Explanation of Terms

Explanation of Terms

 

The following words are shown in italics in this benefit booklet, the Schedule of Benefits, and any riders that apply to your coverage in this health plan. The meaning of these words will help you understand your benefits.

Allowed Charge (Allowed Amount)
Blue Cross and Blue Shield calculates payment of your benefits based on the allowed charge (sometimes referred to as the allowed amount). This is the maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance,” or “negotiated rate.” The allowed charge that Blue Cross and Blue Shield uses depends on the type of health care provider that furnishes the covered service to you. If your health care provider charges you more than the allowed amount, you may have to pay the difference (see below).

  • For Network Providers. For health care providers who have an HMO Blue payment agreement with Blue Cross and Blue Shield of Massachusetts, Inc., the allowed charge is based on the provisions of that health care provider’s network payment agreement for your health plan. (When you are enrolled in a New England health plan, this also applies for health care providers who have a network payment agreement with one of the New England Blue Cross and/or Blue Shield Plans with which Blue Cross and Blue Shield of Massachusetts, Inc. has arranged for the Blue Cross and/or Blue Shield Plan to provide access to covered services to members.) For covered services furnished by these health care providers, you pay only your deductible and/or your copayment and/or your coinsurance, whichever applies. In general, when you share in the cost for your covered services (such as a deductible, and/or a copayment, and/or a coinsurance), the calculation for the amount that you pay is based on the initial full allowed charge for that health care provider (or the actual charge if it is less). This amount that you pay for a covered service is generally not subject to future adjustments—up or down—even though the health care provider’s payment may be subject to future adjustments for such things as provider contractual settlements, risk-sharing settlements, and fraud or other operations.

     
    A network provider’s payment agreement may provide for an allowed charge that is more than the provider’s actual charge. For example, a hospital’s allowed charge for an inpatient admission may be based on a “Diagnosis Related Grouping” (DRG). In this case, the allowed charge may be more than the hospital’s actual charge. If this is the case, Blue Cross and Blue Shield will calculate your cost share amount based on the lesser amount—this means the network provider’s actual charge instead of the allowed charge will be used to calculate your cost share. The claim payment made to the network provider will be the full amount of the allowed charge less your cost share amount.
  • For Health Care Providers Outside of Massachusetts With a Local Payment Agreement. For health care providers outside of Massachusetts who have a payment agreement with the local Blue Cross and/or Blue Shield Plan, the allowed charge is the “negotiated price” that the local Blue Cross and/or Blue Shield Plan passes on to Blue Cross and Blue Shield. (Blue Cross and/or Blue Shield Plan means an independent corporation or affiliate operating under a license from the Blue Cross and Blue Shield Association.) In many cases, the negotiated price paid by Blue Cross and Blue Shield to the local Blue Cross and/or Blue Shield Plan is a discount from the provider’s billed charges. However, a number of local Blue Cross and/or Blue Shield Plans can determine only an estimated price at the time your claim is paid. Any such estimated price is based on expected settlements, withholds, any other contingent payment arrangements and non-claims transactions, such as interest on provider advances, with the provider (or with a specific group of providers) of the local Blue Cross and/or Blue Shield Plan in the area where services are received. In addition, some local Blue Cross and/or Blue Shield Plans’ payment agreements with providers do not give a comparable discount for all claims. These local Blue Cross and/or Blue Shield Plans elect to smooth out the effect of their payment agreements with providers by applying an average discount to claims. The price that reflects average savings may result in greater variation (more or less) from the actual price paid than will the estimated price. Local Blue Cross and/or Blue Shield Plans that use these estimated or averaging methods to calculate the negotiated price may prospectively adjust their estimated or average prices to correct for overestimating or underestimating past prices. However, the amount you pay is considered a final price. In most cases for covered services furnished by these health care providers, you pay only your deductible and/or your copayment and/or your coinsurance, whichever applies.
  • For Other Health Care Providers. For physicians and other covered professional providers who do not have a network payment agreement with Blue Cross and Blue Shield or with the local Blue Cross and/or Blue Shield Plan, Blue Cross and Blue Shield uses the standard fee schedule that Blue Cross and Blue Shield has established for its HMO Blue participating physicians and other participating professional providers to calculate your claim payment for most covered services. The standard fee schedule amount may sometimes be less than the health care provider’s actual charge. If this is the case, you will be responsible for the amount of the covered provider’s actual charge that is in excess of the fee schedule amount (“balance billing”). This is in addition to your deductible and/or your copayment and/or your coinsurance, whichever applies. For this reason, you may wish to discuss charges with your health care provider before you receive covered services. This provision does not apply to covered services that are approved for PCP/Plan Approved Benefits. For these PCP/Plan Approved Benefits covered services, the full amount of the health care provider’s actual charge is used to calculate your claim payment.

