Unit 4: Benefit Plan Programs
2.4 Baby Blueprints®
Baby Blueprints® is a maternity education and support program available to expectant Highmark members. This free program is designed to help expectant families better understand and enjoy every stage of pregnancy and make more informed care and lifestyle decisions.
Baby Blueprints offers expectant Highmark members educational information on all aspects of pregnancy through online resources during each trimester of pregnancy. Topics include prenatal care, proper use of medications, avoiding alcohol and tobacco, working, travel considerations, nutrition and weight gain, exercise, body changes, and many others.
Baby Blueprints will also provide program participants access to individualized support from a Maternity Wellness Coach. Providers are encouraged to promote patient enrollment to reinforce medical care and maternity information so that pregnant women may “have a greater hand in their health.”
Baby Blueprints is available to expectant Highmark members enrolled in a commercial group product, direct pay product, or social mission product.
Baby Blueprints is not available for members enrolled in a Medicare/Medicare Advantage product, Federal Employee Program (FEP), or any self-funded employer groups that have opted out. Enrollment in Baby Blueprints is simple and convenient. Expectant members can enroll at no cost over the phone by calling toll free 866-918-5267.
If members have further questions about Baby Blueprints, encourage them to call Member Services.
2.4 24/7 Nurse Advice Line (Blues On Call)
Blues On Call is a 24/7 Nurse Advice Line, which provides telephonic support for Highmark members, connecting members with registered nurses to get free, confidential advice on medical conditions, symptoms, treatments, medications, and health management. This resource is available to help members make informed decisions and navigate the health care system anytime, day or night.
Most Highmark members are automatically eligible to make use of Blues On Call services. No registration is required and the service is free.
Blues On Call does not:
- Address benefit issues
- Address claims issues
- Provide diagnosis or medical advice
Encourage your patient to call the Blues On Call phone line: 888-BLUE-428 (888-258-3428)
2.4 Diabetes Prevention Program
Certain Highmark members have access to a diabetes prevention program as part of their Highmark preventive benefits schedule. Self-funded employer groups may choose to opt out of the program.
The program is available to Highmark members who have coverage under their preventive benefits and meet the program’s eligibility criteria. Eligible members can choose between attending in-person classes in the community or an option with online classes and support.
Note: The program is effective for State of Delaware employees with coverage under a State of Delaware Group Health Insurance Program administered by Highmark Delaware.
What is the Diabetes Prevention Program?
The Diabetes Prevention Program (DPP) is a structured lifestyle and health behavior change program with the goal of preventing the onset of type 2 diabetes in individuals who are prediabetic. The program is certified by the Centers for Disease Control and Prevention (CDC). The 12-month program includes:
- Choice of an in-person classroom setting or an online/mobile app program
- 16 “core” sessions
- Monthly follow-up meetings
The program’s primary goal is to attain at least 5% average weight loss among participants. According to the CDC, losing 5% of your weight can help prevent diabetes.
Members can choose either an in-person classroom program or a virtual program.
Program Eligibility Criteria
Once members select a program, the vendor will confirm their eligibility prior to offering program enrollment. Eligible members must be at least 18 years of age and meet the following requirements:
- Body Mass Index (BMI) of 25 or greater
- No previous diagnosis of type 1 or type 2 diabetes
- Not be pregnant
To be eligible, members must also meet one of the following requirements:
- Receive a high-risk result (score of five or higher) on the CDC Prediabetes Risk Test found on the CDC’s National Diabetes Prevention Program website
- Had a blood test result in the prediabetes range within the past year:
- Hemoglobin A1C between 5.7% – 6.4%
- Fasting blood glucose of 100 – 125 mg/dL
- Two-hour blood glucose (after a 75g glucose load) of 140 – 149 mg/dL
- Be previously diagnosed with gestational diabetes (diabetes during pregnancy)
YMCA’S Classroom Program
The YMCA Diabetes Prevention Program provides a supportive environment where participants work together in a small group to learn about healthier eating and increasing their physical activity in order to reduce their risk for developing diabetes. The program is led by a trained Lifestyle Coach in a classroom setting over a 12-month period, beginning with 16 weekly sessions followed by monthly maintenance. The program is offered at select YMCA locations.
