FourFront Prior Service Information
| Q: |
What happens when an existing
RBS group moves from their current RBS plan to FourFront
at any time of the year other than January? |
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| A: |
All RBS contracts contain a prior service clause,
which credit prior amounts from previous Regence
contracts (such as deductible, stoploss or benefit
maximums). RBS deductibles, stoploss amounts and
benefit maximums are based on a calendar year. |
For example: Member used $500 for
outpatient rehabilitation therapy services under a prior
contract underwritten or administered by Regence and
then transfers to a new Regence contract with a $1,500
per year maximum for outpatient rehabilitation therapy
services. Member would be allowed the balance of $1,000
under the new contract for any additional benefit used
during that year for outpatient rehabilitation therapy.
This same prior service clause applies to the
FourFront plan.
Scenario 1 – Moving from a PPO plan
On Previous PPO Plan
A member is covered under a previous Regence contract
with a $500 deductible and has seen their physician
twice so far that year. The total allowed amount for
both office calls was two hundred dollars and went
towards meeting their deductible amount.
On FourFront Plan
In June the member’s group moves to FourFront
with a $500 deductible.
- The two hundred dollars that they had previously
met towards their deductible will be credited to their
new contract (meaning they have three hundred dollars
more to accumulate to their deductible before the
deductible is met).
The member then goes to see the physician again in
July and the physician bills an office call.
- Since the previous office calls had accumulated
to the deductible and Regence had not actually paid
for any office calls under the prior contract, this
office call will fall into tier one and count as one
of the first four office calls under FourFront and
will be paid at 100% after the $15 copay and will
not be subject to the deductible.
Scenario 2 – Moving from a Selections
Plan
On Previous Selections Plan
A member is covered under a previous Regence contract
with no deductible (if seen inside the network) and
has seen their physician five times so far that year.
Since there is no deductible to meet, Regence has
paid for five office calls.
On FourFront Plan
In October, the member’s group then moves to
FourFront with a $500 deductible. The member then
goes to see the physician again in November and the
physician bills an office call. Since Regence has
already paid for five office calls this year for this
member, this office call will fall into tier two and
be subject to the $15 copay and deductible and then
paid at 80%.
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