Premera Blue Cross Response to COVID-19

Who is eligible?

All active insured small and large group employers including associations in Washington state that will be receiving an August 2020 premium bill.

Do I have to apply? When will I see the premium relief?

Groups don’t need to apply. We’re currently working through our internal processes and expect to provide this one-time credit in the group’s August billing cycle.

How much is being provided?

Premera is providing up to $25M premium relief through a one-time premium credit estimated to be up to 15%. All eligible groups will receive the same percentage credit.

Why only fully-insured? Why aren’t self-funded groups included?

Self-funded groups are at risk for their claims expenses and are seeing a reduction in health plan costs through a reduction in claims and overall utilization.

Are OptiFlex groups self-funded?

Yes, OptiFlex are self-funded groups. For these groups, we estimate and bill a flat monthly rate based on projected claims experience with a surplus position calculated at the annual accounting.

Will this impact producer commissions?

No; we’re working internally to ensure producer commissions are not impacted.

Will the premium relief impact rate quotes for renewals?

No. It will not impact rating decisions. Premera continues to appropriately rate for risk.

Every business has a different set of circumstances and requirements that should guide their return to work decisions. At Premera, we, too, are evaluating the needs of our business and the needs of our employees as we determine when and how we’ll return to work.

Here are several resources that other businesses are finding helpful in determining their return to work strategy. We’ll continue to update this list as we come across additional resources. 

1. Interim Guidance from the Centers for Disease Control and Prevention (CDC)

2. Wilson Perumal & Co Re-start Playbook

3. Seattle venture community, the Seattle Metropolitan Chamber of Commerce and the Bellevue Chamber of Commerce Playbook: Reopening the Workplace

4. Boston Consulting Group: COVID-19 New Normal Planning

5. State of Washington Safe Start WA

We encourage employers to monitor local, state, federal guidance and clinical expert organizations such as the CDC, as it pertains to return to work protocols. As new information is available, we’ll share that guidance with you. Premera will continue to be as flexible as possible to provide services to our members and supporting you with the most current and reliable information available.

Premera isn’t endorsing or sponsoring any of these resources. We thought you might find them useful as you begin planning your own return to work strategy.

Premera is extending the 30-day premium grace period to 60 days for fully insured groups. This grace period is in place to ensure your employees are receiving the care and medications they need during this critical time. Grace period information can be found in your group contract. 

We’ve also implemented a grace period for OptiFlex monthly funding rates, and ASC Admin Fee only.

This is a “premium grace period” and not “claims grace period.” This guards against cancellation. Premera will hold medical, dental and vision claims during the unpaid premium period though members will continue to show as eligible in the system. This will also allow members to get their prescriptions filled. 

During the first 30 days of the grace period, claims will be paid. Claims will then be held beginning day 31 to end of grace period. This applies to claims beginning March 1. During the unpaid premium period, your members will show as eligible in the system. This will also allow members to get their prescriptions filled.

The extension of the grace period doesn’t eliminate the obligation to pay the premium, but limits policy cancellation for late payment. Grace period information can be found in your group contract.

To assist with premium payments, we have added a temporary online payment with credit card option for groups. Credit card payments can only be made via the employer portal.  We don’t have the ability to accept credit card payments over the phone.  Optiflex groups are excluded from the new credit card payment option as Vimly does not accept credit cards.

For plans with LWAC Stop loss, LWAC will extend the premium grace period to 60 days from the current filed 31 days in the contract. Delinquency notifications are delivered 30 days prior, stating the bill has to be paid in full at the next cycle.

There are restrictions that generally do not allow carriers to offer premium discounts or waivers to employers. 

Yes. Recently the Washington State Office of the Insurance Commissioner (OIC) is requiring that insurers notify employees of a delinquent group of this delinquency. If an employer remains unable to pay their premiums for more than 60 days, employees may be required to pay for any unpaid medical bills. These letters will only go to employees of a fully-insured group that is delinquent.

