April 10, 2013




All Blue Cross and Blue Shield of Kansas Contracting Providers


Connie Winkley – Education/Communication Coordinator
Institutional Provider Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association


Reference Based Benefits

With health care costs increasing, employers are considering alternative approaches to control health care expenses by placing a greater emphasis on employee accountability and encouraging members to take a more active role while making health care decisions.  To aid employers, Plans have begun to introduce a new feature, called Reference Based Benefits, which limits specific benefits to a dollar amount and supports members actively shopping around for health care providers who offer those services.

The goal of Reference Based Benefits is to have members engage in their health choices by giving them an incentive to shop for cost effective providers and facilities.  Reference Based Benefit designs hold the member responsible for any expenses above a calculated “reference cost” ceiling for a single episode of service.  Due to the possibility of increased member cost sharing, Reference Based Benefits will encourage members to use Plan transparency tools, such as the National Consumer Cost Tool (NCCT), to search for and identify services that can be performed by providers and/or facilities that charge at or below the reference cost ceiling.

Services will be covered in full up to the reference cost point without member co-insurance, deductible or copayment for self-funded employer groups participating in the Reference Based Benefits.  Any amount that is over the reference cost point is considered a “not covered” amount and will be the members’ responsibility.  For consistency, any amount considered “not covered” is subject to the same benefit logic as other uncovered benefits.  Therefore, any amount “not covered” would not be applied to deductible or out of pocket maximum.  The reference costs are established for an episode of care based on claims data received by Blue Cross and Blue Shield of Kansas from providers in our provider network.

If you have questions regarding Referenced Based Benefits, please contact your BCBSKS Institutional Provider Representative.  Denny Hartman can be reached at 1-316-269-1602, Cindy Garrison at 1-785-291-8862 and Christie Blenden at 1-785-291-8813.