     
    For all other covered providers who do not have a network payment agreement with Blue Cross and Blue Shield or with the local Blue Cross and/or Blue Shield Plan, Blue Cross and Blue Shield uses the health care provider’s actual charge to calculate your claim payment. For covered services furnished by these covered providers, you pay only your deductible and/or your copayment and/or your coinsurance, whichever applies.

Pharmacy Providers
Blue Cross and Blue Shield may have payment arrangements with pharmacy providers or pharmacy benefit managers that may, in some cases, result in an allowed charge for a covered drug or supply that is higher than the price Blue Cross and Blue Shield negotiated with the pharmacy provider or pharmacy benefit manager, or that result in rebates on covered drugs and supplies. Any difference between the allowed charge and the negotiated price is used to administer the health plan’s pharmacy program. The cost that you pay for a covered drug or supply is determined based on the allowed charge at the time you buy the drug or supply. If you are charged a cost share amount (such as a deductible, or copayment, or coinsurance), your payment will be determined based on the allowed charge, not the price Blue Cross and Blue Shield pays. The cost that you pay will not be adjusted for any later rebates, settlements, or other monies paid to Blue Cross and Blue Shield from pharmacy providers or pharmacy benefit managers.

Balance Billing

There may be certain times when a health care provider will bill you for the difference between the provider’s charge and the allowed charge. This is called balance billing. A network provider cannot balance bill you for covered services. See “allowed charge” above for information about the allowed charge and the times when a health care provider may balance bill you.

Benefit Limit

For certain health care services or supplies, there may be day, visit, or dollar benefit maximums that apply to your coverage in this health plan. Your Schedule of Benefits and Part 5 of this benefit booklet describe the benefit limits that apply to your coverage. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Once the amount of the benefits that you have received reaches the benefit limit for a specific covered service, no more benefits will be provided by this health plan for those health care services or supplies. When this happens, you must pay the full amount of the provider’s charges that you incur for those health care services or supplies that are more than the benefit limit. An overall lifetime benefit limit will not apply for coverage in this health plan.

Blue Cross and Blue Shield

This term refers to Blue Cross and Blue Shield of Massachusetts, Inc., the organization that 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. This includes an employee or designee of Blue Cross and Blue Shield (including another Blue Cross and/or Blue Shield Plan) who is authorized to make decisions or take action called for by this health plan.

Coinsurance

For some covered services, you may have to pay a coinsurance. This means the cost that you pay for these covered services (your “cost share amount”) will be calculated as a percentage. When a coinsurance applies to a specific covered service, Blue Cross and Blue Shield will calculate your cost share amount based on the health care provider’s actual charge or the Blue Cross and Blue Shield allowed charge, whichever is less (unless otherwise required by law). Your Schedule of Benefits shows the covered services for which you must pay a coinsurance (if there are any). If a coinsurance applies, your Schedule of Benefits also shows the percentage that Blue Cross and Blue Shield will use to calculate your cost share amount. (Also refer to riders—if there are any—that apply to your coverage in this health plan.)

