ConnectedCare. Supported by the Saint Alphonsus Health Alliance Network. individual and family Health insurance

Transcription

1 ConnectedCare sm Supported by the Saint Alphonsus Health Alliance Network individual and family Health insurance Form No (12-11) Policy Form Numbers: (01-12) (01-12) (01-12)

2 What is ConnectedCare? Blue Cross of Idaho s ConnectedCare plans bring you, your medical providers and health insurance together to offer proactive, quality care at a price you can afford. With ConnectedCare, you partner with a primary care physician (PCP) of your choice from the Saint Alphonsus Health Alliance Network. These Treasure Valley physicians and providers are dedicated to delivering effective and efficient care. Why Choose ConnectedCare? Better benefits at a lower cost ConnectedCare is supported by Saint Alphonsus and its network of more than 1,000 highly skilled physicians and providers in the Treasure Valley. How Connected Care Helps You Stay Healthy By visiting providers from the Saint Alphonsus network you have access to high quality care close to home, and you can decrease unnecessary and repetitive treatment which may lower your out-ofpocket costs. You and your PCP will work together to navigate your medical options and effectively manage your health and wellness. Your PCP will stay informed of your treatment and test results to monitor your medical progress and coordinate care on your behalf. When you need specialized medical care, your PCP will coordinate care between all of your providers to ensure you receive the best treatment possible. Connected Care: The Coverage You Need Preventive care ConnectedCare provides full coverage meaning you pay nothing for a variety of preventive care services to help you avoid illness and chronic conditions. Your PCP will provide or encourage you to receive these services when you need them. Treatment when you need it If you have an illness or accident, your PCP can provide treatment or arrange for care on your behalf with medical specialists. ConnectedCare also provides coverage when you receive treatment at urgent care and emergency room facilities. Ongoing conditions If you are diagnosed with, or already have, a chronic health condition, your PCP will coordinate your care across all lines of treatment, ensure the treatment you get is necessary, and work with any specialists you may see. Two Options: Standard and Plus Choose from ConnectedCare Standard and ConnectedCare Plus to find the plan that s best for you and your family. Both ConnectedCare options bring Blue Cross of Idaho and Saint Alphonsus Health System to your side so you can take control of your health. Coordinated care with ConnectedCare it s the right choice for you and your family. You can choose a PCP from the Treasure Valley doctors in the Saint Alphonsus Health Alliance Network. You can view a complete list on the Blue Cross of Idaho website at bcidaho.com/ SaintAlphonsus. Connecting your care through your health insurance plan and healthcare providers. Saint Alphonsus Health System is an independent company offering its healthcare provider network to Blue Cross of Idaho members on the ConnectedCare plan in the Treasure Valley.

3 Benefit ConnectedCare Standard Option A - $1,000 per member/ $2,000 per family Deductible (combined in- and out-of-network) Option B - $3,000 per member/$6,000 per family Option C - $5,000 per member/ $10,000 per family Option D - $7,500 per member/ $15,000 per family Option E - $10,000 per member/ $20,000 per family In-network When you receive services from the Saint Alphonsus Out-of-network Health Alliance Network Coinsurance You pay 30% You pay 60% Out-Of-Pocket Maximum Individual: $3,000 + deductible Individual: $5,000 + deductible Family: $6,000 + deductible (max 2 per family aggregate) Prescription Drugs You pay $15 per prescription for generics, insulin and diabetic supplies. (no coverage for brand name drugs, except for diabetic supplies and insulin) Preventive Care Services Immunizations Physician Office Visits includes You pay $40 for visits to any primary care physician urgent care and express facility (PCP), $60 for non-pcp visits with referral services Family: $10,000 + deductible (max 2 per family aggregate) You pay $15 per prescription for generics, insulin and diabetic supplies. (no coverage for brand name drugs, except for diabetic supplies and insulin) Inpatient Hospital Services You pay $500, then deductible and coinsurance You pay $1,000, then deductible and coinsurance Outpatient Hospital Services Outpatient Rehabilitation Therapy You pay deductible and 50% of maximum allowance You pay deductible and 80% of maximum allowance Services includes occupational, (limited to 10 visits, per person, per benefit period) (limited to 10 visits, per person, per benefit period) physical and speech therapy Emergency Room Facility Services Physician, Surgical and Professional Services includes emergency room provider services Pregnancy Services Transplant Services (a $5,000 travel benefit, not subject to deductible and coinsurance, is available for transplants when using Blue Distinction Centers for Transplants (BDCTs)*) Durable Medical Equipment and Prosthetic and Orthotic Devices Home Health Skilled Nursing (30-day maximum, per person, per benefit period) Advanced Imaging Benefit (MRI, MRA, CT scan, PET procedures and nuclear cardiology; prior authorization required) Diagnostic Laboratory and X-ray Services You pay $250, then deductible and coinsurance ($250 waived if admitted to hospital) $7,000 separate maternity deductible, then coinsurance You pay deductible and 50% of maximum allowance You pay $250 and then applicable deductible and coinsurance You pay $250, then deductible and coinsurance ($250 waived if admitted to hospital) $10,000 separate maternity deductible, then coinsurance You pay deductible and 80% of maximum allowance You pay $250 and then applicable deductible and coinsurance * Blue Distinction Centers for Transplants (BDCTs) are major hospitals and treatment facilities found throughout the United States that are affiliated with the Blue Cross Blue Shield Association. For a complete description, please see the exclusions and limitations in this brochure. Connecting your care through your health insurance plan and healthcare providers.

