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Blog
As we near 2025, we’re reflecting on the pivotal changes that have shaped the behavioral health marketplace this year. From policy shifts and expanded veterans’ coverage to updates with providers like Ambetter, MHN, and Healthnet, the landscape continues to evolve. Emerging trends—including the push for localized treatment, reimbursement adjustments, and geographic limitations on care access—are set to impact the year ahead.
Prepare for what’s next with insights into these key changes and challenges. We will continue to keep you informed as more information becomes available. For questions or further clarification, please reach out to our team.
Effective Jan 1, 2025, Evernorth is updating its prior authorization requirements for PHP services. This means prior authorization will not be required for PHP LOC for your patients with coverage under most Evernorth plans. However, a small number of plans will still require preauthorization. Dates of service before Jan 1, 2025, may require pre-authorization.
Beginning January 1, 2025, BCBS plans in certain states will implement new out-of-state (OOS) coverage limitations. These policies may hinder access to care for members traveling or residing near state borders.
More information: BCBS Alabama Overview.
Members enrolled in Blue Choice Preferred PPOSM and MyBlue Plus POSSM plans, whether purchased on or off the marketplace exchange, will face restricted OOS coverage beyond the border counties of Wisconsin, Iowa, Missouri, Kentucky, and Indiana.
More information: BCBSIL OOS Coverage Update
Some plans limit OOS; see “Service Area Available” for each offered plan
More information: BCBS New Jersey Overview
Blue Cross NC’s new HMO plan, Blue Care®, launching in 2025, will provide statewide coverage but limit OOS benefits to urgent and emergency services at the in-network level.
More information: BCBSNC Provider News
Some plans limit OOS (Blue Preferred Security Individual Plan PPOs)
More information: BCBS Montana Overview.
Members enrolled in Blue Advantage PPOSM and Blue Preferred PPOSM plans, whether purchased on or off the marketplace exchange, will only have OOS coverage within border counties of Kansas, Colorado, New Mexico, Texas, Arkansas, and Missouri.
More information: BCBS Oklahoma OOS Benefits Update
Effective January 1, 2025, TriWest Healthcare Alliance will manage the TRICARE West Region. This change is essential for providers and beneficiaries alike, impacting healthcare management across 26 states.
In May 2024, concerns over Multiplan’s potential price-fixing led to calls for a federal investigation; the issue is ongoing. Third-party algorithms often reduce payments for out-of-network claims, allowing insurers to collect higher fees; Multiplan leads the charge. Senator Amy Klobuchar has urged regulators to examine whether these practices allow insurers to conspire to lower provider payments, resulting in higher patient costs.
The investigation is seen as a critical step toward reforming unfair reimbursement practices. Facilities are encouraged to consult legal experts, assess underpayment claims, and reaffirm their participation in client advocacy.
The typical resolution timeline is estimated at two years; claims up to five years old are still being reviewed. Learn more here:
In August 2024, Optum Behavioral Health announced changes to contracting and clinical guidelines for facilities treating adults with addiction, set for implementation in late 2024 and 2025. These changes aligned with the ASAM Criteria 4th Edition, which guides facility roles, responsibilities, and treatment protocols.
Key Points:
Learn more:
Effective October 1, 2024, Cigna implemented a policy change regarding out-of-network (OON) claims priced by Data iSight, affecting post-payment negotiations and reducing the number of claims eligible for additional payments.
To best understand how this may impact your facility, it’s essential to actively review this with your revenue cycle team and internal partners.
Prepare for what’s next with insights into these key changes and challenges. We will continue to keep you informed as more information becomes available. For questions or further clarification, please reach out to our team.
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