Blue Cross and Blue Shield applies the following rules when calculating your coinsurance amounts for your PCP/Plan Approved Benefits:

  • The Effect of Provider Withholds and Risk Sharing on Coinsurance. In some situations, a small amount is withheld from this health plan’s share of the allowed charge payment to the covered provider in accordance with the provider’s network payment agreement. (These covered providers are referred to as “network providers.”) The withheld amount is paid to the network provider only if the network provider’s performance meets certain standards set by Blue Cross and Blue Shield. Even if the network provider ultimately does not earn the withheld amount, your coinsurance is still calculated based on the actual charge or the full allowed charge. Your coinsurance will not be adjusted for any withheld amount or a network provider’s failure to earn a withhold amount. In other situations, Blue Cross and Blue Shield may have arrangements with network providers in which the network providers share the risk of the cost of covered services. Under these arrangements, at the conclusion of a specific performance measuring period, and following the network providers’ receipt of a fee-for-service payment (minus a withhold, if any), Blue Cross and Blue Shield may owe additional incentive fees to network providers, or the network providers may be required to pay back a portion of their fees. The calculation of your coinsurance will not be adjusted for the effects of these risk sharing arrangements.
  • The Effect of Capitation Payments on Coinsurance. In some situations, you will be charged coinsurance for a covered service for which the covered provider is compensated on a capitation basis rather than on a fee-for-service basis. (These covered providers are referred to as “network providers.”) This may happen, for example, when members self-refer to network providers. In these situations, Blue Cross and Blue Shield will calculate your coinsurance payment in the following manner. First, Blue Cross and Blue Shield will determine what the fee-for-service amount would have been had the service been performed by a network provider on a fee-for-service basis. Next, Blue Cross and Blue Shield will apply your applicable coinsurance percentage to this converted fee-for-service figure to determine your coinsurance amount. The periodic capitation payments that the covered providers receive will not be the basis for the coinsurance calculation.
Copayment

For some covered services, you may have to pay a copayment. This means the cost that you pay for these covered services (your “cost share amount”) is a fixed dollar amount. In most cases, a covered provider will collect the copayment from you at the time he or she furnishes the covered service. However, when the health care provider’s actual charge at the time of providing the covered service is less than your copayment, you pay only that health care provider’s actual charge or the Blue Cross and Blue Shield allowed charge, whichever is less (unless otherwise required by law). Any later charge adjustment—up or down—will not affect your copayment (or the cost you were charged at the time of the service if it was less than the copayment). Your Schedule of Benefits shows the amount of your copayment. It also shows those covered services for which you must pay a copayment. (Also refer to riders—if there are any—that apply to your coverage in this health plan.)

Covered Providers

To receive the highest benefit level under this health plan (your PCP/Plan Approved Benefits), you must obtain your health care services and supplies from covered providers who participate in your designated health care network. Your Schedule of Benefits will tell you the name of your health care network. The provider directory that is provided for your health plan lists the health care providers that participate in your health care network. These health care providers are referred to as “network providers.” A network provider is a health care provider who has a written HMO Blue payment agreement with, or that has been designated by, Blue Cross and Blue Shield of Massachusetts, Inc. to provide access to covered services to members. (Or, when your health plan is a New England health plan, the network provider has a network payment agreement with one of the New England Blue Cross and/or Blue Shield Plans to furnish covered services to members.) You also have the option to seek covered services from a covered provider who is not a network provider. (These health care providers are often called “non-network providers.”) In this case, you usually receive the lowest benefit level under this health plan (your Self-Referred Benefits). To find out if a health care provider participates in your designated health care network, you can look in the provider directory that is provided for your health plan. The kinds of health care providers that are covered providers are those that are listed below in this section.

  • Hospital and Other Covered Facilities. These kinds of health care providers are: alcohol and drug treatment facilities; ambulatory surgical facilities; chronic disease hospitals (sometimes referred to as a chronic care or long term care hospital for medically necessary covered services); community health centers; day care centers; detoxification facilities; free-standing diagnostic imaging facilities; free-standing dialysis facilities; free-standing radiation therapy and chemotherapy facilities; general hospitals; independent labs; limited services clinics; mental health centers; mental hospitals; rehabilitation hospitals; and skilled nursing facilities.
  • Physician and Other Covered Professional Providers. These kinds of health care providers are: certified registered nurse anesthetists; chiropractors; clinical specialists in psychiatric and mental health nursing; dentists; licensed audiologists; licensed dietitian nutritionists (or a dietitian or a nutritionist or a dietitian nutritionist who is licensed or certified by the state in which the provider practices); licensed independent clinical social workers; licensed marriage and family therapists; licensed mental health counselors; licensed speech-language pathologists; nurse midwives; nurse practitioners; occupational therapists; optometrists; physical therapists; physicians; physician assistants; podiatrists; psychiatric nurse practitioners; psychologists; and urgent care centers.
  • Other Covered Health Care Providers. These kinds of health care providers are: ambulance services; appliance companies; cardiac rehabilitation centers; early intervention providers; home health agencies; home infusion therapy providers; hospice providers; mail service pharmacy; oxygen suppliers; retail pharmacies; and visiting nurse associations.

