Blue Cross Blue Shield Network – Benefit Description

Introduction

 

This benefit booklet provides you with a description of your benefits while you are enrolled under the health plan offered by your plan sponsor. You should read this booklet to familiarize yourself with this health plan’s main provisions and keep it handy for reference.

Blue Cross and Blue Shield has been designated by your plan sponsor to provide administrative services to this health plan, such as claims processing, individual case management, utilization review, quality assurance programs, disease monitoring and management services as selected by the plan sponsor, claim review and other related services, and to arrange for a network of health care providers whose services are covered by this health plan. The Blue Cross and Blue Shield customer service office can help you understand the terms of this health plan and what you need to do to get your maximum benefits.

Blue Cross and Blue Shield has entered into a contract with the plan sponsor to provide these administrative services to this health plan. This contract, including this benefit booklet and any applicable riders, will be governed by and construed according to the laws of the Commonwealth of Massachusetts, except as preempted by federal law.

Blue Cross and Blue Shield of Massachusetts, Inc. (Blue Cross and Blue Shield) is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans (the “Association”), permitting Blue Cross and Blue Shield to use the Blue Cross and Blue Shield Service Marks in the Commonwealth of Massachusetts. Blue Cross and Blue Shield has entered into a contract with the plan sponsor on its own behalf and not as the agent of the Association.

You are covered under this preferred provider health plan. This health plan is a non-insured, self-funded health benefits plan and is financed by contributions by your group and/or its enrolled employees. For details concerning your group’s contributions, contact your plan sponsor. An organization has been designated by your plan sponsor to provide administrative services to this health plan, such as claims processing, individual case management, utilization review, quality assurance programs, disease monitoring and management services as selected by the plan sponsor, claim review and other related services, and to arrange for a network of health care providers whose services are covered by this health plan. The name and address of this organization is: Blue Cross and Blue Shield of Massachusetts, Inc., Landmark Center, 401 Park Drive, Boston, Massachusetts 02215-3326.

These benefits are provided by your group on a self-funded basis. Blue Cross and Blue Shield is not an underwriter or insurer of the benefits provided by this health plan.

This benefit section explains your health care coverage while you are enrolled in this health plan. This benefit section also has a Schedule of Benefits which describes the cost share amounts that you must pay for covered services (such as a deductible, or a coinsurance, or a copayment). You should read this benefit section and your Schedule of Benefits to become familiar with the key points of your health plan. You should keep them handy so that you can refer to them. The words that are shown in italics have special meanings. These words are explained in Part 2 of this benefit booklet. Blue Cross and Blue Shield and/or your group may change the health care coverage described in this benefit booklet or your Schedule of Benefits. If this is the case, the change is described in a rider. Please keep any riders with your benefit booklet and Schedule of Benefits so that you can refer to them.

As a member of this network health plan, you will be asked to choose (or designate) a primary care provider who participates in your designated health care network. Your primary care provider will furnish most of your health care and, when it is needed, will arrange for or coordinate your other covered services. Except for emergency medical care, you have also agreed that you will receive all of your health care from providers who participate in your health care network. This health plan will not cover services or supplies that you receive from a health care provider who does not participate in your health care network. The only exceptions are described in this benefit booklet in Part 8.

Before using your health care coverage, you should make note of the limits and exclusions. These limits nd exclusions are described in this benefit booklet in Parts 3, 4, 5, 6, 7, and 8.

The term “you” refers to any member who has the right to the coverage provided by this health plan—the subscriber or the enrolled spouse or any other enrolled dependent.