Understanding Your Health Care Benefits

Transcription

1 Understanding Your Health Care Benefits A Handbook For Employees of Air Products and Chemicals, Inc. Preferred Provider Organization Program 2013

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3 TABLE OF CONTENTS I. Introduction... 1 II. Member Services... 2 How Do I Use My Member Handbook?... 2 Who Do I Call For Help?... 2 III. Benefits Summary... 5 What Are My Benefits Under "Blue Cross Core PPO?"... 5 TABLE OF CONTENTS What Are My Benefits Under "Blue Cross Basic PPO?"... 9 What Are My Benefits Under "Blue Cross Premium PPO?" IV. How PPO Works Who Is Eligible? How Do I Obtain Benefits? How Does The Medical Management Program Work? How Are Benefits Administered? What Is My Level Of Coverage? What Do I Do In An Emergency? V. Your Benefits What Benefits Can I Receive? VI. Exclusions What Is Not Covered Under This PPO Program? VII. PPO Claims How Do I File a Medical Claim? How To Appeal If You Disagree With A Claim Decision VIII. General Information On Your PPO Benefits IX. Glossary Of Terms X. Conclusion This handbook describes the principal features of your program. It is an attempt to explain the benefits available to you as clearly and briefly as possible. Capital BlueCross and its wholly owned subsidiary, Capital Advantage Assurance Company provide administrative claims payment services only and do not assume any financial risk or obligation with respect to claims. If at anytime you have questions about your coverage, you may call the Customer Service Number for answers. The toll-free phone number for member inquiries is

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5 I. Introduction Welcome to this Preferred Provider Organization (PPO) Program. Thank you for choosing this PPO Program as the health benefits option for you and/or your family. This PPO Program is administered by Capital BlueCross and its wholly owned subsidiary, Capital Advantage Assurance Company, collectively "Capital." It was created to provide access to quality health care. The program utilizes a network of providers selected to ensure that you and your eligible dependents have access to appropriate medical treatment at a reasonable price. INTRODUCTION The program offers excellent coverage, including physician office visits, hospitalization, diagnostic testing, surgery, laboratory tests and preventive services. This PPO Program offers flexibility in your choice of provider, and it works to your greatest advantage when your care is provided by a participating provider of the preferred provider network. We are pleased to welcome you to this PPO Program. 1

6 MEMBER SERVICES II. Member Services How Do I Use My Member Handbook? This member handbook is provided for employees of Air Products and Chemicals, Inc., and certain of its affiliates and their dependents who are eligible participants of the Air Products Medical Plan and who choose PPO as their option under the Air Products Medical Plan. Your member handbook provides a quick and easy reference to your benefits and discusses how to use the program to your greatest advantage. Please take time to become familiar with the handbook and keep it available for quick reference. This PPO program offers you choices. You made the first important choice when you chose to enroll in the PPO Program. To make full use of the program's coverage and to help better manage health care costs, you should understand how the program works. Toll-Free Customer Service Number: Using a provider who participates in the preferred provider network will allow you to receive the highest level of benefit payment for health care services. To locate a participating provider in Capital s service area, please visit or contact the Customer Service Department at For information on participating providers outside of Capital s service area, see the BlueCard Program information on page 22. To locate a BlueCard participating provider, call BLUE or visit the BlueCard Web site at This handbook is a convenient reference to your benefits and is your guide to the program s health care delivery system. To help acquaint you with the program, we have included explanations of words and phrases that may be unfamiliar to you. Bolded terms are defined in the Glossary at the end of this handbook. The program is provided under the Air Products Medical Plan. Except as provided by the Air Products Medical Plan, this handbook is not intended to extend or change the Plan in anyway, or interpret the Plan except with respect to those areas within the discretion of Capital. The Air Products Medical Plan is more fully discussed in the Summary Plan Description provided to you. In the event of a conflict between this handbook and the official Plan documents, the Plan documents will govern, except in those instances where the Plan documents refer you to your Plan option, the member handbook for your Plan option or the customer services department of your Plan option. Your handbook is just one resource you may use to get fast, accurate answers and information. To assist you further in understanding the program, customer service has been established. Who Do I Call For Help? The Customer Service Department is available to help you understand this PPO Program and address any questions or concerns you may have. This department is a team of professionals specially trained in the details of your health benefits program. We encourage you to call if you have questions or need assistance. WHEN TO CALL Customer Service Representatives are available to answer calls Monday through Friday, 8:00 a.m. to 6:00 p.m. E.S.T. After hours, leave a message, and your call will be returned promptly during the next business day. 2