A covered provider may include other health care providers that are designated for you by Blue Cross and
Blue Shield. For example, this may include a board certified behavior analyst who has been designated for
you, and approved for coverage, by Blue Cross and Blue Shield for treatment of autism spectrum
disorders.

Covered Services

This benefit booklet and your Schedule of Benefits describe the health care services and supplies for which Blue Cross and Blue Shield will provide coverage for you while you are enrolled in this health plan. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) These health care services and supplies are referred to as “covered services.” Except as described otherwise in this benefit booklet and your Schedule of Benefits, all covered services must be medically necessary for you, furnished by covered providers and, when it is required, approved by Blue Cross and Blue Shield.

Custodial Care

Custodial care is a type of care that is not covered by this health plan. Custodial care means any of the following:

  • Care that is given primarily by medically-trained personnel for a member who shows no significant improvement response despite extended or repeated treatment; or
  • Care that is given for a condition that is not likely to improve, even if the member receives attention of medically-trained personnel; or
  • Care that is given for the maintenance and monitoring of an established treatment program, when no other aspects of treatment require an acute level of care; or
  • Care that is given for the purpose of meeting personal needs which could be provided by persons without medical training, such as assistance with mobility, dressing, bathing, eating and preparation of special diets, and taking medications.
Deductible

For some covered services, you may have to pay a deductible before you will receive benefits from this health plan. When your health plan includes a deductible, the amount that is put toward your deductible is calculated based on the health care provider’s actual charge or the Blue Cross and Blue Shield allowed charge, whichever is less (unless otherwise required by law). Your Schedule of Benefits shows the amount of your deductible (if there is one). Your Schedule of Benefits also shows those covered services for which you must pay the deductible before you receive benefits. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) When a deductible applies, there are some costs that you pay that do not count toward the deductible. These costs that do not count toward the deductible are:

  • Any copayments and/or coinsurance that you pay.
  • The costs that you pay when your coverage is reduced or denied because you did not follow the requirements of the Blue Cross and Blue Shield utilization review program. (See Part 4.)
  • The costs that you pay that are more than the Blue Cross and Blue Shield allowed charge.
  • The costs that you pay because your health plan has provided all of the benefits it allows for that covered service.

(There may be certain times when amounts that you have paid toward a deductible under a prior health plan or contract may be counted toward satisfying your deductible under this health plan. To see if this applies to you, you can ask your plan sponsor.)

Diagnostic Lab Tests

This health plan provides coverage for diagnostic lab tests. These covered services include the examination or analysis of tissues, liquids, or wastes from the body. These covered tests also include (but are not limited to): the taking and interpretation of 12-lead electrocardiograms; all standard electroencephalograms; and glycosylated hemoglobin (HgbA1C) tests, urinary protein/microalbumin tests, and lipid profiles to diagnose and treat diabetes.

Diagnostic X-Ray and Other Imaging Tests

This health plan provides coverage for diagnostic x-rays and other imaging tests. These covered services include: fluoroscopic tests and their interpretation; and the taking and interpretation of roentgenograms and other imaging studies that are recorded as a permanent picture, such as film. Some examples of imaging tests are: magnetic resonance imaging (MRI); and computerized axial tomography (CT scans). These types of tests also include diagnostic tests that require the use of radioactive drugs.

Effective Date

This term is used to mean the date on which your coverage in this health plan starts. Or, it means the date on which a change to your coverage in this health plan takes effect.

