Transparency in Coverage
The Affordable Care Act (ACA) requires issuers seeking certification of a health plan as a qualified health plan (QHP) to make accurate and timely disclosures of certain information to the Health Insurance Marketplace, the Secretary of HHS, and the state insurance commissioner, and make it available to the public.
Below is a summary of information related to policies that may impact your health plan. It is meant as a guide. The guide applies to individual QHP products, unless otherwise noted. In the event there is a conflict between the guide and your contract, the terms and conditions of your contract will control. For detailed information please refer to your contract or benefit booklet.
Out-of-network liability and balance billing
Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you may be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.
Services in BlueOptions and BlueSelect plans are either subject to an exclusive provider provision or preferred provider provision.
Services subject to an exclusive provider provision must be rendered by an exclusive provider, except for emergency services. If you do not go to an exclusive provider the service will not be covered and you will be responsible for the entire cost of the services.
For services subject to a preferred provider provision you can go to an in-network or out-of-network provider. If you go to an out-of-network provider you may have a higher cost share. In addition, our payment will be based on the allowed amount and may be less than the charge. You then may be balance billed for charges in excess of the allowed amount. Balance billing may be waived for emergency services received at an out-of-network facility, or for services received by an out-of-network provider at an in-network facility.
SimplyBlue and myBlue are HMO plans. This means that services are only covered when rendered by an in-network provider except for emergency services. f you receive services from an out-of-network provider you will be responsible for the entire cost of the service except in the case of emergency services. If you are enrolled in the myBlue plan you also must receive all services from your primary care physician (PCP) or receive a referral from your PCP to see another provider. If you do not obtain a referral, you will be responsible for the entire cost of the service.
BlueCare is an HMO plan with a Point of Service (POS) rider. This means that services are only covered at the in-network cost share when rendered by an in-network provider, except for emergency services. Certain services may be covered if you receive them from an out-of-network provider. However, the amount you will have to pay out of your pocket for such services will almost always be more than if services were rendered by an in-network provider under your HMO benefit. Certain services may require authorization to use the out-of-network benefits and you may also be responsible for any charges that exceed the allowed amount. Before payments for covered services under the out-of-network benefit are made, you will have to meet the out-of-network deductible. The out-of-network deductible is separate from the HMO deductible and the two amounts will accumulate separately.
Regardless of what plan you have you should always verify if a provider is in-network prior to obtaining services. Please refer to your contract to find out if the service will be covered and to find out how much of the cost you will have to pay.
You can check to see whether a provider is in-network by checking our provider directory.
Learn more about how you are protected from balance billing and surprise medical bills.
Grace periods and claims pending policies during the grace period
If you are enrolled in an individual QHP and do not pay your premium on or before the due date, you are entitled to a grace period. The length of your grace period depends on whether or not you are receiving Advanced Payments of the Premium Tax Credit (APTC) as determined by the Marketplace.
If you receive an APTC your grace period is three months, as long as you have paid at least one full month’s premium. During the first month of your grace period, claims will be paid. During the second and third months of your grace period claims may pend. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your premium in full by the end of the grace period, your coverage will terminate the last day of the first month of the grace period. Any pended claims will be denied, and you will be responsible for paying your doctors and other providers directly for the services you received.
If you do not receive APTC, your grace period is 31 days. If we do not receive your premium by the end of the grace period, coverage will terminate as of your premium due date. Any services you received during this grace period will then be denied and you will be responsible for paying your doctors and other providers directly for the services you received.
We perform reviews and audits to ensure claims are paid correctly. If a claim is incorrectly paid and not related to fraud, we may retroactively deny or adjust the claim in accordance with state and federal law.
You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider. To avoid denials based on eligibility, ensure you have submitted all of the required documentation to the Marketplace, if applicable.
Enrollee claims submission
In-network providers have agreed to file claims directly with us. If for any reason a provider does not file a claim such as in the case of an out-of-network provider, it is your responsibility to file the claim. We must receive a Post-Service Claim within 90 days of the date the Health Care Service was rendered or, if it was not reasonably possible to file within such 90-day period, as soon as possible. In any event, no Post-Service Claim will be considered for payment if we do not receive it at the address indicated on your ID Card within one year of the date the Service was rendered unless you are legally incapacitated.
We will need an itemized bill or invoice from the provider which includes the following information in order to process your claim:
- date of service;
- description of service including procedure codes;
- charged amount;
- diagnosis including diagnosis codes;
- provider’s name and address;
- name of the person who received the service; and
- contract holder’s name and contract number as shown on the ID card.
If you visit an out-of-network pharmacy for emergency services or when authorized by us the full cost of the drug may be required at time of purchase. To be reimbursed, an itemized paid receipt must be submitted.
Claim forms may be found by clicking here and should be sent to the address found on the claim form. If you have any questions related to the forms please contact customer service at the number on the back of your ID card or 1-800-352-2583. Please send your claims to the following addresses:
P.O. Box 1798
Jacksonville, FL 32231-0014
All pharmacy claims:
Prime Therapeutics, LLC
P.O. Box 25136
Lehigh Valley, PA 18002-5136
Enrollee recoupment of overpayments
Individual Policies: If you overpaid your premium amount, we will refund you any overpayment. A credit will be applied to your account and it will be shown on your next bill. If you would prefer to receive a check instead of a credit you can contact us at the phone number on the back of your ID card.
