Wyoming Machinery Recommended Updates 2024 as of 8/2/23

PPACA Preventive (Required for Non-Grandfathered)

Prevention and Control of Seasonal Influenza with Vaccines 

• Currently we cover Influenza Vaccination for members ages 3 and older.

o Plan change language: Update the benefit logic expand the age range to allow for members ages 6 months and older. 

Statin use for Primary Prevention of Cardiovascular Disease in Adults 

• Currently we cover Lovastatin and Pravastatin in members aged 40 through 75, which are low to moderate-intensity statins.

o Plan change language: Update the benefit logic to include coverage of Atorvastatin, Rosuvastatin, Simvastatin, Fluvastatin and Pitavastatin to allow for coverage of moderate to high-intensity statins.

Screening for Anxiety in Children and Adolescents 

• Currently we cover Behavioral/Social/Emotional Screening in children aged birth through 21.

o Plan change language: Update the benefit logic to include two additional Diagnosis Codes, Z13.30 and Z13.39 to allow for the SCARED, PHQ-9, and/or GAD-7 screening instruments.

Collaborative Care Mandate 

• Required for Non-ERISA clients.

• Optional for ERISA clients but they must take a stance on covering or excluding the benefit.

• When: at renewal 

• Plan Change Language:

o Add for Non-ERISA: Benefits include the psychiatric Collaborative Care Model as defined by the American Medical Association, and pursuant to Wyo. Stat. Ann. § 26-20-702.

o Add for ERISA: Benefits include healthcare services provided under the psychiatric Collaborative Care Model as defined by the American Medical Association. 

o Exclude for ERISA: Benefits provided through the psychiatric Collaborative Care Model as defined by the American Medical Association are not Covered Services.  

• Reason for update: 

• Wyoming statute was released in early 2023 and applies to non-ERISA self-funded clients as well as fully insured. The purpose of Collaborative Care is to act as a way to amplify the impact of a highly trained professional in the psychiatric area, where instead of them interacting directly with patients, they consult with practitioners who are interacting with the patient to support care with the practitioner on nervous mental/substance use. 

• This benefit will be subject to deductible and coinsurance.

• BCBSWY will not be able to provide financial impact due to the lack of data on these types of services today.

Out of Network Pharmacy Coverage 

• When: at renewal

• Plan Change Language: Remove coverage for Out of Network pharmacies and update benefit document indicating OON pharmacy is not a benefit.

• Reason For Update: With Transparency mandate for 2024, the Price Comparison Tool will have to include all covered services and items on the tool, including pharmacy. Prime is not going to support OON pharmacy. Most WY pharmacies are In network. CVS is not in network.

• IMPACT – 10 claims for 3 members from 1/1/21 to current.

Cochlear Implants/Bone Anchored Hearing Aids (BAHA):

• Optional for Self-Funded Groups (Plan change required either way).

• When: at renewal

• Plan Change Language if they want the benefit: Add Cochlear Implants and BAHAs 

• Reason for Update: putting it in our Fully Insured products as Cochlear Implants and BAHA’s are medically appropriate and will be subject to medical policy. 

Prescription Drugs

• Optional for Self-Funded Groups (plans that currently have Rx copayments)

• When: at renewal

• Plan change language: update mail order to be 3x the retail copayment.

• Reason for Update: With the emergency of extended supply network, that savings of mail order over retail eroded to where mail order is no longer a savings strategy. 

Abortion as required by State and Federal Law 

• High recommended and dependent on clients benefit for Self-Funded Groups

• When: at renewal

• Plan change language: update booklet to clarify that abortion coverage is subject to applicable Federal and State Law. 

• Reason for Update: to ensure compliance.

Nutritional Counseling 

• Optional for Self-Funded Groups

• When: at renewal

o Plan change language: Add nutritional counseling under Mental Health and Substance Use benefit and limited to the diagnosis of eating disorders.

• Reason for Update: to ensure compliance with Mental Health Parity and if they don’t add it, it can be an NQTL issue.

Car-T / Advanced Therapies

• Required for Self-Funded Groups

• When: at renewal

• Plan change language: Add Advanced Therapies benefit booklet language

• Reason for Update: Currently the benefit is silent for CAR-T and advanced therapies. BCBSWY needs to have groups to clarify the benefit and how it’s covered. We want to make it clear that these services are separate from transplants.  

Learning Disability Exclusion

• Optional for Self-Funded Groups

• When: at renewal

• Plan change language: remove Learning Disabilities Exclusion

• Reason for Update: We don’t have it in our fully insured documents. If a group chooses to keep it, it is an NQTL issue, and they would need to support it. 

Booklet Updates  

• Add statement in benefit document to indicate that dependents will remain covered for 30 days following death of employee.

Global Booklet Updates: to clarify benefits; meet client/member needs; and ensure compliance with changes in state and federal law. 

• ERISA clients: need to confirm what their plan number is

• Update appeals language to reflect internal change to 45 days to 30 days and claims for benefits to 60 days. Removing the notes under “Appealing and Adverse Benefit Determination of a Claim for Benefits and remove “Hospital Admission” under that same section. 

• Add “Review” after all “Authorizations.”

• Update Authorization Review limitation and exclusion to reflect “as required by this Benefit Booklet or Medical Policy.”

• Update Authorization Review definition to reflect “An Authorization Review will be processed within 15 days and 72 hours for urgent care.”

• Groups on NetResults Performance: add exceptions/appeals language if it doesn’t have it already.

• Update language under "UNDERSTANDING REGARDING BLUE CROSS BLUE SHIELD OF WYOMING’S STATUS AS INDEPENDENT CORPORATION.” Some groups already have the language added.

• NAIC guidelines for Primary vs. Secondary language update

• Check to make sure there is a limitation for Educational Programs

• Add general exclusion for Illegal Services and Research Studies

o  

• Update language under prescription drugs to the standard language for “Member Pays the Difference (MPTD) Penalty”.