Blue Exclusive SM Upstate 1 BusinessADVANTAGE Select Upstate Small Group Narrow Network Products

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1 Blue Exclusive SM Upstate 1 BusinessADVANTAGE Select Upstate Small Group Narrow Network Products MyHealth First Network is an independent company that offers a provider network on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan Note! Contents are subject to change and are not a guarantee of payment.

2 Agenda Exclusive Provider Organization (EPO) Member ID Cards Finding an EPO Network Provider BlueChoice HealthPlan BlueCross BlueShield of South Carolina Resources Questions 2

3 Exclusive Provider Organization What is an EPO Network? An EPO is a type of product in which members only receive benefits when seeking care from the providers, hospitals and pharmacies within the EPO narrow network. There are no out-of-network benefits, except for true emergency services provided in an emergency room setting. 3

4 Exclusive Provider Organization Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks BlueCross and BlueChoice have partnered with MyHealth First Network (MyHFN) to offer an array of small group EPO or narrow network products beginning January 1, MyHFN is a clinically integrated narrow network of providers who collaborate and share a common goal of improving health outcomes, reducing health care costs and enhancing the patient experience. 4

5 Exclusive Provider Organization Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks EPO networks consist of these various provider types in the Upstate region of South Carolina: Ancillary Providers Behavioral Health Clinics Hospitals Primary Care Providers Specialists 5

6 Exclusive Provider Organization Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks We created the EPO network to serve Small employers (two to 50 employees) in six Upstate counties: Abbeville Greenville Greenwood Laurens Oconee Pickens 6

7 Exclusive Provider Organization Out of EPO network area Options outside of SC BlueCard network Emergency services rendered in an emergency room setting only Caremark s list of national pharmacies. Caremark is an independent company that provides pharmacy benefits management on behalf of BlueCross. Important: Cannot travel across state borders to access BlueCard providers for routine or non-emergency medical care. 7

8 Exclusive Provider Organization Options within SC CVS Minute Clinics Doctors Care All SC locations EXCEPT those within the six county EPO network and Newberry County Important: Cannot travel across state borders to access BlueCard providers for routine or non-emergency medical care. 8

9 Exclusive Provider Organization How we pay when Scenario: A member needs a transplant or burn treatment. We will coordinate care at a Blue Distinction Center of Excellence. We will pay benefits at regular contract benefits with applicable member liability. Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. A Local Blue Plan may require additional criteria for facilities located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers need for affordable healthcare. Each facility s cost of care is evaluated using data from its Local Blue Plan. Facilities in CA, ID, NY, PA, and WA may lie in two Local Blue Plans areas, resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on Individual outcomes may vary. For details on a provider s in-network status or your own policy s coverage, contact your Local Blue Plan and ask your provider before making an appointment. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers. 9

10 How we pay benefits when Exclusive Provider Organization Scenario: Out-of-network (OON) emergency care leads to a subsequent OON hospital admission and/or surgery: We will pay OON services at the Medicare-allowable amount. If services were rendered out-of-state, services will pay at the BlueCard network-allowable amount. You can bill applicable member cost sharing. 10

11 Exclusive Provider Organization How we pay benefits when Scenario: A college student receives nonemergent care from an out-of-state provider and/or fills medications at an outof-state pharmacy. Benefits are not payable for non-emergent services rendered by an out-of-state provider. Members can fill medications at an out-of-state Caremark retail pharmacy location only. 11

12 Exclusive Provider Organization South Carolina Upstate Region Provider Types Hospitals Clinics Primary Care Providers Specialists Ancillary Providers MD360 Express Medical Care CVS Minute Clinics (All SC locations) Doctors Care (All SC locations EXCEPT those within the six county EPO network and Newberry County) Pharmacies Caremark s list of national and South Carolina pharmacies Urgent Care Facilities 12

13 Agenda Exclusive Provider Organization (EPO) Member ID Cards Finding a Network Provider BlueChoice HealthPlan BlueCross BlueShield of South Carolina Resources Questions 13

14 Member ID Cards BlueChoice HealthPlan ID Card BusinessADVANTAGE Select Upstate 1 High Deductible Health Plan (HDHP) 14

15 Member ID Cards BlueChoice HealthPlan ID Card BusinessADVANTAGE Select Upstate 1 15

16 Member ID Cards BlueCross ID Cards Blue Exclusive Upstate 1 16

17 Agenda Exclusive Provider Organization (EPO) Member ID Cards Finding an EPO Network Provider BlueChoice HealthPlan BlueCross BlueShield of South Carolina Resources Questions 17

18 Finding an EPO Network Provider Doctor & Hospital Finder Available on these websites: Find a Doctor or Hospital Verify provider network access Refine search Read patient reviews 18

19 Finding an EPO Network Provider Doctor & Hospital Finder Select Doctor & Hospital Finder» Select Find a Doctor or Hospital 19

20 Finding an EPO Network Provider Doctor & Hospital Finder Search by name, location and/or specialty Select Show me only doctors and hospitals in my Plan Enter the alpha prefix from the ID card 20