Yes, in addition to the previous ACH payment option, we have added a temporary online payment with credit card option for groups. Credit card payments can only be made via the employer portal.  We do not have the ability to accept credit card payments over the phone.

Premera will cover the 2.5% credit card transaction fee.

Self-funded groups can pay administrative fees through the new credit card payment option, but not claims reimbursements or stop loss premiums.

Optiflex groups are excluded from the new credit card payment option as Vimly does not accept credit cards.

The group will need to log into the secure Employer Portal and select billing, then select Pay Online and agree to the online payment Terms and Conditions, add your email address and setup their payment account information. For groups that already have an account set-up, you can manage your funding sources and change to a credit card.

Our current leave of absence (LOA) allowance for large and small group standard contracts is up to 90 days for furloughed employees and those on leave. For self-insured and OptiFlex groups, we'll allow them to waive the LOA and actively at work requirements through October 1, 2020.

No. This could impact a group’s health plan eligibility for all employees and require a full open enrollment period and the plan year to restart. Some employees who waived enrollment may be eligible for individual plans on the state or federal exchanges.

Premera processes eligibility based on information provided by the employer. As long as the employee remains on the eligibility file, they will remain covered. 

Premera processes eligibility based on information provided by the employer. As long as the employee remains on the eligibility file, they will remain covered. 

We're waiving any re-rating rules for all groups (insured, OptiFlex, and self-funded). Groups who fall under an eligibility threshold will be able to maintain their rates through the end of their plan year.

Our standard rules remain which allow for reinstatement during the same plan year without experiencing a waiting period or losing their out-of-pocket accumulators.  For groups whose plan year ends before June 30, we will treat them as if they were coming back within the same plan year.

Premera doesn’t have decision making authority on the state-regulated continuation of coverage rules. Anytime someone experiences a job loss, they may be eligible for individual plans on the state or federal exchanges.

Groups should be aware that individual coverage is available in Washington and you would meet the Washington Health Insurance Market place special enrollment criteria if they don’t meet eligibility requirements on their group plan. Due to the number of COVID-19 cases in our state, Washington Healthplanfinder extended a special enrollment period through May 8, 2020 for people without insurance. Coverage will start May 1, 2020 for people who enroll after April 8.   

On April 29, the U.S. Department of Labor (DOL) announced guidance which extends a number of regulatory deadlines for ERISA plans and plan participants.

The DOL’s FAQ on health benefit and retirement benefit issues related to COVID-19 are intended to help employee benefit plan participants and beneficiaries, plan sponsors and employers impacted by the coronavirus outbreak understand their rights and responsibilities under ERISA. Model Notice FAQ.

Premera processes eligibility based on information provided by the employer. As long as the employee remains on the eligibility file, they will remain covered.

To support this increasing request, on Tuesday April 28th at 6 p.m., we’re launching new secure employer website functionality that will show the last 24 months of invoices. Employers will be able to access this on the billing page. This functionality will be permanent.

Premera expanded its telehealth network to give members greater access and address the increased demand related to COVID-19. This expanded network is available until June 30, 2020, with the potential to extend the duration based on business and epidemiological considerations.

Who’s eligible for this benefit?

This benefit will apply to members of insured groups, individual, grandfathered, non-grandfathered, associations and OptiFlex. Self-funded plans have the option to participate.

Who's not eligible: Shared admin, FEP, BlueCard, Providence, HCA, Medicare Supplement, Medicare Advantage, and self-funded plans that opt out.

What’s the cost of these new providers to the member? 

Telehealth cost shares will be waived for all in-network providers.  If a telehealth provider charges you a copay, deductible, or coinsurance for telehealth services through June 30, the provider is responsible for reimbursing the member once the claim is processed and the provider is paid.

Are brick and mortar in-network offices covered?

Yes. All in-network providers who offer telehealth options are covered under this expansion.

When should I use telehealth services and what can they help me with?

If you’re feeling ill with non-COVID-19 symptoms, you can contact a telehealth provider. Telehealth providers can answer questions, diagnose, and treat acute and chronic illness for non-COVID-19 related symptoms. They can also fulfill necessary prescriptions or order lab tests at local facilities.  

