Other Plan Provisions

Other Health Plan Provisions

 
Access to and Confidentiality of Medical Records

Blue Cross and Blue Shield and health care providers may, in accordance with applicable law, have access to all of your medical records and related information that is needed by Blue Cross and Blue Shield or health care providers. Blue Cross and Blue Shield may collect information from health care providers or from other insurance companies or the plan sponsor. Blue Cross and Blue Shield will use this information to help them administer the coverage provided by this health plan and to get facts on the quality of care that is provided under this and other health care contracts. In accordance with law, Blue Cross and Blue Shield and health care providers may use this information and may disclose it to necessary persons and entities as permitted and required by law. For example, Blue Cross and Blue Shield may use and disclose it as follows:

  • For administering coverage (including coordination of benefits with other insurance plans); managing care; quality assurance; utilization management; the prescription drug history program; grievance and claims review activities; or other specific business, professional, or insurance functions for Blue Cross and Blue Shield.
  • For bona fide medical research according to the regulations of the U.S. Department of Health and Human Services and the U.S. Food and Drug Administration for the protection of human subjects.
  • As required by law or valid court order.
  • As required by government or regulatory agencies.
  • As necessary for the operations of Blue Cross and Blue Shield of Massachusetts, Inc.
  • As required by the subscriber’s group or by its auditors to make sure that Blue Cross and Blue Shield is administering your coverage in this health plan properly.
  • For the purpose of processing a claim, medical information may be released to your group’s reinsurance carrier.

Commitment to Confidentiality:
 
To get a copy of Blue Cross and Blue Shield’s Commitment to Confidentiality statement, call the Blue Cross and Blue Shield customer service office. (See Part 1.)

Blue Cross and Blue Shield will not share information about you with the Medical Information Bureau (MIB). Blue Cross and Blue Shield respects your right to privacy. Blue Cross and Blue Shield will not use or disclose personally identifiable information about you without your permission, unless the use or disclosure is permitted or required by law and is done in accordance with the law. You have the right to get the information Blue Cross and Blue Shield collects about you. You may also ask Blue Cross and Blue Shield to correct any of this information that you believe is not correct. Blue Cross and Blue Shield may charge you a reasonable fee for copying your records, unless your request is because Blue Cross and Blue Shield is declining or terminating your coverage in this health plan.

Acts of Providers

Blue Cross and Blue Shield is not liable for the acts or omissions by any individuals or institutions that furnish care or services to you. In addition, a health care provider who participates in your health care network and has a payment agreement with Blue Cross and Blue Shield or any other health care provider does not act as an agent on behalf of or for Blue Cross and Blue Shield. And, Blue Cross and Blue Shield does not act as an agent for health care providers who participate in your health care network and have payment agreements with Blue Cross and Blue Shield or for any other health care providers.

Blue Cross and Blue Shield will not interfere with the relationship between health care providers and their patients. You are free to select or discharge any health care provider. Blue Cross and Blue Shield is not responsible if a provider refuses to furnish services to you. Blue Cross and Blue Shield does not guarantee that you will be admitted to any facility or that you will get a special type of room or service. If you are admitted to a facility, you will be subject to all of its requirements. This includes its requirements on admission, discharge, and the availability of services.

Assignment of Benefits

You cannot assign any benefit or monies due from this health plan to any person, corporation, or other organization without Blue Cross and Blue Shield’s written consent. Any assignment by you will be void. Assignment means the transfer of your rights to the benefits provided by this health plan to another person or organization. There is one exception. If Medicaid has already paid the health care provider, you can assign your benefits to Medicaid.

Authorized Representative

You may choose to have another person act on your behalf concerning your health care coverage in this health plan. You must designate this person in writing to Blue Cross and Blue Shield. Or, if you are not able to do this, a person such as a conservator, a person with power of attorney, or a family member may be your authorized representative. In some cases, Blue Cross and Blue Shield may consider your health care facility or your physician or other health care provider to be your authorized representative. For example, Blue Cross and Blue Shield may tell your hospital that a proposed inpatient admission has been approved. Or, Blue Cross and Blue Shield may ask your physician for more information if more is needed for Blue Cross and Blue Shield to make a decision. Blue Cross and Blue Shield will consider the health care provider to be your authorized representative for emergency medical care. Blue Cross and Blue Shield will continue to send benefit payments and written communications regarding your health care coverage according to Blue Cross and Blue Shield’s standard practices, unless you specifically ask Blue Cross and Blue Shield to do otherwise. You can get a form to designate an authorized representative from the Blue Cross and Blue Shield customer service office. (See Part 1.)

Changes to Health Plan Coverage

Blue Cross and Blue Shield and/or the plan sponsor may change the provisions of your coverage in this health plan. For example, a change may be made to the cost share amount that you must pay for certain covered services such as your copayment or your deductible or your coinsurance. The plan sponsor is responsible for sending you a notice of any change. The notice will describe the change being made. It will also give the effective date of the change. When a change is made to your health care coverage, you can get the actual language of the change from your plan sponsor. The change will apply to all benefits for services you receive on or after its effective date.

