Federal Employee Program Benefit Change – Dialysis Services
Effective January 1, 2016, the Blue Cross Blue Shield Service Benefit Plan (Service Benefit Plan) will change the benefit reimbursement for services received from dialysis providers that do not participate in Blue Cross Blue Shield of Montana's (BCBSMT) network. This includes services rendered by nonparticipating dialysis providers, including those who provide dialysis services in outpatient dialysis centers, outpatient departments of hospitals, nursing facilities, and homes.
The Service Benefit Plan will no longer provide reimbursement based on the provider’s charge. Rather, the amount we pay for dialysis services will be based on the allowance established by the local Blue Cross and Blue Shield (BCBS) plan where the services are provided. If a dialysis provider in the BCBSMT area does not participate with BCBSMT, the amount we pay will be based on BCBSMT’s participating provider allowance. This may result in an increase in the amount a member may have to pay the provider (out-of-pocket amount). If dialysis services are received in another BCBS plan’s area and the provider does not participate with the local BCBS plan serving the area where the dialysis provider is located, the allowance will be determined by that BCBS plan.
If the plan allowance for dialysis services provided by a nonparticipating dialysis facility is less than the dialysis facility’s charge, the nonparticipating dialysis facility may balance bill up to its charge after benefits are provided by the Service Benefit Plan.
If the member has Basic Option; there is no out-of-network coverage. Therefore, there will be no change for these members. Members can continue to receive treatment from a nonparticipating provider after December 31, 2015, in which case the member will be wholly responsible for the charges and will not receive reimbursement for the services rendered.