In addition to our existing Premera contracted behavioral health providers (TalkSpace, Teladoc BH*, brick and mortar providers, and employer assistance programs), we’re introducing new virtual access for behavioral health and substance use disorder treatment (opioid and alcohol):   

• Doctor On Demand – We're adding Doctor On Demand's behavioral health services for dates of service April 16 through June 30, 2020. These services are available to member adults and children in all states.
• Boulder Care - Boulder Care is a digital care provider, offering long-term support and medication-based treatment for opioid use disorder (OUD) and common co-occurring conditions for members 18 years and older. Their digital platform allows patients to connect with providers 24/7 through secure video and messaging with clinicians, care advocates, and peer coaches. Boulder Care is working towards 50 states licensure. If they aren’t licensed in a certain state they will transition the member to an in-network provider for the appropriate services. 
• Workit Health – Workit Health is a digital care provider offering support for alcohol use disorder (AUD). Via Workit web and phone apps, members age 18 and older have a “recovery in their pocket” harm reduction and sobriety solution that provides 24/7 access to interactive therapeutic courses, online support groups supervised by licensed care teams. Workit is working towards 50 states licensure. If they aren’t licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.  

* Teladoc behavioral health is currently available only for self-funded groups who previously opted-in to Teladoc behavioral health in addition to their general Teladoc election.  

Effective May 1, 2020, as self-funded groups renew, Teladoc behavioral health will automatically be added for groups that already have general Teladoc services elected. Cost shares would then apply for Teladoc behavioral health through June 30, depending on whether the group elected to temporarily waive cost shares for telehealth. Teladoc behavioral health will not be added for self-funded groups who do not already have Teladoc services.

Currently, many telehealth providers cannot diagnosis or test for COVID-19 and in many cases, can’t provide a "prescription" for a COVID-19 test. Local providers offering telehealth services, however, may be able to provide a referral to a testing site. Contact your primary care provider for information.

We’ve created a ready-to-share flyer you can show to your employees with more information about these providers.

Yes. Premera-contracted providers are able to provide telehealth services to the extent allowed by their licensure. Members can check with their current provider office to see if they offer telehealth services. 

For Medicare Advantage: CMS has loosened guidelines around telehealth services during the COVID-19 Public Health Emergency. Starting March 6, 2020, Premera will cover telehealth visits for Medicare Advantage members billed by any healthcare facility at the same cost shares as an in-clinic visit. The previous requirement for services to be provided in certain types of originating sites and locations has been waived for the duration of the COVID-19 Public Health Emergency.

Yes, this applies to all services where Premera policies and procedures allow for telehealth billing. Please remember that these are all still subject to medical and payment policies. 

We recently modified our medical policies to allow all speech therapy and ABA services to be provided virtually for dates of service on or after 3/20/20 during this emergency period only.

For groups who did participate in the telehealth expansion and don’t cover telehealth services, these may not apply.

Yes. Premera offers Talkspace for all our members. This is an online, virtual behavioral health provider resource. Many local mental health providers are also offering virtual services. Your patient should check with their provider first, or they can go directly to Talkspace. 

The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for diagnostic testing, including U.S. Food and Drug Administration (FDA)-approved COVID-19 diagnostic testing products and items and services related to testing furnished during an office, telehealth, urgent care center or emergency room visit. We have removed the group waivers that were previously in place to comply with this mandate. As additional guidance is issued, a business decision may be made to allow opt-outs of additional criteria.

For commercial, Medicare Supplement, and self-funded or OptiFlex groups: We're waiving cost shares for members requiring FDA-approved diagnostic testing for COVID-19. Per the new Washington State Office of the Insurance Commissioner (OIC) requirements, we’re also waiving in-network copays and deductibles for other virus/respiratory testing tied to a COVID-19 diagnosis.This applies to testing and the related provider visit. All other treatments and services including hospitalizations will be subject to the usual benefits and cost shares. We’ll continue to evaluate guidance and the scope of COVID-19 and adjust as needed.

