PEIA Update---The Latest on Special Enrollment 2017
(information from WV PEIA)
With the adoption of a state budget with funding for PEIA, there are substantial changes in the benefits for State agencies, colleges, universities and county boards of education, as well as non-Medicare retirees, so PEIA will be holding a Special Enrollment period from July 1 - 15, 2016. All changes will be retroactive to July 1, 2016.
This Special Enrollment period is NOT an extension of the
2017 Healthy Tomorrows deadline that passed in May.
PEIA will conduct a reconciliation in August to true-up premiums, deductibles, out-of-pocket maximums and copays resulting from retroactive plan changes.
The WVSMA asked for clarification regarding PEIA claim processing during this re-enrollment period and was advised that HealthSmart will continue to process claims July 1 per the Plan the member selected during the regular Open Enrollment. If the member changes Plans during this enrollment period, HealthSmart will process the adjustment. You may want to make your billing department aware of this potential reprocessing.
The following benefit changes take effect July 1, 2016:
Urgent Care copay increases to $50 for PEIA PPB Plans A, B and D.
For Comprehensive Care Partnership (CCP) Program members, ANY non-CCP office visit now requires the $40 specialist office visit copay.
The Face-2-Face Diabetes Program will be limited to two years. Current F2F members will be permitted two more years of services starting July 1, 2016, as long as they continue to meet the other requirements of the plan.
Out-of-state, non-network services are no longer covered in any of the PEIA PPB Plans. Patients will be responsible for 100% of billed charges from non-network providers outside West Virginia, except in a medical emergency or when approved in advance by HealthSmart. PEIA PPB Plan members who reside more than one county outside of West Virginia may use in-network providers where they live without prior approval from HealthSmart, as long as PEIA has been notified of the member's residential address.
Facility- fee limits for select facility-based services/procedures. If the member chooses an out-of-state facility that charges more than the PEIA facility fee limit, the member will be responsible for the difference between PEIA's payment and the facility's charge.
- Additional emergency room copay of $500 for high-risk behaviors, such as:
- Accidents while driving motorcycle or UTV/ATV without a helmet
- DUI/DWI or drug -related accidents
- Failure to wear seatbelt(s)
Opioid pain medications will have a quantity limit (QL) for all medications in the opioid class. Additional quantities require Prior Authorization.
Highmark West Virginia News
In March, physicians were sent a communication from Highmark regarding a change in reimbursement for their ACA product. This change affects about 45,000 covered lives who participate via the ACA plans. Highmark West Virginia advised physicians that they were taking a measured approach to managing ACA fees with an aggregate adjustment (reduction) of 0.6 percent for ACA direct-pay products.
Effective May 1, 2016, Highmark began to adjust the provider fee schedule to implement new fees for their ACA individual (direct-pay) products. Current fees are available in NaviNet®. These fees are not published on the public Provider Resource Center and questions regarding the new fees should be addressed to Highmark's Provider Resource Center.
The Highmark mailing also included an addendum to memorialize the fee changes and other agreements relevant to Highmark West Virginia's ACA network and products. Physicians should retain this document with their contract records.
Remember, your contract is your source for all your legal information regarding participation with insurers.
Highmark West Virginia has also announced that the plan is doing business differently in 2016. Physicians no longer have an assigned Provider Relations representative, but are instead encouraged to utilize the plan's self-service options. Highmark encourages you to take advantage of the online and telephonic tools that the plan offers.
NaviNet should be utilized as the primary resource for inquiries related to West Virginia Family Health members. Questions that cannot be resolved through NaviNet functionality for these members should be directed to West Virginia Family Health Provider Services at 1-855-412-8002.