This guide is designed to provide you with clear and concise answers to the most frequently asked questions regarding our EBMS ELAP (Reference-based pricing) High Deductible and PPO Health Plans. Our goal is to help you better understand how these plans work, what to expect, and how they can benefit you and your family.
Q: What exactly is reference-based pricing, and how does it differ from a traditional network plan like Cigna?
A: Reference-based pricing (RBP) does not use a conventional network like Cigna. Instead, it sets a fair price for each medical service based on Medicare rates and other pricing benchmarks, such as the hospitals' actual reported cost for services.
Q: Will I still be able to see my current doctor or specialist under the ELAP RBP plan?
A: Yes! You can still see your current doctor or specialist. With RBP there are no network restrictions so you can choose any provider. If your provider has questions about RBP or the payment process, they should call EBMS for assistance.
Q: What happens if my provider refuses to accept the reference-based pricing rate?
A: If a provider is concerned about the payment rate, they should call EBMS for additional information. We will work directly with your provider to find a resolution, and most of the time, the provider agrees to the standard rate.
Q: How are prices determined for services under the RBP plan for facilities?
A: Prices under RBP are generally based on a percentage above Medicare rates or the facility's actual reported cost, ensuring that you pay a fair and reasonable price for services. This helps to keep costs lower than what you might see with traditional network plans.
Q: What should I do if my provider bills me more than what the plan covers?
A: If you receive a bill for more than what the plan covers, ELAP’s support team will help you. They will work with your provider to resolve any balance billing issues, so you do not have to handle it alone.
Q: Will I experience balance billing? And how is that handled if it occurs?
A: Balance billing can happen if a provider wants to charge more than the plan's payment amount. ELAP has a team dedicated to handling these cases. They will work with your provider to resolve the issue and help you understand the process. Balance bills occur less than 5% of the time.
Q: What support does Liviniti or ELAP provide if I have billing disputes or need to negotiate with a provider?
A: ELAP’s support team is there to assist you with any billing disputes or negotiations. They work directly with providers to address concerns and ensure you are paying a fair price.
Q: Are emergency room visits covered under the RBP plan? How does that work without a network?
A: Yes, emergency room visits are covered under the RBP plan. In an emergency, you can visit any ER and can never be denied care.
Q: How will the transition to the RBP plan impact my out-of-pocket costs compared to the Cigna HDHP?
A: The RBP plan is designed to have similar out-of-pocket costs (they have the same deductibles and out-of-pocket maximums) to the Cigna HDHP but with lower premium costs. This means your regular contributions could be lower, potentially saving you money overall.
Q: Is there a difference in the prescription drug coverage between the RBP HDHP and the Cigna HDHP?
A: No, the prescription drug coverage remains the same across all plans, including the RBP HDHP and Cigna HDHP, ensuring that you have access to the medications you need.
Q: Can I continue using my HSA if I switch to the RBP HDHP?
A: Yes, you can continue using your Health Savings Account (HSA) with the RBP HDHP, just like with the Cigna HDHP. This allows you to save and use pre-tax dollars for eligible healthcare expenses.
Q: What happens if I need a major surgery or specialized treatment… will it be covered similarly under the RBP plan?
A: Major surgeries and specialized treatments are covered under the RBP plan. Your provider will submit your claim to EBMS for processing and payment.
Q: How can I find a provider who is familiar with reference-based pricing in my area?
A: Since the RBP plan allows you to see any provider, you are not limited to a specific network. If a provider is unfamiliar with RBP, EBMS can communicate directly with them to explain how it works.
Q: What steps should I take if a provider is unfamiliar with reference-based pricing?
If a provider is unfamiliar with RBP, they should be advised to call EBMS for assistance. We encourage you to continue to see your provider as you wish and present your ID card at the time of service.
Q: Are there any providers or services that are explicitly not covered under the RBP plans?
A: The RBP plan covers a wide range of medical services, similar to traditional plans. There are no specific exclusions for providers, but like any plan, certain treatments or procedures might require pre-authorization.
Q: What are the key differences between the RBP HDHP and the RBP PPO plan?
A: The RBP HDHP comes with an HSA, which can help you save pre-tax dollars for healthcare expenses. The RBP PPO, on the other hand, offers set co-pays for certain services, providing a more predictable way to manage costs without an HSA.
Q: Why are the premiums for the RBP plans lower than those for the Cigna plan?
A: RBP plans do not have the high network fees and Provider reimbursements that traditional plans like Cigna have.
Q: If the Cigna plan is being phased out, does that mean the RBP plans are better for employees?
A: The decision to phase out the Cigna plan is based on increasing costs and our desire to offer more affordable options. The RBP plans provide similar coverage at a lower cost, making them a better option for most employees.
Q: How do I know if the RBP plan is the right fit for my family’s medical needs?
A: Consider your typical healthcare needs, like doctor visits or treatments. The RBP plan offers flexibility in choosing providers and often lowers costs. If you have specific concerns, our HR team can help guide you through the decision-making process.
Q: Will I need to get pre-authorization for certain treatments or services under the RBP plans?
A: Yes, some treatments may require pre-authorization, just like with traditional plans. This helps ensure that you receive the right care and that the costs are managed fairly.
Q: What kind of care coordination or support does the RBP plan offer, especially for complex medical conditions?
A: EBMS provides care coordination for complex medical conditions, working directly with providers to ensure you receive quality care.
Q: How does the transition impact coverage for mental health services?
A: The RBP plan includes coverage for mental health services like the Cigna plan. You can choose your provider, and EBMS will work with them to ensure fair pricing for your care.
Q: Will there be a gap in coverage if I transition from the Cigna plan to an RBP plan?
A: No, there will not be a gap in your coverage. As long as you make your plan selection during open enrollment, your new RBP plan will begin seamlessly in January 2025.
Q: Are wellness and preventive care services covered similarly under the RBP plans?
A: Yes, the RBP plans cover wellness and preventive services, such as annual check-ups, just like the Cigna plan.
Q: What happens if I travel out of state and need medical care… how does RBP handle this?
A: The RBP plan allows you to seek care wherever you are, without being restricted by a network. EBMS will work with the provider to ensure you receive care at a fair price, even when you are out of state.
Q: If I am currently undergoing treatment, will the RBP plan cover my ongoing care?
A: Yes, ongoing treatments can continue under the RBP plan. EBMS will work with your providers to ensure a smooth transition, so you do not experience disruptions in your care. Please let HR know if you are impacted by a complex, ongoing care need or call EBMS for assistance.
Q: How does reference-based pricing impact the quality of care I will receive?
A: The quality of care you receive depends on the provider you choose. RBP focuses on ensuring fair pricing for services, but it does not limit your access to quality care providers.
Q: What are the risks associated with switching to an RBP plan?
A: The main concern with RBP is that some providers may initially be unfamiliar with the payment process. However, EBMS’ support team is there to address these issues.
Q: How will Liviniti support employees during this transition, especially those with significant healthcare needs?
A: We are committed to supporting you through this change with resources like Lunch & Learn sessions, one-on-one support, and EBMS’ dedicated team. Our goal is to ensure that you understand your options and feel confident about your care.
Q: Can I switch back to the Cigna plan if I try the RBP plan and find it does not work for me?
A: For 2025, the Cigna plan is only available to those who were already enrolled in 2024, and new enrollments are not allowed. We encourage you to explore the RBP plans as a sustainable option for 2025 and beyond.
Q: What resources are available to help me understand how RBP will impact my healthcare costs?
A: We will provide a comprehensive benefits guide, along with access to our HR team and EBMS’ support, to help you understand the costs and benefits of the RBP plans.