80th Percentile Repeal Endorsement for Employers and Members

Below is a copy of the 80^th Percentile Repeal Endorsement. The endorsement is now posted on the secure employer and member portals as well as a secondary link to the benefit booklets.

80^th percentile repeal ENDORSEMENT

Applies To All Fully Insured Small and Large Group Medical Plans With A Renewal Date Outside of January 1, 2024

This endorsement makes important changes to your medical plans. This endorsement describes language updates relating to the 80^th percentile repeal effective January 1, 2024.

1. In the Summary of Your Costs, the Dialysis benefit has been updated to now reflect the following:

• • For High Deductible Health Plans (HDHPs), benefits are subject to deductible then 0% coinsurance for ESRD after Medicare’s waiting period.
  • For Non-High Deductible Health Plans, there is no charge for ESRD after Medicare’s waiting period.

2. In the Dialysis benefit, the language has been updated to now state the following:

When you have end stage renal disease (ESRD) you may be eligible to enroll in Medicare. If eligible, it is recommended to enroll in Medicare as soon as possible. When you enroll in Medicare, this plan and Medicare will coordinate benefits. In most cases, this means that you will have little or no out-of-pocket expenses.

As soon as you are enrolled in Medicare Part B, Premera will pay your Medicare Part B premiums. Premera will continue to pay these premiums for as long as you are enrolled in this plan and eligible for Medicare due to ESRD.

When covered dialysis services are provided by a non-participating provider, the in-network cost shares will apply. For non-participating providers during Medicare’s waiting period, the allowed amount is 300% of the fee schedule determined by the Center for Medicare and Medicaid Services (Medicare). After Medicare’s waiting period, the allowed amount for non-participating providers inside our service area is 185% of the fee schedule determined by the Center for Medicare and Medicaid Services. The allowed amount for non-participating providers outside our service area after Medicare’s waiting period is 125% of the fee schedule determined by the Center for Medicare and Medicaid Services.

If the dialysis services are provided by a non-participating provider and you do not enroll in Medicare, you will owe the difference between any billed charges and the payment the plan will make for the covered services.

3. The Allowed Amount language under Definitions has been updated to now state the following:

• • Providers Who Don’t Have Agreements With Us Or Another Blue Cross Blue Shield Licensee

The allowed amount shall be defined as indicated below.  When you get services from a provider who does not have an agreement with us or another Blue Cross Blue Shield Licensee, you are responsible for any amounts not paid by us, including amounts over the allowed amount except for emergency services as described below.

Using this methodology, the allowed amount will be the least of the following:

• In circumstances where the Centers of Medicare and Medicaid Services (Medicare) does not have a fee schedule, we will use an amount that is no less than the lowest amount we allow for the same or similar service from a comparable provider that has a contracting agreement with us.
• For providers within our service area, the allowable will be 185% of the fee schedule determined by the Centers for Medicare and Medicaid Services, if available.
• For providers outside our service area, the allowed amount will be 125% of the fee schedule determined by the Centers for Medicare and Medicaid Services, if available.
• The provider’s billed charges. Ground ambulance providers are always paid based on billed charges.
• Dialysis Due To End-Stage Renal Disease

         Providers Who Have Agreements With Us Or Other Blue Cross Blue Shield Licensees
         The allowed amount is the amount explained above in this definition.

         Providers In Alaska Who Don’t Have Agreements With Us Or Another Blue Cross Blue Shield Licensee
         The allowed amount will be 185% of the fee schedule determined by the Centers for Medicare and Medicaid Services.

         Providers Outside of Alaska Who Don’t Have Agreements With Us or Another Blue Cross Blue Shield Licensee
         The amount the plan allows for dialysis will be 125% of the fee schedule determined by the Centers for Medicare and Medicaid Services.
Please see the Dialysis benefit for more details.

• Non-Emergency Services Protected From Balance Billing
  For these services, the allowed amount is calculated consistent with the requirements of federal law.

• Emergency Services
• The allowed amount for non-participating providers will be calculated consistent with the requirements of federal law.
• Air Ambulance
  The allowed amount for non-participating air ambulance providers will be calculated consistent with the requirements of federal law.
  Note: Ground ambulance providers that don’t have agreements with us or another Blue Cross Blue Shield Licensee are always paid based on billed charges.  

If you have questions about this information, please call us at the number listed on your ID card.

No change to subscription charges is required.

All other terms and limitations of the plan remain unchanged. This endorsement forms a part of the Premera Blue Cross Blue Shield of Alaska contract. Please keep it with your benefit booklet for future reference.

If you have questions regarding this information, please contact our customer service department.  The phone numbers are located on the back of your benefit booklet.  You can also refer to our website at premera.com.

Jim Grazko
President and Chief Executive Officer

Premera Blue Cross Blue Shield of Alaska