Charges for Non-Medically Necessary Services

You may receive health care services that would otherwise be covered by this health plan, except that these services are not determined to be medically necessary for you by Blue Cross and Blue Shield. This health plan does not cover health care services or supplies that are not medically necessary for you. If you receive care that is not medically necessary for you, you might be charged for the care by the health care provider. In some cases, Blue Cross and Blue Shield will defend you from a claim for payment for this care. Blue Cross and Blue Shield will defend you when this care is furnished by a health care provider who has a payment agreement with Blue Cross and Blue Shield not to charge for services that are not medically necessary. This does not apply if you were told, knew, or reasonably should have known before you received this treatment that it was not medically necessary. To obtain Blue Cross and Blue Shield’s defense in this situation, you must notify Blue Cross and Blue Shield. You must do this within 10 days of the date the lawsuit to collect for the service has been started. And, you must cooperate in the defense. If it is determined in the action that the covered services were medically necessary, this health plan will cover them.

Clinical Guidelines and Utilization Review Criteria

Blue Cross and Blue Shield applies medical technology assessment criteria and medical necessity guidelines when it develops its clinical guidelines, utilization review criteria, and medical policies. Blue Cross and Blue Shield reviews its clinical guidelines, utilization review criteria, and medical policies from time to time. Blue Cross and Blue Shield does this to reflect new treatments, applications, and technologies. For example, when a new drug is approved by the U.S. Food and Drug Administration (FDA), Blue Cross and Blue Shield reviews its safety, effectiveness, and overall value on an ongoing basis. While a new treatment, technology, or drug is being reviewed, it will not be covered by this health plan. Another example is when services and supplies are approved by the U.S. Food and Drug Administration (FDA) for the diagnosis and treatment of insulin dependent, insulin using, gestational, or non-insulin dependent diabetes. In this case, coverage will be provided for those services or supplies as long as they can be classified under a category of covered services.

Disagreement With Recommended Treatment

When you enroll for coverage in this health plan, you agree that it is up to your health care provider to decide the right treatment for your care. You may (for personal or religious reasons) refuse to accept the procedures or treatments that are advised by your health care provider. Or, you may ask for treatment that a health care provider judges does not meet generally accepted standards of professional medical care. You have the right to refuse the treatment advice of the health care provider. Or, you have the right to seek other care at your own expense. If you want a second opinion about your care, you have the right to coverage for second and third opinions. (See Part 5.)

Member Cooperation

You agree to provide Blue Cross and Blue Shield with information it needs to comply with federal and/or state law and regulation. If you do not do so in a timely manner, your claims may be denied and/or your coverage in this health plan may be affected.

Pre-Existing Conditions

Your coverage in this health plan is not limited based on medical conditions that are present on or before your effective date. This means that your health care services will be covered from the effective date of your coverage in this health plan without a pre-existing condition restriction or a waiting period. But, benefits for these health care services are subject to all the provisions of this health plan.

Quality Assurance Programs

Blue Cross and Blue Shield uses quality assurance programs. These programs affect different aspects of health care. This may include, for example, health promotion. From time to time, Blue Cross and Blue Shield may add or change the programs that it uses. Blue Cross and Blue Shield will do this to ensure that it continues to provide you and your family with access to high-quality health care and services. For more information, you can call the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. Some of the clinical programs that Blue Cross and Blue Shield uses are:

  • A breast cancer screening program. It encourages female members who are over 50 to have mammograms.
  • A cervical cancer screening program. It helps to get more female members who are age 18 and older to have a Pap smear test.
  • A program that furnishes outreach and education to an expectant mother. It adds to the care that the member gets from her obstetrician or nurse midwife.
  • A program that promotes timely postnatal checkups for new mothers.
  • Diabetes management and education. This helps diabetic members to self-manage their diabetes. It also helps to identify high-risk members and helps to assess their ongoing needs.
  • Congestive heart failure disease management, education, and monitoring.
Services Furnished by Non-Preferred Providers

As a member of this health plan, you will usually receive the highest benefit level (your in-network benefits) only when you obtain covered services from a covered provider who participates in your PPO health care network. There are a few times when this health plan will provide in-network benefits for covered services you receive from a covered provider who does not participate in your PPO network. These few situations are described below in this section. If you receive covered services from a covered provider who does not participate in your PPO health care network, you will receive in-network benefits only when:

  • You receive emergency medical care.
  • You receive covered services that are not reasonably available from a preferred provider (see “covered provider” in Part 2 of this benefit booklet) and you had prior approval from Blue Cross and Blue Shield to obtain these covered services. Or, you receive covered services from a covered provider before a preferred network is established for that type of provider.
  • You are living or traveling outside of Massachusetts and you receive covered services from a type of covered provider for which the local Blue Cross and/or Blue Shield Plan has not, in the opinion of Blue Cross and Blue Shield, established an adequate PPO health care network.
  • You receive covered services from a non-preferred hospital-based anesthetist, pathologist, or radiologist while you are at a preferred hospital.
Services in a Disaster

Blue Cross and Blue Shield is not liable if events beyond its control—such as war, riot, public health emergency, or natural disaster—cause delay or failure of Blue Cross and Blue Shield to arrange for or coordinate access to health care services and coverage for members. Blue Cross and Blue Shield will make a good faith effort to arrange for or to coordinate health care services to be furnished in these situations.

Time Limit for Legal Action

Before you pursue a legal action against Blue Cross and Blue Shield for any claim under this health plan, you must complete the Blue Cross and Blue Shield internal formal grievance review. (See Part 10.) You may, but you do not need to, complete an external review before you pursue a legal action. If, after you complete the grievance review, you choose to bring a legal action against Blue Cross and Blue Shield, you must bring this action within two years after the cause of the action arises. For example, if you are filing a legal action because you were denied a service or you were denied a claim for coverage from this health plan, you will lose your right to bring a legal action against Blue Cross and Blue Shield unless you file your action within two years after the date of the decision of the final internal appeal of the service or claim denial.