For Medicare Advantage members: We’re waiving all cost shares for the healthcare provider visit and FDA-authorized COVID-19 diagnostic testing for members who meet CDC criteria for testing. All other treatments and services including hospitalization are subject to the usual benefits and cost shares.

For groups, including self-insured and OptiFlex: The IRS issued guidance allowing COVID-19 testing and treatment cost-share waivers for high deductible health plan and non-high deductible health plan members. 

HHS guidance requires plans and insurers to cover the serology antibody test without cost-sharing when used in conjunction with other COVID-19 diagnostic testing for a COVID-19 diagnosis. We’re currently evaluating the tests and their availability to ensure we have correct processes in place to manage claims for these. 

The FDA has cautioned that these serology tests should not be used as the sole basis to diagnose or exclude COVID-19 infection or to inform infection status.

Yes, this comprehensive approach means that Premera members nationwide will have easier access to medications and testing. These benefits are based on the state the plan was sold in, not where the member resides.

Additionally, all 36 participating Blue Cross Blue Shield plans across the country are implementing similar approaches to show their collective support.

Yes, all changes to our insured business apply to Peak Care. MultiCare has also established three respiratory clinics across the region that are by appointment only, as opposed to walk-in visits. They offer COVID-19 testing and additional testing for respiratory issues based on the provider's assessment. Any Peak Care member has additional access to MultiCare’s free e-visits to anyone who has COVID-19 symptoms through their Virtual Care, where their providers will help them navigate to the next appropriate step, if testing for COVID-19 is warranted. Use promo code “COVID19” at the payment page to unlock the free e-visit after completing their protocol. 

Yes. Drive-through testing (tents) for COVID-19 is covered and cost shares will be waived as they are for in-clinic testing.

Yes, the Families First Act expanded the types of diagnostic COVID-19 lab tests that must be covered by insurance. On April 21, the FDA granted emergency clearance to the first in-home diagnostic test for COVID-19, a nasal swab kit that will be sold by LabCorp. The test will be available to consumers with a doctor’s order in most states within a few weeks. We’re working through the details of how claims will be received and reimbursed.  

The IRS issued guidance allowing COVID-19 testing and treatment cost-share waivers for high deductible health plan and non-high deductible health plan members.

We currently have processes in place to pay government hospitals such as VA facilities and pop-up military hospitals.  We are prepared to process claims if necessary. At this time, we have indicators that these facilities may not bill, but are still working to confirm. Many of these facilities will be covering care not related to COVID-19 to help alleviate the burden on facilities as they care for COVID-19 related patients.

Based on the claims we’ve received as of April 7, the average cost for testing is $42, which doesn’t include charges for the associated office or ER visit.

We encourage members to call their providers if they suspect they’ve been exposed to COVID-19 or if they’re experiencing flu-like symptoms. If you do go to the doctor, make sure to call first so they can prepare for your arrival.

If you have symptoms like a cough, fever, or other respiratory problems, call your doctor first. Do not go to the emergency room. Emergency rooms need to be able to serve those with the most critical needs. If you have difficulty breathing, it doesn't mean you have COVID-19, but you should call 911 if it’s serious.

24-Hour NurseLine or other telehealth services may be included in your benefits and are also excellent resources if you’re concerned about your symptoms. Many providers offer telehealth services by phone or video chat. Ask your provider if they offer these services.

Premera doesn’t cover employment-based testing. 

For members who are out of country: Standard Premera plans don’t cover medical evacuation or repatriation to those overseas who may become ill. 

For members within the U.S.: Plans cover ambulance transport for a medical emergency, when a person’s health is in serious danger and an ambulance is the only safe way to get to the closest medical facility equipped to treat their condition. Emergency transport is subject to the usual benefits and cost shares Transport from a hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or physician isn’t considered medically necessary.