4 Benefit ConnectedCare Plus Option A - $1,000 per member/ $2,000 per family Deductible (combined in- and out-of-network) Option B - $3,000 per member/$6,000 per family Option C - $5,000 per member/ $10,000 per family Option D - $7,500 per member/ $15,000 per family Option E - $10,000 per member/ $20,000 per family In-network When you receive services from the Saint Alphonsus Out-of-network Health Alliance Network Coinsurance You pay 20% You pay 50% Out-Of-Pocket Maximum Individual: $2,000 + deductible Individual: $4,000 + deductible Prescription Drugs Preventive Care Services Immunizations Physician Office Visits includes urgent care and express facility services Family: $4,000 + deductible (max 2 per family aggregate) You pay $15 per prescription for generics, insulin and diabetic supplies. Brand-name prescriptions require separate $5,000 deductible and then you pay a $30 copayment per prescription. You pay $20 for visits to any primary care physician (PCP), $40 for non-pcp visits with referral Family: $8,000 + deductible (max 2 per family aggregate) You pay $15 per prescription for generics, insulin and diabetic supplies. Brand-name prescriptions require separate $5,000 deductible and then you pay a $30 copayment per prescription. Inpatient Hospital Services You pay $250, then deductible and coinsurance You pay $500, then deductible and coinsurance Outpatient Hospital Services Outpatient Rehabilitation Therapy You pay deductible and 20% of maximum allowance You pay deductible and 80% of maximum allowance Services includes occupational, (limited to 20 visits, per person, per benefit period) (limited to 20 visits, per person, per benefit period) physical and speech therapy Emergency Room Facility Services Physician, Surgical and Professional Services includes emergency room provider services Pregnancy Services Transplant Services (a $5,000 travel benefit, not subject to deductible and coinsurance, is available for transplants when using Blue Distinction Centers for Transplants (BDCTs)*) Durable Medical Equipment and Prosthetic and Orthotic Devices Home Health Skilled Nursing (30-day maximum, per person, per benefit period) Advanced Imaging Benefit (MRI, MRA, CT scan, PET procedures and nuclear cardiology; prior authorization required) Diagnostic Laboratory and X-ray Services You pay $100, then deductible and coinsurance ($100 waived if admitted to hospital) $5,000 separate maternity deductible, then coinsurance You pay $250 and then applicable deductible and coinsurance You pay $100, then deductible and coinsurance ($100 waived if admitted to hospital) $10,000 separate maternity deductible, then coinsurance You pay $250 and then applicable deductible and coinsurance * Blue Distinction Centers for Transplants (BDCTs) are major hospitals and treatment facilities found throughout the United States that are affiliated with the Blue Cross Blue Shield Association. For a complete description, please see the exclusions and limitations in this brochure. Connecting your care through your health insurance plan and healthcare providers.