Emergency Medical Care

As a member of this health plan, you have worldwide coverage for emergency medical care. This is medical, surgical, or psychiatric care that you need immediately due to the sudden onset of a condition that manifests itself by symptoms of sufficient severity, including severe pain, which are severe enough that the lack of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing your life or health or the health of another (including an unborn child) in serious jeopardy or serious impairment of bodily functions or serious dysfunction of any bodily organ or part or, as determined by a provider with knowledge of your condition, to result in severe pain that cannot be managed without such care. Some examples of conditions that require emergency medical care are: suspected heart attacks; strokes; poisoning; loss of consciousness; convulsions; and suicide attempts. This also includes treatment of mental conditions when: you are admitted as an inpatient as required under Massachusetts General Laws, Chapter 123, Section 12; you seem very likely to endanger yourself as shown by a serious suicide attempt, a plan to commit suicide, or behavior that shows that you are not able to care for yourself; or you seem very likely to endanger others as shown by an action against another person that could cause serious physical injury or death or by a plan to harm another person.

For purposes of filing a claim or the formal grievance review (see Parts 9 and 10 of this benefit booklet), Blue Cross and Blue Shield considers “emergency medical care” to constitute “urgent care” as defined under the Employee Retirement Income Security Act of 1974, as amended (ERISA).

Group

The term “group” refers to the corporation, partnership, individual proprietorship, or other organization that has entered into an agreement under which Blue Cross and Blue Shield provides administrative services for the group’s self-insured health benefits plan. The group is your agent and is not the agent of Blue Cross and Blue Shield.

Inpatient

The term “inpatient” refers to a patient who is a registered bed patient in a hospital or other covered health care facility and Blue Cross and Blue Shield has determined that inpatient care is medically necessary. This also includes a patient who is receiving Blue Cross and Blue Shield approved intensive services such as: partial hospital programs; or covered residential care. A patient who is kept overnight in a hospital solely for observation is not considered an inpatient even though the patient uses a bed. In this case, the patient is considered an outpatient. This is important for you to know since your cost share amount and benefit limits may differ for inpatient and outpatient coverage.

Medical Policy

To receive your health plan coverage, your health care services and supplies must meet the criteria for coverage that are defined in each Blue Cross and Blue Shield medical policy that applies. Each health care service or supply must also meet the Blue Cross and Blue Shield medical technology assessment criteria. (See below.) The policies and criteria that will apply are those that are in effect at the time you receive the health care service or supply. These policies are based upon Blue Cross and Blue Shield’s assessment of the quality of the scientific and clinical evidence that is published in peer reviewed journals. Blue Cross and Blue Shield may also consider other clinical sources that are generally accepted and credible. (These sources may include specialty society guidelines, textbooks, and expert opinion.) These medical policies explain Blue Cross and Blue Shield’s criteria for when a health care service or supply is medically necessary, or is not medically necessary, or is investigational. These policies form the basis of coverage decisions. A policy may not exist for each health care service or supply. If this is the case for a certain health care service or supply, Blue Cross and Blue Shield may apply its medical technology assessment criteria and its medical necessity criteria to determine if the health care service or supply is medically necessary or if it is not medically necessary or if it is investigational. To check for a Blue Cross and Blue Shield medical policy, you can go online and log on to the Blue Cross and Blue Shield Web site at www.bluecrossma.com. (Your health care provider can also access a policy by using the Blue Cross and Blue Shield provider Web site.) Or, you can call the Blue Cross and Blue Shield customer service office. You can ask them to mail a copy to you.

Medical Technology Assessment Criteria

To receive your health plan coverage, all of your health care services and supplies must conform to Blue Cross and Blue Shield medical technology assessment criteria. These criteria assess whether a technology improves health outcomes such as length of life or ability to function when performing everyday tasks. The medical technology assessment criteria that apply are those that are in effect at the time you receive a health care service or supply. These criteria are:

  • The technology must have final approval from the appropriate government regulatory bodies. This criterion applies to drugs, biological products, devices (such as durable medical equipment), and diagnostic services. A drug, biological product, or device must have final approval from the U.S. Food and Drug Administration (FDA). Any approval granted as an interim step in the FDA regulatory process is not sufficient. (The FDA Humanitarian Device Exemption is one example of an interim step.) Except as required by law, this health plan may limit coverage for drugs, biological products, and devices to those specific indications, conditions, and methods of use approved by the FDA.
  • The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes. The evidence should consist of well-designed and well-conducted investigations published in peer-reviewed English-language journals. The qualities of the body of studies and the consistency of the results are considered in evaluating the evidence. The evidence should demonstrate that the technology can measurably alter the physiological changes related to a disease, injury, illness, or condition. In addition, there should be evidence or a convincing argument based on established medical facts that the measured alterations affect health outcomes. Opinions and evaluations by national medical associations, consensus panels, and other technology evaluation bodies are evaluated according to the scientific quality of the supporting evidence upon which they are based.
  • The technology must improve the net health outcome. The technology’s beneficial effects on health outcomes should outweigh any harmful effects on health outcomes.
  • The technology must be as beneficial as any established alternatives. The technology should improve the net outcome as much as or more than established alternatives. The technology must be as cost effective as any established alternative that achieves a similar health outcome.
  • The improvement must be attainable outside the investigational setting. When used under the usual conditions of medical practice, the technology should be reasonably expected to improve health outcomes to a degree comparable to that published in the medical literature.
Medically Necessary (Medical Necessity)

To receive your health plan coverage, all of your health care services and supplies must be medically necessary and appropriate for your health care needs. (The only exceptions are for certain routine and preventive health care services that are covered by this health plan.) Blue Cross and Blue Shield decides which health care services and supplies that you receive (or you are planning to receive) are medically necessary and appropriate for coverage. It will do this by using all of the guidelines described below.

All health care services must be required services that a health care provider, using prudent clinical judgment, would provide to a patient in order to prevent or to evaluate or to diagnose or to treat an illness, injury, disease, or its symptoms. And, these health care services must also be:

  • Furnished in accordance with generally accepted standards of professional medical practice (as recognized by the relevant medical community);
  • Clinically appropriate, in terms of type, frequency, extent, site, and duration; and they must be considered effective for your illness, injury, or disease;
  • Consistent with the diagnosis and treatment of your condition and in accordance with Blue Cross and Blue Shield medical policies and medical technology assessment criteria;
  • Essential to improve your net health outcome and as beneficial as any established alternatives that are covered by Blue Cross and Blue Shield;
  • Consistent with the level of skilled services that are furnished and furnished in the least intensive type of medical care setting that is required by your medical condition; and
  • Not more costly than an alternative service or sequence of services at least as likely to produce the same therapeutic or diagnostic results to diagnose or treat your illness, injury, or disease.

This does not include a service that: is primarily for your convenience or for the convenience of your family or the health care provider; is furnished solely for your religious preference; promotes athletic achievements or a desired lifestyle; improves your appearance or how you feel about your appearance; or increases or enhances your environmental or personal comfort.

Member

The term “you” refers to any member who has the right to the coverage provided by this health plan. A member may be the subscriber or his or her enrolled eligible spouse (or former spouse, if applicable) or any other enrolled eligible dependent.

Mental Conditions

This health plan provides coverage for treatment of psychiatric illnesses or diseases. These include drug addiction and alcoholism. The illnesses or diseases that qualify as mental conditions are listed in the latest edition, at the time you receive treatment, of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

Mental Health Providers

This health plan provides coverage for treatment of a mental condition when these covered services are furnished by a covered provider who is a mental health provider. These covered providers include any one or more of the following kinds of health care providers: alcohol and drug treatment facilities; clinical specialists in psychiatric and mental health nursing; community health centers (that are a part of a general hospital); day care centers; detoxification facilities; general hospitals; licensed independent clinical social workers; licensed marriage and family therapists; licensed mental health counselors; mental health centers; mental hospitals; physicians; psychiatric nurse practitioners; psychologists; and other mental health providers that are designated for you by Blue Cross and Blue Shield.