Currently, COVID-19 is treatable at many facilities. In the event a patient is transported to one of these facilities under the direction of the Department of Health and Human Services and is otherwise not covered, we'll review the situation to determine eligibility for benefits

As long as the member is still eligible and has the Blue Cross Blue Shield Global Core program (formerly known as BlueCard Worldwide®) they should be covered outside the United States. Members should look for the suitcase logo on their ID card and can call the number on the back of their card to be connected for services out of the country. 

With Global Core, Premera applies the benefits and coverage determination and approves payment. BCBS Core works with the provider in other countries to set up guarantee of payments. Members must call the number on the back of the card to set up a guarantee of payment.

You can access proof of coverage from your Premera.com account. Your online benefit booklet has proof of coverage that can be printed and used for your travel.

The CDC recommends that travelers at higher risk for COVID-19 complications avoid all cruise travel and non-essential air travel. We highly recommend that members work with their healthcare provider to come to a care decision that balances risks and expected outcomes with their preferences and values.

For PDCOE, a key element of that program is to identify and outreach to encourage eligible members to travel to our identified high value specialty care providers. Since travel is a concern and many facilities are cancelling elective procedures, we are temporarily ceasing targeted outreach letters and calls for all lines of business. If a member wants to pursue medical travel, our customer service team's personal health clinicians are available to help. 

For elective medical travel, we recommend that members work closely with their healthcare providers to determine if travel is recommended and safe. Many hospitals are delaying elective surgeries due to COVID-19, and procedures may be delayed to ensure staff and patient safety. The elective medical travel benefit remains available to members for all approved travel.

Yes. We’ve adjusted our refill too soon policy for medications. This allows pharmacies to override refill too soon edits during a declared emergency at the pharmacy counter.

90-day refills:

• Most plans have access to mail-order prescriptions. Ask your provider about getting a 90-day supply.
• Medicare Advantage members: Use this mail-order form.
• Medicare Supplement members: If you have a separate Part D prescription drug plan, contact your Part D plan administrator for more info.

Some telehealth providers have also temporarily waived their refill policies prohibiting the refill of chronic medications beyond twice in a calendar year. Providers will consider clinical appropriateness, patient safety and professional judgement.

Note: Some prescriptions aren’t eligible for mail order. Members should check their plan benefits or contact customer service at the number on the back of their ID card.

Currently, controlled substances are not carved out. Pharmacies can override the refill too soon edit at the point of sale by entering a submission code. The dispensing pharmacist will review the need to override refill too soon rejections on controlled substances (such as opioids and benzodiazepines) by working with the prescriber. 

Yes. The Premera pharmacy network maintains rigorous safety standards for inventory and follows guidance from multiple regulatory agencies (including the FDA, CDC, and U.S. Preventive Services Task Force) to ensure drugs are approved by the FDA for the U.S. market. All drugs approved for use in the U.S. must meet FDA-manufacturing standards to assure quality and product label requirements.

We frequently see drug shortages in the U.S. based on manufacturer issues, raw product issues, etc. We may see new reported shortages based on the COVID-19 impact to Chinese manufacturers.

Premera will respond to these shortages the same way we do today, by ensuring the following:

• The pharmacy team will check public and industry resources to identify new shortages that may impact our members.
• We’ll review medical policies to determine if adjustments are needed to ensure access to alternative medications (should we change our preferred drugs or update prior authorization criteria to account for shortages both short and long term).
• Our review processes already account for drug shortages. If a drug we require as first-line therapy is in short supply, we’ll waive this requirement based on market realities and approve coverage when preferred formulary alternatives are in short supply.

We’re also reviewing rejected claims to see if members are getting the medications they need. If we see any drug shortages, we’ll seek other options to meet member needs. We’ll continue to monitor the situation with our pharmacy partners, so members won’t run out of needed medications.

Both chloroquine and hydroxychloroquin are available to members for the treatment of COVID-19. We are continually reviewing our medical policies to determine if adjustments are needed to ensure access to needed alternative medications. Our review processes today already account for drug shortage situations. If a drug we require as first line therapy is in short supply, we will waive this requirement based on market realities and approve coverage where appropriate where preferred drug alternatives are in short supply.