New for 2026: Plan Benefit and Admin Changes

Notable administrative changes

• Medicare ends VBID model: Medicare announced the termination of its value-based insurance design (VBID) model, effective Dec. 31, 2025. This industry-wide change affects all Medicare Advantage insurance carriers—not just Peoples Health plans—that offer benefits under the VBID program.
• Peoples Health food and utility benefit design change: The VBID program allowed us to offer members of our dual-eligible special needs plans the option to use their over-the-counter (OTC) health and wellness items credit to buy healthy food and pay utility bills. To continue these tailored offerings in 2026, we’re providing the healthy food and utility payment portion through Medicare’s Special Supplemental Benefits for the Chronically Ill (SSBCI) program. SSBCI benefits are intended for individuals with a chronic condition who may be at a higher risk of hospitalization and require intensive care coordination.
• While these members continue to have full access to an OTC credit, they must qualify through verification of an eligible chronic condition to use the credit for healthy food and utility bills. This change ensures continued support for those with the greatest need.
• The verification process does not affect plan enrollment. Members who don’t qualify are able to use their plan’s full credit amount for the purchase of OTC items.
• Qualifying conditions include but are not limited to chronic high blood pressure, chronic high cholesterol, chronic and disabling mental health conditions, diabetes, and cardiovascular disorders.
• Referral requirements: Starting Jan. 1, 2026, most members enrolled in a Peoples Health HMO-POS plan* will be required to obtain a referral from their primary care provider (PCP) before accessing certain specialist services in outpatient, office or home settings. Referrals must be submitted by the PCP prior to the specialist visit.

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Key points

• Member ID cards indicate, as applicable, that referrals are required.
• Referral requirements are separate from prior authorization and advance notification requirements. 
• Claims may still be denied even if a referral is on file if the services are not covered under the member’s benefit plan or required prior authorization was not obtained.
• Specialists and other health care professionals should confirm that a PCP referral has been issued before seeing a Peoples Health member for services requiring a referral.
  • Services provided without a referral are the care provider’s responsibility and the member cannot be balance billed.
• Referrals cannot be submitted before Jan. 1.