7 WHAT TO HAVE READY WHEN CALLING Please have available the following information, which can be found on your PPO Program identification card: Your member identification number (this is the employee or retiree's unique identification number, preceded by the letters AIR ) Your group number. If calling about medical services already performed, please provide the: MEMBER SERVICES date when the services were received; patient's name; provider s name; type of service(s) provided; and claim number, if applicable. WHERE TO WRITE If you prefer to write to us, please send your inquiry to: Customer Service Department Capital BlueCross PO Box Harrisburg, PA When calling Customer Service, please have your ID card handy. In Person Members can meet with a Customer Service Representative at our offices at: 2500 Elmerton Avenue or 1221 W. Hamilton Street Harrisburg, PA Allentown, PA Staff is available to assist members Monday through Friday from 8:00 a.m. to 4:30 p.m. Internet and Electronic mail ( ) Our website, contains information about Capital s products and how to use benefits and access services, including benefit descriptions, provider directories, forms, etc. Members may access material on standard benefits and search our online provider directory to locate area physicians, hospitals, and ancillary providers. Members can us at inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the member's inquiry. 3

8 MEMBER SERVICES 24-Hour NurseLine The Capital NurseLine is a 24-hour, 7-day/week-telephone service that is available to all Capital members. The service is designed to offer health and medical information, education and support. Members are encouraged to call this number when they have the need for health education materials or want information to assist them in determining how to best handle specific medical symptoms after hours. WHERE TO CALL NurseLine Health Information Library , dial 499 4

9 III. Benefits Summary What Are My Benefits Under "Blue Cross Core PPO?" Use this chart for a quick reference to your benefits. WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE Does not include copayments or penalties. One individual deductible must be met before family aggregate is met. $400 individual,* $800 individual plus one,* $1,200 family aggregate* $750 individual,* $1,500 individual plus one,* $2,250 family aggregate* BENEFITS SUMMARY ANNUAL OUT-OF-POCKET LIMIT Does not include deductibles, copayments, penalties, charges in excess of the plan allowance or charges for infertility services. $1,250 individual,* $2,500 family aggregate* $2,250 individual,* $4,500 family aggregate* PREAUTHORIZATION PENALTY (Applies to all inpatient admissions and other procedures described on pages 18 and 19.) HOSPITAL SERVICES Includes room and board in semi-private room, general nursing, use of operating room, lab, x-ray, drugs and medications. $300 $300 EMERGENCY CARE Physician Office Visits $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician*** $30/visit when provided by all other professional providers*** 5

10 BENEFITS SUMMARY WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK Hospital Emergency Room When emergency criteria met, subject to, in-network deductible, 20% coinsurance and a $100 copay. Copay is waived if member is admitted as an inpatient. When emergency criteria are not met, subject to, innetwork deductible, 40% coinsurance, and a $100 copay. When emergency criteria met, subject to, in-network deductible, 20% coinsurance and $100 copay. Copay is waived if member is admitted as an inpatient. When emergency criteria are not met, subject to, out-of-network deductible, 40% coinsurance and $100 copay. Urgent Care Emergency Ambulance ADDITIONAL SERVICES Skilled nursing facility services (120 days/year) Home Health Care (out-of-network 50 visits/year) Transplant Services from a BCBSA-Approved Blue Quality Center for Transplant Facility ($10,000 per transplant episode for travel, lodging and meals) Subject to, in-network deductible, 20% coinsurance and a $50 copay. Subject to in-network deductible and 20% coinsurance. Subject to, out-of-network deductible, 40% coinsurance and a $50 copay. Subject to in-network deductible and 20% coinsurance. Hospice Care ($50,000 lifetime), Includes Residential Hospice Care Home Medical Equipment (including oxygen) Prosthetics (Other Than Wigs) and Orthotics Wigs (limited to a $300/year maximum) Outpatient Therapy Services Speech and Occupational (each service limited to 30 visits/year) Physical (30 visits/calendar year) Chemotherapy, Dialysis, Radiation, Respiratory (unlimited) Manipulation Therapy (limited to 10 visits per calendar year) 6