Out-of-Pocket Maximum (Out-of-Pocket Limit)

Under this health plan, you may have a maximum cost share amount that you will have to pay (such as the total of your deductible and/or copayments and/or coinsurance) for certain covered services. This is referred to as an “out-of-pocket maximum.” Your Schedule of Benefits will show whether or not your coverage has an out-of-pocket maximum and, if it does, it will also describe the cost share amounts you pay that will count toward the out-of-pocket maximum. Your Schedule of Benefits will also show the amount of your out-of-pocket maximum and the time frame for which it applies—such as each calendar year or each plan year. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) If the cost share amounts you have paid that count toward the out-of-pocket maximum add up to the out-of-pocket maximum amount, your health plan will provide full benefits based on the Blue Cross and Blue Shield allowed charge if you receive more of these covered services during the rest of the time frame in which the out-of-pocket maximum provision applies. When an out-of-pocket maximum applies, there are some costs that you pay that do not count toward the out-of-pocket maximum. These costs that do not count toward the out-of-pocket maximum are:

  • The amount that you pay for your health plan.
  • The costs that you pay when your coverage is reduced or denied because you did not follow the requirements of the Blue Cross and Blue Shield utilization review program. (See Part 4.)
  • The costs that you pay that are more than the Blue Cross and Blue Shield allowed charge.
  • The costs that you pay because your health plan has provided all of the benefits it allows for that covered service.

Important Note: See your Schedule of Benefits for any other costs that you may have to pay that do not count toward your out-of-pocket maximum.

Outpatient

The term “outpatient” refers to a patient who is not a registered bed patient in a hospital or other health care facility. For example, a patient who is at a health center, at a health care provider’s office, at a surgical day care unit, or at an ambulatory surgical facility is considered an outpatient. A patient who is kept overnight in a hospital solely for observation is also considered an outpatient even though the patient uses a bed. (This does not include a patient who is receiving Blue Cross and Blue Shield approved intensive services. This means services such as: a partial hospital program; or covered residential care. See the explanation for “Inpatient” in this Part 2 in this benefit booklet.)

Plan Sponsor

The plan sponsor is usually your employer and is the same as the plan sponsor designated under the Employee Retirement Income Security Act of 1974, as amended (ERISA). If you are not sure who your plan sponsor is, you should ask the subscriber’s employer.

Plan Year

When your health plan includes a deductible and/or an out-of-pocket maximum, these amounts will be calculated based on a calendar year or a plan year basis. Your Schedule of Benefits will show whether a calendar year or a plan year calculation applies to your coverage. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) If a plan year calculation applies, it means the 12-month period of time that starts on the original effective date of your group’s coverage and continues for 12 consecutive months or until your group’s annual renewal date. A new plan year begins each 12-month period thereafter. If you do not know when your plan year begins, you can ask your plan sponsor.

Primary Care Provider

To receive the highest level of coverage under this health plan (your PCP/Plan Approved Benefits), you will be required to choose (or designate) a primary care provider to furnish your primary medical care and to arrange for or coordinate other covered services. Your primary care provider can be a network physician who is an internist, family practitioner, or pediatrician, or a network nurse practitioner, or a network physician assistant. You have the right to choose (or designate) any primary care provider who participates in your health care network and who is available to accept you or your family members. The provider directory for your health plan lists the network primary care providers. See page 2 for information on how to contact Blue Cross and Blue Shield if you need help to choose a primary care provider or to find a listing of your health care network. The network primary care provider who you chose (or designate) is often referred to as your “PCP.” Certain other network primary care providers have agreed to be “on call” for your primary care provider at times when he or she is not available. These are known as “covering primary care providers.” This health plan provides the same coverage for these covering primary care providers that it provides for your primary care provider.

At any time, you may change your primary care provider from a physician to a nurse practitioner or a physician assistant who is listed in your provider directory as a primary care provider. (See Part 1 in this benefit booklet for help on how to change your primary care provider.) When you choose (or designate) a nurse practitioner or a physician assistant as your primary care provider, all of the same provisions that apply to a primary care provider who is a physician will apply.

Rider

Blue Cross and Blue Shield and/or your group may change the terms of your coverage in this health plan. If a material change is made to your coverage in this health plan, it is described in a rider. For example, a rider may change the amount that you must pay for certain services such as the amount of your copayment. Or, it may add to or limit the benefits provided by this health plan. Your plan sponsor will supply you with riders (if there are any) that apply to your coverage in this health plan. You should keep these riders with this benefit booklet and your Schedule of enefits so that you can refer to them.

Room and Board

For an approved inpatient admission, covered services include room and board. This means your room, meals, and general nursing services while you are an inpatient. This includes hospital services that are furnished in an intensive care or similar unit.

