How we make medical policy and member benefit decisions

Increasing the quality of care while containing costs

When health insurance picks up most of the cost of medical care, there is a perception that “someone else” is paying. But really, it’s your money. When you, your family, and your co-workers use more and more medical services, the cost is passed on in the form of higher premiums, copayments, coinsurance, and deductibles. That’s why medical policies are so important. They provide a set of rules that prioritizes quality care while keeping costs in check.

What are medical policies?

Medical policies are a set of guidelines that outline the medical services, procedures, devices, and drugs that are eligible for coverage or excluded from coverage. Every health insurer its own set of medical policies.

Why are medical policies necessary?

Health insurance plans and pharmacy programs do not provide coverage for every medical service, procedure, piece of equipment, or drug used to prevent, diagnose, or treat a particular medical condition. If this were the case, health care coverage would be far more expensive than it already is. To help keep premiums affordable, health care coverage must contain certain restrictions.

How do medical policies impact what benefits are covered? 

Some benefits are mandated by the federal government. Others are included or excluded by employer groups. And the decisions around covering many other benefits are informed through medical policies. At Blue Cross and Blue Shield of Kansas, we have a benefit design team whose focus is on benefits creation and determining whether a member has benefits for an item.

What is your benefits design team?

Our team consists of subject matter experts from across Blue Cross and Blue Shield of Kansas, including medical experts, legal counsel, and more. They review current benefits and requests for benefits. The cross-sectional group reviews data based on market segments, interest and demand. The group makes annual recommendations to our top executive leadership team, who ultimately approves or denies recommendations on an annual basis.

How do you make decisions about what is covered?

Our team uses clinical evidence established by medical societies, health care associations, academic medical research centers and the Blue Cross and Blue Shield Association. We look at regional and local trends and guidelines to establish our own medical policy. Over 200 medical policies are published on our website. Ultimately, our goal is to make policy decisions that will improve health outcomes.

Why are certain benefits not covered?

Some restrictions are specific (e.g., cosmetic surgery) while some are more general, for example over-the-counter drugs. Some emerging technologies are also excluded from coverage. Experimental or investigational technologies might not be effective, and some may even prove harmful. Sometimes, these new technologies are used before there is any medical or scientific consensus that they are safe and effective.

What is the purpose of prior authorization or prior approval?

We have a wide range of policies that serve as a check and balance system to ensure the proper use of insurance benefits. For example, prior authorization requirements and quantity limits for certain prescriptions help limit the risk of off-label, inappropriate, or unsafe use of expensive drugs.

We also recommend prior approval for certain procedures and treatments to help control the risk of inappropriate use. For some services such as home care, admissions to skilled nursing facilities or hospice care, precertification is required to help you receive care in the right place for the appropriate length of time.

What is the process for reviewing medical and pharmacy benefits?

We have medical policy and pharmacy teams that meet monthly to review and discuss new changes or perform annual reviews on policies. Our pharmacy policies are evidence-based, created from data from multiple references and reviewed by experts in the field of medicine. Pharmacy policies are updated annually, and often more frequently as new medications are approved, or guidelines updated.

4 thoughts on “How we make medical policy and member benefit decisions

  1. To whom it may concern; I am trying to review your policy for IB-Stim, PENFS. I would like to send info to the medical policy department. If someone would kindly send me the email that is appropriate, I would appreciate the help.
    Sue Beth Murphree

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