21 Agenda Exclusive Provider Organization (EPO) Member ID Cards Finding an EPO Network Provider BlueChoice HealthPlan BlueCross BlueShield of South Carolina Resources Questions 21

22 BlueChoice HealthPlan Business ADVANTAGE Select Upstate 1 Product Silver 2000 Silver 2500 Silver 3500 Gold 1011 Gold 2100 Gold 2503 Important: We provide benefits in network only. We provide no benefits for services received out of network unless the service is due to an emergency rendered in an emergency room setting. 22

23 BlueChoice HealthPlan Business ADVANTAGE Select Upstate 1 23

24 BlueChoice HealthPlan Business ADVANTAGE Select Upstate 1 24

25 BlueChoice HealthPlan Business ADVANTAGE Select Upstate 1 25

26 BlueChoice HealthPlan Business ADVANTAGE Select Upstate 1 26

27 BlueChoice HealthPlan Excluded Services Benefits we will not pay for: Any services or benefits not specifically covered under the terms of this policy. Services and/or supplies for which the member is entitled to payment or benefits from other sources. Services and supplies related to cosmetic surgery or weight loss and morbid obesity. Eyeglasses, contact lenses or any procedures that are designed to alter the refractive properties of the cornea. Treatment, services or supplies received because of suicide, attempted suicide or intentionally self-inflicted injuries. Treatment resulting from war or acts of war. Any loss that results from committing, or attempting to commit a crime, felony or misdemeanor. Any service or treatment for complications resulting from any non-covered procedure or condition. 27

28 BlueChoice HealthPlan Excluded Services Benefits we will not pay for: Hospital or skilled nursing facility charges for which the member doesn t get the required prior authorization. Investigational or experimental services. Any services or supplies a family member provides, including the dispensing of drugs. Any type of fee or charge for handling medical records, filing a claim or missing a scheduled appointment. Any service (other than substance abuse services), medical supplies, charges or losses resulting from a member being legally intoxicated or under the influence of any drug or other substance. Services or supplies related to temporomandibular joint syndrome (TMJ). Note: A full list of excluded services, supplies or limitations is available on 28

29 Agenda Exclusive Provider Organization (EPO) Member ID Cards Finding an EPO Network Provider BlueChoice HealthPlan BlueCross BlueShield of South Carolina Resources Questions 29

30 BlueCross BlueShield of South Carolina Blue Exclusive Upstate 1 Product Gold 1 HRA Gold 2 Silver 1 Silver 2 Important: We provide benefits in network only. We provide no benefits for services received out of network unless the service is due to an emergency rendered in an emergency room setting. 30

31 Blue Exclusive Upstate 1 Products 31

32 BlueCross BlueShield of South Carolina Blue Exclusive Upstate 1 Products 32

33 BlueCross BlueShield of South Carolina Blue Exclusive Upstate 1 Products 33

34 BlueCross BlueShield of South Carolina Blue Exclusive Upstate 1 Products 34

35 BlueCross BlueShield of South Carolina Excluded Services Benefits we will not pay for: Any services or benefits not specifically covered under the terms of this policy. Services or charges for which the member is entitled to payment or benefits from other sources for which the provider does not charge, or for which the member is not legally obligated to pay. Cosmetic surgery or surgery or treatment for the purpose of weight reduction. Refractive care, such as radial keratotomy, laser eye surgery or Lasik. Services for the detection and correction of structural imbalance, distortion or subluxation to remove nerve interference. Treatment, services or supplies received because of suicide, attempted suicide or intentionally self-inflicted injuries. Treatment resulting from war or acts of war. An illness received while committing or attempting to commit a crime. 35

36 Excluded Services Benefits we will not pay for: BlueCross BlueShield of South Carolina Non-emergency services when received at or from out-of-network providers or hospitals. Hospital or skilled nursing facility charges when the member does not receive a preauthorization. Services and supplies not medically necessary, investigational/experimental and non-covered. Service or supplies provided by a member of the patient s family or by the patient, including the dispensing of drugs. Charges for missed appointments or for filling out claim forms. Any loss resulting from a member being legally intoxicated or impaired while under the influence of alcohol or narcotic drug. Services or supplies related to temporomandibular joint disorders (TMJ). Note: A full list of excluded services, supplies or limitations is available on 36

37 Agenda Exclusive Provider Organization (EPO) Member ID Cards Finding an EPO Network Provider BlueChoice Health Plan BlueCross BlueShield of South Carolina Resources Questions 37

38 Resources Provider Education Advocates BlueCross and BlueChoice HealthPlan Ashlie Graves Telephone: MyHealth First Network Sara Dereng Shamblin Telephone: or Provider advocates are always eager to assist you! 38

39 Save the Dates Save the Dates Get ready for the 2016 Regional Benefit Update Meetings! Columbia, South Carolina Thursday, December 3, 2015 BlueCross BlueShield of South Carolina Tower Auditorium 2501 Faraway Drive, Columbia, SC Greenville, South Carolina Thursday, December 10, 2015 Greenville Memorial Hospital Medical Staff Auditorium 701 Grove Road, Greenville, SC Visit for more details and to register. 39

40 Thank You! Questions? 40