5 Non-emergency Services Requiring Prior Authorization Annual Notice EFFECTIVE: January 1, 2012 NOTICE: Prior Authorization is required to determine if the services listed below are Medically Necessary and a Covered Service. If Prior Authorization has not been obtained to determine Medical Necessity, services may be subject to denial. Any dispute involved in Blue Cross of Idaho s Medical Necessity decision must be resolved by use of the Blue Cross of Idaho appeal process. If Non-Medically Necessary services are performed by Contracting Providers, without the Prior Authorization by Blue Cross of Idaho, and benefits are denied, the cost of said services are not the financial responsibility of the Member. The Member is financially responsible for Non-Medically Necessary services performed by a provider who does not have a provider contract with Blue Cross of Idaho. Blue Cross of Idaho will respond to a request for Prior Authorization received from either the Provider or the Member within two (2) business days of the receipt of the medical information necessary to make a determination. For additional information, please check with your Provider, call Customer Service at the telephone number listed on the back of the Member s Identification Card or check the BCI Web site at bcidaho.com. Prior Authorization is not a guarantee of payment. It is a pre-service determination of Medical Necessity based on information provided to Blue Cross of Idaho at the time the Prior Authorization request is made. Blue Cross of Idaho retains the right to review the Medical Necessity of services, eligibility of services and benefit limitations and exclusions after services are received. When Prior Authorization for a Covered Service is required of and obtained by or on behalf of a Member, we will provide benefits in accordance with the Prior Authorization and the terms of this Contract after the Covered Service has been provided except in cases of fraud, misrepresentation, nonpayment of premium, exhaustion of benefits or if the Member for whom the Prior Authorization was granted is not enrolled at the time the Covered Service was provided. The following services require Prior Authorization: Surgical Services Inpatient or Outpatient Organ and tissue Transplants Gallbladder Surgery Arthroscopic Surgery of the knee, hip, shoulder, wrist, or jaw Nasal and sinus procedures Eyelid Surgery Spinal Surgery Hysterectomy Gastric reflux procedures Plastic and reconstructive Surgery Surgery for snoring or sleep problems Invasive treatment of lower extremity veins (including but not limited to varicose veins) Advanced imaging services: (not applicable for Inpatient Services) Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Computed Tomography Scans (CT Scan) Positron Emission Tomography (PET) Nuclear Cardiology Other Services Form No (01-12) Inpatient stays including those that originate from an Outpatient service. Home intravenous therapy Non-emergent ambulance Certain Prescription Drugs as listed on the BCI Web site, bcidaho.com Restorative dental services following Accidental Injury to a Sound Natural Tooth Hospice services Genetic testing services Home health skilled nursing services The following services require Prior Authorization when the expected charges exceed three hundred dollars ($300): Rental or purchase of Durable Medical Equipment Prosthetic Appliances Orthotic Devices Referrals To receive Covered Services at the In-Network benefit level, a referral is required for Covered Services not provided by the Member s Primary Care Physician (PCP). It is the PCP s responsibility to evaluate conditions or request for referral and make referrals based on his or her medical judgment. If the PCP refers a Member to another Covered Provider, the PCP will provide the Member with a referral. Referral services authorized and provided according to the Member s PCP s referral will be eligible for benefits for In-Network Services as long as they are Covered Services under this Contract. If a referral is not completed for services provided by a Non-PCP, the benefits may be paid at the Out-of-Network benefit level. The only exceptions to the referral requirement are Members may selfrefer to Contracting Providers who are pediatricians, obstetricians and gynecologists for Covered Services for maternity care, annual visits and follow-up gynecological care for conditions diagnosed during maternity care or annual visits. Members may also self-refer for Emergency Services. Exclusions and Limitations In addition to the exclusions and limitations listed elsewhere in this Contract, the following exclusions and limitations apply to the entire Contract, unless otherwise specified.