Under the YMCA in-person classroom program, the benefits/services include:
- Member attends structured sessions at an on-site location
- Led by a trained Lifestyle Coach
- Year-long program of 25 sessions
- Food, weight, and activity tracking
- Peer support and accountability
- CDC-approved curriculum
Noom: Weight Management
Noom is a leading digital health care company committed to chronic disease prevention and weight loss solutions through lifestyle change and behavior modification. Earning the highest CDC recognition (Full Plus recognition) for a diabetes prevention program, Noom offers an app-based, fully virtual 12-month diabetes prevention program consisting of personalized coaching, tracking tools, and peer support.
The benefits/services for eligible Highmark members include:
- Mobile apps include food, weight, and activity tracking
- CDC-approved Full Plus recognition curriculum
- Daily, “bite-sized” lessons designed to build lasting habits
- One-on-one lifestyle coaching support
- Peer support and online community platform
- Wireless scale earned through sustained engagement
- Note: Currently available for ASO clients only.
Verify Program Eligibility Via Availity®
Providers can verify a member’s coverage for the Diabetes Prevention Program in Availity’s Eligibility and Benefits Inquiry by selecting Additional Benefit Notes.
2.4 Health Promotion Programs
Health promotion and risk reduction are part of the overall health management program. Highmark’s Health Engagement Operations (HEO) department offers a variety of condition management, case management, and wellness programs. Services and programs are offered digitally, at the workplace, and telephonically.
Programs are designed to raise member awareness of healthy versus unhealthy habits, make healthy choices, reduce risk of injury, and help members with an acute or chronic condition. The health promotion activities focus on three key areas:
- Health Assessment
- Worksite Health Promotion Programs
- Lifestyle Improvement Programs
Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) are committed to helping our members take an active role in achieving and maintaining good health. That's why we offer health and wellness programs. These programs support your efforts to keep our members healthy by providing them with coverage benefits for health promotion and education services.
Members are more likely to attend health and wellness programs if they receive encouragement from their physicians or other providers, and we invite providers to encourage their patients to participate in the programs.
Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) have an extensive network of credentialed providers offering health education programs. Patients do not require a referral or written approval for most approved programs.
Programs are currently offered in the following categories:
- Diabetes education
- Maternal and infant health nutrition
- Physical activity
- Smoking cessation
- Stress management
- Weight management
We also offer programs on topics such as AIDS/HIV, children and adolescent health, arthritis, cancer information, holistic health, substance abuse, senior health, women's health, asthma, heart health, and a variety of support groups.
We encourage our members to take a variety of programs in order to enhance their overall wellness. Programs of similar topics (stress management, diabetes education, nutrition etc.) are limited to one class/program per year with the exception of fitness programs (Pilates, yoga, spinning), which are limited to two programs each year. Maternal and infant health programs are unlimited.
To register, members should contact the health and wellness program provider directly. Members are able to verify program eligibility by calling the customer service number on the back of their identification card.
Digital Resources – All Providers
Digital resources are available to Commercial, Affordable Care Act (ACA), and individual medically insured members, as well as Medicare Advantage and Medigap members. See the Reference Guide of Highmark Member Programs for more information.
Worksite Programs
Worksite programs are offered as an optional service to employers wishing to promote a healthy culture among their employees through awareness, education, and activities to encourage engagement.
Services that encourage awareness include on-site biometric screenings. Education services may include individual coaching in conjunction with the biometric screening experience and online resources. Engagement is encouraged through a variety of "Reward" and “Challenge” programs that track participation for incentive purposes.
Case and Disease Management Model
Highmark's Health Engagement Operations team serves as a catalyst to improve health outcomes for our members. Our multidisciplinary team orchestrates a comprehensive suite of programs and support, including case and disease management, behavioral health, social work, pharmacy, wellness, member engagement guides, and business operations strategy. These are not just isolated services, but a coordinated effort to address whole-person health.
Highmark's multidisciplinary clinical team focuses on the holistic care of the member to better manage their overall health using a disease-agnostic, whole-person care approach.
Key strengths include:
- Holistic, whole-person care: The program focuses on the member's overall health, not just specific diseases, addressing their physical, mental, and social well-being. This is a significant differentiator.
- Omnichannel approach: The use of multiple communication channels (phone calls, text messaging, 24/7 Nurse Advice Line) ensures members can be reached regardless of their communication preferences. This significantly improves accessibility and engagement.
- Targeted outreach: Outbound calls prioritize members with the greatest need, maximizing the impact of the program's resources.
- Integrated multidisciplinary team: Access to behavioral health specialists, pharmacists, dietitians, and wellness coaches provides comprehensive support addressing various aspects of a member's health.
- Access to virtual care and condition management programs: Members can choose from multiple virtual care and condition-specific management programs, offering a range of support options based on individual needs.