Medical necessity and prior authorization timeframes and enrollee responsibilities
Medically necessary describes care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. We review whether services are medically necessary to determine coverage, benefits or payment under the terms of your plan. If a service is not determined to be medically necessary, it will not be covered and you will be responsible for the cost of those services. This determination is made only to determine if a service is covered under the terms of your plan and not for the purpose of recommending or providing medical care.
Prior authorization is a review performed to determine if certain services are eligible for payment under your plan before they are rendered or obtained.
You are responsible for obtaining required authorizations before services are rendered. Prior authorization is not required when emergency services are rendered for the treatment of an emergency medical condition.
In most cases in-network providers will request a prior authorization on your behalf. Out-of-network providers have not agreed to accept this responsibility. Therefore, in all cases where a prior authorization is required you should verify that prior authorization has been approved BEFORE you receive services or supplies. If you do not receive a prior authorization the service may not be covered and you may be responsible for the entire cost of the service.
For all urgent services we will make our best efforts to provide notice of decision within 72 hours after receipt of the request unless additional information is required. For all other services we will make our best efforts to provide notice of decision within 15 days of receipt provided additional information is not required.
For a list of services that require prior authorization please refer to your contract. You can access a copy of your contract on your member account at www.floridablue.com or you can call the customer service number on your member ID card. For more information on prior authorizations click here.
Prior Coverage Authorizations expire on the earlier of, but not to exceed 12 months: a. the termination date of your policy, or b. the period authorized by us, as indicated in the letter your receive from us.
Subject to our review and approval, we may authorize continued coverage of a previously approved Service. To request a continuation we must receive appropriate documentation from your Provider. The fact that we may have previously authorized coverage does not guarantee a continued authorization.
Drug exceptions timeframes and enrollee responsibilities
You have the right to submit an exception request for drugs not covered on the formulary. There are two levels of exception requests. You may request an internal exception and if that is not approved you have the right to request an external exception from an independent review organization. Below is information on how to request both types of exceptions.
To request either a standard or expedited internal exception click here to complete and submit the exception application, or call the number on the back of your member ID card. After you complete the application please fax or mail it to:
Prime Therapeutics LLC
C/O Clinical Review Department
2900 Ames Crossing Road
Eagan, MN 55121
For standard internal exception requests, we will notify you of our decision within 72 hours of receipt of the request. If approved, coverage of the excepted medication will be provided for the duration of the prescription, including refills, subject to the terms of your contract.
An expedited exception request may be requested based on exigent circumstances that exist when you are:
- suffering from a medical condition that may seriously jeopardize your life, health or ability to regain maximum function; or
- undergoing a current course of treatment using a medication that is not covered on our formulary.
We will notify you of our decision within 24 hours of receipt of an expedited request. If approved, coverage of the excepted medication will be provided for the duration of the exigency, subject to the terms of your contract.
You will be notified if your internal exception request is denied and provided with instructions on how to request an external exception review by an independent review organization (IRO). If a standard external exception request is denied, we will notify you of the decision within 72 hours of our receipt of the request. If an expedited external exception request is denied, we will notify you of the decision within 24 hours of our receipt of the request. If your request is approved by the IRO, coverage of the excepted medication will be provided for the duration of the prescription, subject to the terms of your contract.
The information provided herein is to share compensation provided to brokers for members enrolling in a Florida Blue Individual Under 65 Healthcare plan, including short-term limited duration plans. The broker compensation rate for Individual Under 65 plans of $20.64 is applicable on a per member, per month (PMPM) basis and reflective of any compensation programs offered, including base commission and bonus. PMPM rates are built into a member’s premium, which is filed and approved by the Florida Office of Insurance Regulation.
Information on Explanation of Benefits (EOB)/Member Health Statement
All claim decisions will be sent to you in writing through your monthly member health statement, also referred to as an explanation of benefits (EOB). . A member health statement is a summary of finalized health and pharmacy claims for the prior month. The member health statement is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive a member health statement, review it closely and compare it to the receipt or statement from the provider.
Your member health statement may include the following information:
- Details of how your claim was processed including actions of payment, denial, or pending for further information.
- Specific reason(s) the claim was denied.
- Reference to specific contract provisions, internal rule, guideline, protocol, or other similar criterion that was relied upon in making the denial determination.
- Description of any additional information needed and why it’s necessary.
- Explanation of your appeal rights and the steps to take to have a denial reviewed.
- Description of the denial review procedures and time limits.
You can log in to your member account to view your member health statements.
Coordination of benefits (COB)
When you are covered by us and another plan COB determines which plan pays first. COB is designed to avoid duplication of payment. We will coordinate payment to the maximum extent allowed by law. The amount we pay is based on whether we are the primary or secondary payer. If we are primary, we will pay without regard to coverage under other plans. If we are not primary, our payment may be reduced so the total benefits under all plans will not exceed 100 percent of the total charge or allowed amount.
For more information on how COB works please refer to your contract. You can find a copy of your contract on your member account.
Contraception and Women’s Preventive Services
Under ACA’s contraceptive coverage requirement, Florida Blue must cover a full range of contraceptive methods and services, without copayments or other cost-sharing. Florida Blue must cover at least one product in every contraceptive method category. See the list of Women’s Preventive Services in the Pharmacy medication guides for more information.
Florida Blue may use medical management techniques, such as pre-authorizations and/or formularies, to influence a member’s choice of contraceptive products within those method categories.
If there are contraception products not covered on the prescription formulary, Florida Blue has the Contraceptive Tier Exception Request form in place for when you and your provider determine a non-covered product would best meet your medical needs. Submit your request to CoverMyMeds or complete the form and fax it to Prime Therapeutics at 1-855-212-8110 for determination of coverage.