BCBS NJ and AmeriHealth Announce Major Changes to Medicare Advantage Plans

docatdeskBCBSNJ Changes Members’ Medicare Plans

New Jersey BCBS has made changes to their Medicare population plans in 2015, terminating their Horizon Medicare TotalCare plan and introducing a new patient-centered Medicare Advantage plan.

Horizon Medicare Blue TotalCare is Discontinued

BCBSNJ will no longer offer the Horizon Medicare Blue TotalCare (HMO SNP) plan to dual-eligible individuals in 2015.  BCBSNJ will work closely with its Managed Medicaid subsidiary, Horizon NJ Health, to ensure that all current members of the TotalCare plan are transitioned to an appropriate managed Medicaid plan. BCBSNJ expects most of the membership to transition to traditional Medicare and Horizon NJ Health’s managed Medicaid plan and those with Medicare Part D benefits will transition to another Part D sponsor.

The benefits of Horizon NJ Health’s managed Medicaid plan along with original Medicare and Part D coverage are similar to the the TotalCare plan.  However, members will now have to carry three separate ID cards to access each of these plans instead of carrying one card for all three benefits.

New Medicare Advantage Plan

BCBSNJ now offers a Medicare Advantage plan that incorporates its patient-centered programs.  The plan is called Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.  The plan uses lower member cost sharing to encourage members to select and use a Primary Care Physician (PCP) affiliated with one of their established Patient-Centered Medical Home and/or Accountable Care Organizations.

If a member of the plan does not choose a PCP during enrollment, BCBSNJ will choose one for the patient.  Members can change that assignment and select another participating PCP once enrolled.  There will be no out-of-network benefits, except in the case of emergency where members are covered regardless of provider participation status.

Member ID cards will show the prefix YKO and the online Provider Directory will list the in-network participation status of all affiliated physicians and other health care professionals for this product.

Reimbursement will be at the managed care fee schedule. PCPs will be reimbursed based on their current payment methodology and capitated health care professionals will be reimbursed at existing negotiated rates.

More information can be found on the NJBCBS website for providers.

AmeriHealth NJ Medicare Advantage HMO Migrates to New Platform

On January 1, 2015, all AmeriHealth New Jersey Medicare Advantage HMO members will be migrated to the new operating platform including claims processing.  The new platform changes for members is that they will receive new member ID cards and a new, easier-to-read billing statement.

Providers should note the following changes:

  • Members have been issued a new 12 digit AmeriHealth ID number and Pharmacy ID number.
  • Members with AmeriHealth Medigap, have a 13-digit number, with the last digit being an alpha character
  • Providers should verify eligibility and benefits using the NaviNet® web portal prior to rendering a service.
  • Providers will receive a Provider Explanation of Benefits, replacing the Statement of Remittance.
  • Once a member has been migrated to the new platform, the Provider Automated System is no longer available for eligibility inquiries, submitting or retrieving referrals, submitting encounters, or checking claims status.  NaviNet should be used to retrieve all this information.

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