Comorbidities Addressed
The case managers address comorbidities that many seriously ill individuals face. The Case and Disease Management Model uses motivational interviewing and coaching techniques, and focuses on the whole person. These techniques allow the case managers to address the member's full spectrum of health care issues rather than focusing on a single issue or condition.
Enrollment Time Period
The time period a member is enrolled in a condition management program varies and is specific to the member's needs. The case managers assist the member in developing care goals whose focus is member self-management. Cases are considered "open" when the member agrees to work with a nurse case manager to identify health condition-related goals and review progress toward these mutually agreed-upon goals regularly.
Once identified for case management, the member’s case will remain in an open status as long as there are health improvement opportunities that have not been addressed and the member remains engaged and participating in the program.
Cases are "closed" when the member and their nurse case manager agree that identified goals have been achieved or the member declines continued participation.
Members are encouraged to re-engage with the case managers at any time that their clinical condition requires, or when they simply want the additional support of the case managers to work toward attainment of their goals.
2.4 Health Spending Accounts
Highmark offers the following health spending account options to respond to those needs:
- Health Savings Accounts (HSAs)
- Health Reimbursement Accounts (HRAs)
- Flexible Spending Accounts (FSAs) including Limited Purpose FSA and Dependent Care FSA
- Commuter Accounts including Parking and Transportation
Health spending accounts help Highmark members save money to cover their out-of-pocket medical costs, to better manage their health-related expenses, and offers significant tax savings. Members are able to track all of their health care spending online at their secure Highmark member website.
Direct Payment to Provider
If a member’s health spending account is set up for “Direct Payment to Provider” and money is available in the account, you will receive a separate payment (check or Electronic Funds Transfer, or EFT) and notice (known as an Explanation of Payment, or EOP) for claims paid under a member’s spending account.
If the member’s HSA, HRA, or FSA does not have sufficient funds for the entire amount due, you will receive whatever amount is available in the account. You can then bill the member directly for the remaining balance due. As subsequent deposits are made and additional funds become available in the account, the remaining portion of the payment will be distributed to the member.
Explanation of Payment (EOP)
Whenever a full or partial payment is made to you from a member’s health spending account, you and the member will receive an EOP to document the transaction. Availity-enabled providers will receive their EOPs via the Availity Remittance Viewer function. These are also available in PNC’s ECHO Health platform.
This Direct Payment to Provider option from a member’s health spending account does not eliminate your ability to collect patient liability, such as copayments or other outstanding balances, due at the time of service. Highmark provides “Real-Time” tools, accessed via Availity, that help providers determine member responsibility prior to or at the time of services.
- The Patient Cost Estimator function can assist you in estimating the member’s financial responsibility, including any deductible, coinsurance, and/or copayments included in the member’s plan benefits.
- The Claims and Encounters function gives providers the added ability to submit claims for specific health care services and may receive a fully adjudicated response within seconds. This allows providers to determine, at the time of service, the correct amount the member owes.
These real-time estimation and adjudication tools provide immediate responses and give providers the ability to discuss member financial liability with patients when services are scheduled or provided. They also enable providers to collect payment or make payment arrangements for the member’s share of the cost at the time of service. Please note, however, that if you collected payment upfront for member liability, and subsequently receive payment from the member’s health spending account, the refund must be issued directly to the member.
Note: Real-time transactions are accurate at the time of viewing or request. The member’s liability status could change by the time your claim is adjudicated based on claims received but not yet processed, additional services received prior to the adjudication of your claim, or if services rendered are different than those estimated.
For additional information about the Real-Time Tools available via Availity, see the Highmark Provider Manual's Chapter 1, Unit 3: Electronic Solutions – EDI and Availity.
Spending Account Inquiries
For spending account questions or issues in, contact the dedicated Provider Spending Account Information Line:
- Delaware: 800-346-6262
- New York: 844-945-5507
- Pennsylvania and West Virginia: 800-652-9478
Refund Checks for HSA, HRA, and FSA Overpayments
If you receive an overpayment from a member’s HSA, HRA, or FSA, it will be necessary for you to submit this overpayment back to Highmark at the applicable postal address below. Please do not send any overpayments directly to the member. Highmark will ensure that the proper monies are deposited back into the member’s account.
|
Delaware |
New York |
Pennsylvania and West Virginia |
|---|---|---|
|
Attention: Treasury |
Highmark New York |
Attention: Cashier |
2.4 Disclaimers
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Care Benefits Inc., or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