11 WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK MENTAL HEALTH CARE SERVICES Inpatient Services Partial Hospitalization Outpatient Services $15/visit when provided by all professional providers*** BENEFITS SUMMARY SUBSTANCE ABUSE SERVICES Detoxification-Inpatient Rehabilitation-Inpatient Rehabilitation-Outpatient PHYSICIAN & OUTPATIENT SERVICES Physician Office Visits* (*includes Outpatient Therapy evaluations.) Preventive Care Services, pediatric and adult, (includes physical examinations*, immunizations and tests as well as specific women s preventive services as required by law) *Preventive visits are subject to the applicable office visit copayment when a medical condition is diagnosed by the provider. $15/visit when provided by all professional providers*** $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician*** $30/visit when provided by all other professional providers*** $0 Cost Share 100% 7

12 BENEFITS SUMMARY WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK Contraceptives (Limited to coverage for those prescribed contraceptive products or devices as mandated by law, including but not limited to contraceptive implants such as intrauterine devices (IUD). Refer to your prescription medication booklet for contraceptive coverage under your drug plan.) $0 Cost Share 100% Infertility (limited testing & treatment) Surgical Services Hospital Visits and Consultations Diagnostic Services 50%** 70%** * In-network deductible/out-of-pocket amounts do not accumulate towards out-ofnetwork deductible/out-of-pocket amounts. Out-of-network deductible/out-of-pocket amounts do not accumulate towards in-network deductible/out-of-pocket amounts. ** You must first pay the deductible, after which you are responsible for this percentage, which is applied to the plan allowance. A network provider cannot bill you for the difference between the plan allowance and his or her actual charge. A non-network provider may bill you for the difference between the plan allowance and the actual charge. *** You pay this copayment amount each time you visit the provider's office. Copayment amounts do not apply towards the deductible amount. 8

13 What Are My Benefits Under "Blue Cross Basic PPO?" Use this chart for a quick reference to your benefits. WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE Does not include copayments or penalties. One individual deductible must be met before family aggregate is met. $600 individual,* $1,200 individual plus one,* $1,800 family aggregate* $1,250 individual,* $2,500 individual plus one,* $3,750 family aggregate* BENEFITS SUMMARY ANNUAL OUT-OF-POCKET LIMIT Does not include deductibles, copayments, penalties, charges in excess of the plan allowance or charges for infertility services. $1,500 individual* $3,000 family aggregate* $2,750 individual* $5,500 family aggregate* PREAUTHORIZATION PENALTY (Applies to all inpatient admissions and other procedures described on pages 18 and 19.) HOSPITAL SERVICES Includes room and board in semi-private room, general nursing, use of operating room, lab, x-ray, drugs and medications. $300 $300 EMERGENCY CARE Physician Office Visits $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician*** $30/visit when provided by all other professional providers*** 9