6 Preexisting Condition Waiting Periods For Member s under the age of nineteen (19) there are no waiting periods, limitations or exclusions for Covered services, supplies, drugs or other charges that are incurred on or after the Member s Effective Date for any Preexisting Condition. For Member s age nineteen (19) and over there are no benefits available under this Contract for services, supplies, drugs or other charges that are provided within twelve (12) months after a Member s Enrollment Date for any Preexisting Condition. Blue Distiction Centers Designation as Blue Distinction Centers means these facilities overall experience and aggregate data met objective criteria established in collaboration with expert clinicians and leading professional organizations recommendations. Individual outcomes may vary. To find out which services are covered under your policy at any facilities, please call your local Blue Cross and/or Blue Shield Plan; and call your provider before making an appointment, to verify the most current information on its Network participation and Blue Distinction status. Neither Blue Cross and Blue Shield Association nor any of its Licensees are responsible for any damages, losses, or non-covered charges that may result from using Blue Distinction or other provider finder information or receiving care from a Blue Distinction or other provider. General Exclusions and Limitations There are no benefits for services, supplies, drugs or other charges that are: Not Medically Necessary. If services requiring Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Member. However, the Member could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider. In excess of the Maximum Allowance. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Member has a non dental, life endangering condition which makes hospitalization necessary to safeguard the Member s health and life. Not prescribed by or upon the direction of a Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed General Hospitals, Physicians, and other Providers. Investigational in nature. Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Member is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work related injuries or conditions. This exclusion applies whether or not the Member claims such benefits or compensation or recovers losses from a third party. Provided or paid for by any federal governmental entity except when payment under the Contract is expressly required by federal law, or provided or paid for by any state or local governmental entity where its charges therefore would vary, or are or would be affected by the existence of coverage under the Contract, or for which payment has been made under Medicare Part A and/or Medicare Part B, or would have been made if a Member had applied for such payment except when payment under the Contract is expressly required by federal law. Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the Member by blood or marriage and who ordinarily dwells in the Member s household. Received from a dental, vision, or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group. For Surgery intended mainly to improve appearance or for complications arising from Surgery intended mainly to improve appearance, except for: Reconstructive Surgery necessary to treat an Accidental Injury, infection or other Disease of the involved part; or Reconstructive Surgery to correct Congenital Anomalies in a Member who is a dependent child. Rendered prior to the Member s Effective Date; or during an Inpatient admission commencing prior to the Member s Effective Date, subject to the requirements of the Health Insurance Portability and Accountability Act of For personal hygiene, comfort, beautification (including nonsurgical services, drugs, and supplies intended to enhance the appearance), or convenience items or services even if prescribed by a Physician, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, homeopathic or naturopathic, massage, or music. For telephone consultations, and all computer or Internet communications. For failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, unless specified as a Covered Service in this Contract or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider. For Inpatient admissions that are primarily for Diagnostic Services, Therapy Services, or Physical Rehabilitation, except as specified in the Contract; or for Inpatient admissions when the Member is ambulatory and/or confined primarily for bed rest, a special diet, behavioral problems, environmental change or for treatment not requiring continuous bed care. For Inpatient or Outpatient Custodial Care; or for Inpatient or Outpatient services consisting mainly of educational therapy, behavioral modification, self care or self help training, except as specified as a Covered Service in this Contract. For any cosmetic foot care, including but not limited to, treatment of corns, calluses and toenails (except for surgical care of ingrown or Diseased toenails).

