Pathway X Tiered PCP & Hospital Plans — new for the Individual market starting January 1, 2024

In the October 2023 and November 2023 editions of Provider News, Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. shared information about Pathway X Tiered PCP & Hospital Plans, our new benefit plan offering beginning January 1, 2024, for the individual market in select cities and counties in Virginia (view the service area map in the attachment section to the right). Members who no longer qualify for Medicaid coverage or are not enrolled in any health benefits plan may find this new lower-cost product a potential coverage option. 

Network information

The new Pathway X Tiered PCP & Hospital Plans comply with the Affordable Care Act (ACA) and will be sold on our current ACA-compliant network, Pathway X Tiered 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 gatekeeper products. 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.

Referrals

As stated above, 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:

• Behavioral health and substance use specialists
• Chiropractors
• Hematology/oncology/radiation oncology specialists
• Obstetricians, gynecologists, maternal fetal medicine, certified nurse midwives
• Ophthalmologists
• Optometrists
• Oral surgeons
• Urgent care (when filed with place of service (POS) 20)
• Dermatology
• Retail Health Clinics

Sample ID cards

We’ve included a sample of one of the member ID cards from the new Pathway X Tiered PCP & Hospital Plans so you can easily identify members on these new plans.

Quick Reference Guide

We’ve put together everything you need to know about the Pathway X Tiered PCP & Hospital Plans in a useful Quick Reference Guide, available in the attachments section on the right.

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 Individual ACA plan with Anthem. 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. In the attachments section, we’ve included a Paytient flyer you can download and share with your patients.

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.

Additional individual health plans available in Virginia

The following individual plans will continue to be offered throughout the Virginia service area in 2024 as in the past:

• Pathway X Tiered Hospital Plans (HMO and POS):
  • Network: Pathway X Tiered
  • Open access products that do not require PCP selection and referrals to specialists
  • In the Find Care tool, select Pathway X Tiered Hospital.
• KeyCare PPO Plans:
  • Network: PPO
  • 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.

Thank you for the quality care you continue to provide your patients, our members. We look forward to working together to achieve improved outcomes.

* The Pathway X Tiered network is the HMO network that has been available since 2014; the name changed from Pathway X Tiered Hospital network on December 1, 2023.