doctors and hospitals are in?
You can see all of the Keystone Health Plan East HMO network hospitals arranged by tier and county at ibx.com/proactivehospitals. You can also see which tiers your doctors and hospitals are assigned by using our Find a Doctor tool.
Will my cost-sharing always vary based on the provider and tier I choose?
There are some services that have the same cost-sharing across all tiers. Examples include preventive care and emergency room, 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 ibxpress.com for more details.
Are certain services covered at the same cost-sharing amount regardless of tier level?
Many covered services will cost the same amount to you no matter the tier level of the provider or facility you choose. These are:
- Preventive care
- Emergency room
- Emergency ambulance
- Urgent care
- Prescription drugs
- Pediatric dental and vision
- Behavioral health
- Spinal manipulation
- Outpatient lab/pathology†
- Routine radiology/diagnostic†
- MRI/MRA, CT/CTA scan, PET scan†
- Physical/occupational therapies†
Do I need to worry about tiers in the event of an emergency?
If you have an emergency, you should always visit the nearest hospital. Emergency room services, in addition to a few other services, 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 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 (highest cost-sharing) will apply.
What happens if I am admitted to a Tier 2 – Enhanced or Tier 3 – Standard hospital through their emergency room?
Emergency room fees are the same no matter which tier hospital you choose. However, if you are admitted to the hospital from the emergency room, your out-of-pocket costs for the inpatient hospital stay will be determined by the tier that hospital is in.
If my doctor refers me to a specialist in Tier 2 – Enhanced or Tier 3 – Standard, is there anything I can do?
You can speak with your doctor about why he or she chose the 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.
- What is the Mandatory Generic Program?
- How much will I pay for generic medications?
- What is the FutureScripts Preferred Pharmacy network?
- What are specialty drugs, and how are they covered?
What is the Mandatory Generic Program?
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 both HMO Proactive plans and all Silver and Bronze plans.
How much will I pay for generic medications?
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.
For the HMO Gold and Silver Proactive plans, you will pay $4 for preferred generics and $15 for all other generic drugs. View a list of $4 preferred generics.
$7 after deductible
HMO/DPOS Bronze Essential
$15 after deductible
HMO Gold and Silver Proactive
All other Blue Solutions plans
What is the FutureScripts Preferred Pharmacy network?
The FutureScripts Preferred Pharmacy network is a smaller version of our full FutureScripts pharmacy network. There are more than 50,000 pharmacies in the Preferred Pharmacy network, including CVS, Walmart, and Target, in addition to independent pharmacies.
Please note that Rite Aid and Walgreens are not part of the Preferred Pharmacy network. If you fill a prescription at Rite Aid or Walgreens, it will be 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 ibxpress.com to find a participating pharmacy.
What are specialty drugs and how are they covered?
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 coinsurance up to a maximum cost-share per prescription for a specialty drug.
You can determine if a drug is a specialty drug by searching for the drug on the Formulary Lookup tool. Specialty drugs are indicated with the Specialty Product icon shown at right.
For Keystone HMO Gold and Silver Proactive plans, members should search the 5 Tier Formulary to determine if their drug is on the Specialty drug list. For all other Blue Solutions plans, members should search the 4 Tier Formulary.
You have the option of filling your prescription at a participating retail pharmacy or through BriovaRx, a leading specialty pharmacy and expert in specialty medication management. When you use BriovaRx, you can take advantage of a 24/7, hands-on approach to patient support from specialty pharmacists and registered nurses familiar with treating patients with certain conditions. These BriovaRx specialists can advise your care team to him you achieve the best health outcomes through:
- 24/7 video consultations
- Ongoing patient education and support
- Confidential, convenient order and delivery
- Refill reminders
Additionally, members will usually pay a lower coinsurance amount when obtaining specialty medications through BriovaRx rather than a retail pharmacy as BriovaRx provides better discounts on most specialty drugs. These discounts are also applicable to members with a high deductible plan prior to the deductible being met. This means members with a high deductible plan can start saving as soon as they use their specialty pharmacy benefit, without waiting to meeting their plan’s deductible.
Does my plan include pediatric dental benefits?
If your employer purchased your health plan directly from Independence, it includes pediatric dental benefits for your covered dependents up to age 19. View your Summary of Benefits and Coverage and benefits booklet at ibxpress.com for details about your plan’s pediatric dental benefits.
If your employer purchased your health plan through the Small Business Health Options (SHOP) exchange, you should contact your employer to determine if you have coverage for pediatric dental.
How are adult dental benefits covered?
Independence 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.
Do all plans include coverage for vision benefits?
All of our small employer health plans include in-network coverage for adult and pediatric vision exams and glasses or contacts.
How much can I spend on glasses or contacts?
Your health plan includes up to a $150 allowance for glasses for adults age 19 and older when you purchase your glasses from a Visionworks store, and up to $100 when visiting other Davis Vision locations. If you prefer contacts, your plan includes up to a $100 allowance. For covered dependents up to age 19, all plans include coverage for glasses or contacts. This allowance/coverage applies for in-network care only.
- If I am a tobacco user, does it affect how much I pay for my health plan?
- What if I quit smoking or enroll in a tobacco cessation program during the plan year?
- Can I get reimbursed for participating in a tobacco cessation program?
If I am a tobacco user, does it affect how much I pay for my health plan?
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.
What if I quit smoking or enroll in a tobacco cessation program during the plan year?
If you initially indicated that you are a “tobacco user” when you enrolled in your Independence Blue Cross health plan but you are now in a tobacco cessation program, you may call 1-800-ASK-BLUE (1-800-275-2583).
Can I get reimbursed for participating in a tobacco cessation program?
Independence Blue Cross will reimburse you for participating in an approved tobacco cessation program. Call 1-800-ASK-BLUE (1-800-275-2583) or go to ibx.com/reimbursements for more information.
* MDLIVE is an independent company providing telemedicine services for Independence Blue Cross.
† When you receive services at a designated site referred by your PCP.