7 For any of the following: For appliances, splints or restorations necessary to increase vertical tooth dimensions or restore the occlusion, except as specified as a Covered Service in this Contract; For orthognathic Surgery, including services and supplies to augment or reduce the upper or lower jaw; For implants in the jaw; for pain, treatment, or diagnostic testing or evaluation related to the misalignment or discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies; For alveolectomy or alveoloplasty when related to tooth extraction. For hearing aids or examinations for the prescription or fitting of hearing aids. For orthoptics, eyeglasses or contact lenses or the vision examination for prescribing or fitting eyeglasses or contact lenses, unless specified as a Covered Service in the Contract. For any treatment of either gender leading to or in connection with transsexual Surgery, gender transformation, sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition. Made by a Licensed General Hospital for the Member s failure to vacate a room on or before the Licensed General Hospital s established discharge hour. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. Furnished by a facility that is primarily a place for treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home. For Acute Care, rehabilitative care, diagnostic testing, evaluation or treatment of Inpatient or Outpatient Mental or Nervous Conditions, Alcoholism, Substance Abuse or Addiction, or for Pain Rehabilitation, except as specified as a Covered Service in the Contract. Incurred by an enrolled Eligible Dependent child for care or treatment of any condition arising from or related to pregnancy, childbirth, delivery, or an Involuntary Complication of Pregnancy unless specified as a Covered Service in the Contract. For weight control or treatment of obesity or morbid obesity, including but not limited to Surgery for obesity, except when Surgery for obesity is Medically Necessary to control other medical conditions that are eligible for Covered Services under the Contract, and nonsurgical methods have been unsuccessful in treating the obesity. For reversals or revisions of Surgery for obesity, except when required to correct an immediately life-endangering condition. For an elective abortion, unless to preserve the life of the female upon whom the abortion is performed. For use of operating, cast, examination, or treatment rooms or for equipment located in a Contracting or Noncontracting Provider s office or facility, except for emergency room facility charges in a Licensed General Hospital, unless specified as a Covered Service in the Contract. For the reversal of sterilization procedures, including but not limited to, vasovasostomies or salpingoplasties. Treatment for infertility and fertilization procedures, including but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance a Member s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures. For Transplant Services and Artificial Organs, except as specified as a Covered Service in the Contract. For acupuncture. For Chiropractic Care. For surgical procedures that alter the refractive character of the eye, including but not limited to, radial keratotomy, myopic keratomileusis, Laser-In-Situ Keratomileusis (LASIK), and other surgical procedures of the refractive keratoplasty type, to cure or reduce myopia or astigmatism, even if Medically Necessary. Additionally, reversals, revisions, and/or complications of such surgical procedures are excluded, except when required to correct an immediately life endangering condition. For Hospice Home Care, except as specified as a Covered Service in the Contract. For pastoral, spiritual, bereavement, family and/or marriage counseling. For homemaker and housekeeping services or home delivered meals. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence. Any services or supplies for which a Member would have no legal obligation to pay in the absence of coverage under the Contract or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage. For a routine or periodic mental or physical examination that is not connected with the care and treatment of an actual Illness, Disease or Accidental Injury or for an examination required on account of employment; or related to an occupational injury; for a marriage license; or for insurance, school or camp application; or for sports participation physical; or a screening examination including routine hearing examinations, except as specified as a Covered Service in the Contract. For immunizations, except as specified as a Covered Service in the Contract. For breast reduction Surgery or Surgery for gynecomastia. For nutritional supplements. For replacements or nutritional formulas, except when administered enterally due to impairment in digestion and absorption of an oral diet and is the sole source of caloric need or nutrition in a Member. For vitamins and minerals, unless required through a written prescription and cannot be purchased over the counter. For alterations or modifications to a home or vehicle.

8 For special clothing, including shoes (unless permanently attached to a brace). Provided to a person enrolled as an Eligible Dependent, but who no longer qualifies as an Eligible Dependent due to a change in eligibility status that occurred after enrollment. Provided outside the United States, which if had been provided in the United States, would not be a Covered Service under the Contract. Furnished by a Provider or caregiver that is not listed as a Covered Provider, including but not limited to, naturopaths and homeopaths. For Outpatient pulmonary and/or cardiac rehabilitation. For complications arising from the acceptance or utilization of noncovered services. For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service. For arch supports, orthopedic shoes, and other foot devices. Any services or supplies furnished by a facility that is primarily a health resort, or sanatorium, residential treatment facility, transitional living center, or primarily a place for Outpatient treatment or residential facility care of Mental or Nervous Conditions. Contraceptives, oral or other, whether medication or device, unless specifically provided as a Covered Service in this Contract. For wigs. For cranial molding helmets, unless used to protect post cranial vault surgery. For surgical removal of excess skin that is the result of weight loss or gain, including but not limited to association with prior weight reduction (obesity) surgery. For the purchase of Therapy or Service Dogs/Animals and the cost of training/maintaining said animals. For allergy injections and allergy testing. For growth hormone therapy.