Common use of Member Liability Calculation Clause in Contracts

Member Liability Calculation. The calculation of a Member’s liability on claims for covered health care services received outside of Massachusetts and processed through the BlueCard Program will be based on the provider’s actual charge or the negotiated price (allowed charge), whichever is less. The methods used by a Host Plan to determine a negotiated price will vary among Host Plans based on the terms of each Host Plan’s provider contracts. The negotiated price that a Host Plan passes on to Blue Cross and Blue Shield for a claim for covered health care services processed through BlueCard may represent:  The actual price paid on the claim by the Host Plan to the health care provider; or  An estimated price, determined by the Host Plan in accordance with the BlueCard Program, based on the actual price increased or reduced to reflect aggregate payments expected to result from settlements, withholds, other contingent payment arrangements, and other claim- and non-claim-related transactions (such as interest on provider advances) with all of the Host Plan’s health care providers or with one or more particular providers; or  An average price, determined by the Host Plan in accordance with the BlueCard Program, based on a billed charges discount that represents the Host Plan’s average savings expected after settlements, withholds, other contingent payment arrangements, and other claim- and non-claim-related transactions (such as interest on provider advances) with all of the Host Plan’s health care providers or with one or more specific groups of providers. An average price may result in greater variation to the Member and the Account from the actual price than would an estimated price. Those Host Plans that use either the estimated price or average price may, in accordance with the BlueCard Program, prospectively increase or reduce the estimated price or average price to correct for over- or underestimation of past prices (that is, prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid to or received from providers). However, the amount paid by the Member is a final price and no future price adjustment will result in increases or decreases to the pricing of past claims. The BlueCard Program requires that the price submitted by a Host Plan to Blue Cross and Blue Shield is a final price irrespective of any future adjustments based on the use of estimated or average pricing. Statutes in a small number of states may require a Host Plan to either (1) use a basis for calculating the Member’s liability for covered health care services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (2) add a surcharge. In these situations, Blue Cross and Blue Shield would then calculate the Member’s liability for covered health care services consistent with the applicable state statute that is in effect at the time those services are furnished.

Member Liability Calculation. The calculation of a Member’s liability on claims for covered health care services received outside of Massachusetts and processed through the BlueCard Program will be based on the provider’s actual charge or the negotiated price (allowed charge), whichever is less. The methods used by a Host Plan to determine a negotiated price will vary among Host Plans based on the terms of each Host Plan’s provider contracts. The negotiated price that a Host Plan passes on to Blue Cross and Blue Shield for a claim for covered health care services processed through BlueCard may represent:  • The actual price paid on the claim by the Host Plan to the health care provider; or  • An estimated price, determined by the Host Plan in accordance with the BlueCard Program, based on the actual price increased or reduced to reflect aggregate payments expected to result from settlements, withholds, other contingent payment arrangements, and other claim- and non-claim-related transactions (such as interest on provider advances) with all of the Host Plan’s health care providers or with one or more particular providers; or  • An average price, determined by the Host Plan in accordance with the BlueCard Program, based on a billed charges discount that represents the Host Plan’s average savings expected after settlements, withholds, other contingent payment arrangements, and other claim- and non-claim-related transactions (such as interest on provider advances) with all of the Host Plan’s health care providers or with one or more specific groups of providers. An average price may result in greater variation to the Member and the Account from the actual price than would an estimated price. Those Host Plans that use either the estimated price or average price may, in accordance with the BlueCard Program, prospectively increase or reduce the estimated price or average price to correct for over- or underestimation of past prices (that is, prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid to or received from providers). However, the amount paid by the Member is a final price and no future price adjustment will result in increases or decreases to the pricing of past claims. The BlueCard Program requires that the price submitted by a Host Plan to Blue Cross and Blue Shield is a final price irrespective of any future adjustments based on the use of estimated or average pricing. Statutes in a small number of states may require a Host Plan to either (1) use a basis for calculating the Member’s liability for covered health care services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (2) add a surcharge. In these situations, Blue Cross and Blue Shield would then calculate the Member’s liability for covered health care services consistent with the applicable state statute that is in effect at the time those services are furnished.