Schedule of Benefits

This benefit booklet includes a Schedule of Benefits. It describes the cost share amount that you must pay for each covered service (such as a deductible, or a copayment, or a coinsurance). And, it includes important information about your deductible and out-of-pocket maximum. It also describes benefit limits that apply for certain covered services. Be sure to read all parts of this benefit booklet and your Schedule of Benefits to understand all of your health care benefits. You should read the Schedule of Benefits along with the descriptions of covered services and the limits and exclusions that are described in this benefit booklet.

Important Note: A rider may change the information that is shown in your Schedule of Benefits. Be sure to read each rider (if there is any).

Service Area

The service area is the geographic area in which you will receive all of your health care services and supplies for PCP/Plan Approved Benefits. This means that no PCP/Plan Approved Benefits will be provided for health care services or supplies that you receive outside of your service area, except as described in Part 3 of this benefit booklet for: emergency medical care; and urgent care. Your service area is described in your Schedule of Benefits.

Special Services (Hospital and Facility Ancillary Services)

When you receive health care services from a hospital or other covered health care facility, covered services include certain services and supplies that the health care facility normally furnishes to its patients for diagnosis or treatment while the patient is in the facility. These special services include (but are not limited to) such things as:

  • The use of special rooms. These include: operating rooms; and treatment rooms.
  • Tests and exams.
  • The use of special equipment in the facility. Also, the services of the people hired by the facility to run the equipment.
  • Drugs, medications, solutions, biological preparations, and medical and surgical supplies that are used while you are in the facility.
  • Administration of infusions and transfusions and blood processing fees. These do not include the cost of: whole blood; packed red blood cells; blood donor fees; or blood storage fees.
  • Internal prostheses (artificial replacements of parts of the body) that are part of an operation. These include things such as: hip joints; skull plates; intraocular lenses that are implanted after corneal transplant, cataract surgery, or other covered eye surgery, when the natural eye lens is replaced; and pacemakers. They do not include things such as: ostomy bags; artificial limbs or eyes; hearing aids; or airplane splints.
Subscriber

The subscriber is the eligible person who signs the enrollment form at the time of enrollment in this health plan.

Urgent Care

This health plan provides coverage for urgent care. This is medical, surgical, or psychiatric care, other than emergency medical care, that you need right away. This is care that you need to prevent serious deterioration of your health when an unforeseen illness or injury occurs. In most cases, urgent care will be brief diagnostic care and treatment to stabilize your condition. (For purposes of filing a claim or a formal grievance review, Blue Cross and Blue Shield considers “emergency medical care” to constitute “urgent care” as defined under the Employee Retirement Income Security Act of 1974, as amended (ERISA). As used in this benefit booklet, this urgent care term is not the same as the “urgent care” term defined under ERISA.)

Utilization Review

This term refers to the programs that Blue Cross and Blue Shield uses to evaluate the necessity and appropriateness of your health care services and supplies. Blue Cross and Blue Shield uses a set of formal techniques that are designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures or settings, and drugs. These programs are designed to encourage appropriate care and services (not less care). Blue Cross and Blue Shield understands the need for concern about underutilization. Blue Cross and Blue Shield shares this concern with its members and health care providers. Blue Cross and Blue Shield does not compensate individuals who conduct utilization review activities based on denials. Blue Cross and Blue Shield also does not offer incentives to health care providers to encourage inappropriate denials of care and services. These programs may include any or all of the following.

  • Pre-admission review, concurrent review, and discharge planning.
  • Pre-approval of some outpatient services, including drugs (whether the drugs are furnished to you by a health care provider along with a covered service or by a pharmacy).
  • Drug formulary management (compliance with the Blue Cross and Blue Shield Drug Formulary). This also includes quality care dosing which helps to monitor the quantity and dose of the drug that you receive, based on Food and Drug Administration (FDA) recommendations and clinical information.
  • Step therapy to help your health care provider furnish you with the appropriate drug treatment. (With step therapy, before coverage is approved for certain “second step” drugs, it is required that you first try an effective “first step” drug.)
  • Post-payment review.
  • Individual case management.