New Pathway X Tiered PCP & Hospital Plans for the Individual market beginning January 1, 2024

In the October 2023 edition of Provider News, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. shared our plans to introduce a new benefit plan offering for the Individual market in select cities and counties in Virginia beginning January 1, 2024. As a reminder, these new plans comply with the Affordable Care Act (ACA) and are called the Pathway X Tiered PCP & Hospital Plans. The new plans will be sold on our current ACA-compliant network: Pathway X Tiered network.* Members who no longer qualify for Medicaid coverage or are not enrolled in any health benefits plan may find this lower cost, new product a potential coverage option.

Individual healthcare coverage service area map

To view locations where our 2024 Individual plan offerings will be available in Virginia, please see the service area map in the attachment section to the right.

Types of Individual health plans in Virginia

Since the implementation of the ACA in 2014, Anthem has been offering ACA-compliant individual healthcare plans. For easy reference, we’re once again including information about our Individual market plan offerings for 2024:

1. Pathway X Tiered PCP & Hospital Plans (NEW for 2024 in select cities and counties in Virginia)

Network: Pathway X Tiered Hospital network:*

• Primary care physicians (PCPs) and hospitals (including facilities) participating in these plans are in one of two tiers. Members’ cost shares are different depending on whether PCPs or hospitals are in:
  • Tier 1 (lower copayment requirement for PCP office visits and a lower coinsurance for inpatient and outpatient hospital/facility services), or
  • Tier 2 (a standard copayment requirement for PCP office visits and a higher coinsurance for inpatient and outpatient hospital/facility services).

In the Find Care tool, select Pathway X Tiered PCP & Hospital.

Important note: These new Pathway X Tiered PCP & Hospital plans are a gatekeeper product. This means that members must select a PCP to coordinate care and provide formal referrals through the health plan for most specialty care should members need to see a specialist.

2. Pathway X Tiered Hospital Plans

Network: Pathway X Tiered Hospital network:*

• These plans will continue to be offered throughout the Virginia service area in 2024 as in the past.

In the Find Care tool, select Pathway X Tiered Hospital.

Important note: Pathway X Tiered Hospital Plans are open access and do not require PCP selection and referrals to specialists.

3. KeyCare PPO Plans

Network: PPO  

• Individual plans will continue to be offered throughout the Virginia service area in 2024 as in the past.

In the Find Care tool, select KeyCare (EPO / Individual / Off Exchange).

Some physicians and hospitals are not in these plans’ networks, except for emergency or urgent care for our HMO and EPO plans. POS plans offer out-of-network benefits; however, members’ costs will be lower when they see an in-network provider. As always, members should check to ensure their physicians or hospitals are in their plan’s network before receiving care.

Referrals

As stated, the new Pathway X Tiered PCP & Hospital plans require referrals from members’ PCPs to cover care from most specialists. A referral is not needed for:

• Chiropractors
• Dermatologists
• Mental health or substance use professionals
• Obstetrician-gynecologists (OB-GYN) for services related to the female reproductive system
• Ophthalmologists
• Optometrists
• Oral surgeons
• Urgent care (when filed with POS 20)

Accept the Paytient card — a new way to help patients pay for needed healthcare services

Often, patients may experience difficulties with making payments for healthcare services received. That’s why Anthem is partnering with Paytient — a health payment account (HPA), providing interest-free payment plans for medical and pharmacy expenses for patients on an Anthem Individual ACA plan. This is one more way Anthem is working to help your patients (our members) access and pay for the care they need, while reducing your administrative burden of collections.

Benefits to you when accepting the Paytient card from our members:

• As simple as a swipe. Offered as a Visa card, Paytient pays you as soon as your patients swipe their card.
• You’re removed from the debt equation. You do not assume any of the debt risk to your balance sheet.
• Accelerated collections and lessened revenue cycle management (RCM) burdens gets you paid faster.
• The burden of unpaid or late bills is lowered, saving you and your staff time and money. Your patients can use the card for unpaid or late bills, so long as it is not with a collection agency.
• Peace of mind for you and your patients. With zero interest, zero fees, and zero credit checks, your patients have the comfort of knowing they can pay for out-of-pocket healthcare costs.

Watch for the December 2023 Provider News

Watch for further details about the new Pathway X Tiered PCP & Hospital Plans — including ID card illustrations and a quick reference guide — in upcoming editions of Provider News.

We are excited to help solve real health needs in a sustainable way.

* This is the HMO exchange network available since 2014. The name will change to the Pathway X Tiered network effective December 1, 2023.