14 BENEFITS SUMMARY WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK Hospital Emergency Room When emergency criteria met, subject to, in-network deductible, 20% coinsurance and $100 copay. Copay is waived if member is admitted as an inpatient. When emergency criteria are not met, subject to $100 copay, in-network deductible and 40% coinsurance. When emergency criteria met, subject to in-network deductible, 20% coinsurance, and $100 copay. Copay is waived if member is admitted as an inpatient. When emergency criteria are not met, subject to $100 copay, out-ofnetwork deductible and 40% coinsurance. Urgent Care Emergency Ambulance ADDITIONAL SERVICES Skilled nursing facility services (120 days/year) Home Health Care (out-of-network 50 visits/year) Transplant Services from a BCBSA-Approved Blue Quality Center for Transplant Facility ($10,000 per transplant episode for travel, lodging and meals) Subject to $50 copay, innetwork deductible and 20% coinsurance. Subject to in-network deductible and 20% coinsurance. Subject to $50 copay, outof-network deductible and 40% coinsurance. Subject to in-network deductible and 20% coinsurance. Hospice Care ($50,000 lifetime), Includes Residential Hospice Care Home Medical Equipment (including oxygen) Prosthetics (Other than Wigs) and Orthotics Wigs (limited to a $300/year maximum) Outpatient Therapy Services Speech and Occupational (each service limited to 30 visits/year) Physical (30 visits/calendar year) Chemotherapy, Dialysis, Radiation, Respiratory (unlimited) Manipulation Therapy (limited to 10 visits per calendar year) 10

15 WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK MENTAL HEALTH CARE SERVICES Inpatient Services Partial Hospitalization Outpatient Services $15/visit when provided by all professional providers*** BENEFITS SUMMARY SUBSTANCE ABUSE SERVICES Detoxification-Inpatient Rehabilitation-Inpatient Rehabilitation-Outpatient PHYSICIAN & OUTPATIENT SERVICES Physician Office Visits* (*includes Outpatient Therapy evaluations.) Preventive Care Services, pediatric and adult, (includes physical examinations*, immunizations and tests as well as specific women s preventive services as required by law) *Preventive visits are subject to the applicable office visit copayment when a medical condition is diagnosed by the provider. $15/visit when provided by all professional providers*** $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician*** $30/visit when provided by all other professional providers*** $0 Cost Share 100% 11

16 BENEFITS SUMMARY WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK Contraceptives (Limited to coverage for those prescribed contraceptive products or devices as mandated by law, including but not limited to contraceptive implants such as intrauterine devices (IUD). Refer to your prescription medication booklet for contraceptive coverage under your drug plan.) $0 Cost Share 100% Infertility (limited testing & treatment) Surgical Services Hospital Visits and Consultations Diagnostic Services 50%** 70%** * In-network deductible/out-of-pocket amounts do not accumulate towards out-ofnetwork deductible/out-of-pocket amounts. Out-of-network deductible/out-of-pocket amounts do not accumulate towards in-network deductible/out-of-pocket amounts. ** You must first pay the deductible, after which you are responsible for this percentage, which is applied to the plan allowance. A network provider cannot bill you for the difference between the plan allowance and his or her actual charge. A non-network provider may bill you for the difference between the plan allowance and the actual charge. *** You pay this copayment amount each time you visit the provider's office. Copayment amounts do not apply towards the deductible amount. 12

17 What Are My Benefits Under "Blue Cross Premium PPO?" Use this chart for a quick reference to your benefits. WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE Does not include copayments or penalties. One individual deductible must be met before family aggregate is met. $250 individual,* $500 individual plus one,* $750 family aggregate* $500 individual,* $1,000 individual plus one,* $1,500 family aggregate* BENEFITS SUMMARY ANNUAL OUT-OF-POCKET LIMIT Does not include deductibles, copayments, penalties, charges in excess of the plan allowance or charges for infertility services. $1,000 individual* $2,000 family aggregate* $1,750 individual* $3,500 family aggregate* PREAUTHORIZATION PENALTY (Applies to all inpatient admissions and other procedures described on pages 18 and 19.) HOSPITAL SERVICES Includes room and board in semi-private room, general nursing, use of operating room, lab, x-ray, drugs and medications. $300 $300 10%** 30%** EMERGENCY CARE Physician Office Visits $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician*** $30/visit when provided by all other professional providers*** 30%** 30%** 13

18 BENEFITS SUMMARY WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK Hospital Emergency Room When emergency criteria met, subject to in-network deductible, 10% coinsurance and $100 copay. Copay is waived if member is admitted as an inpatient. When emergency criteria are not met, subject to $100 copay, in-network deductible and 30% coinsurance. When emergency criteria met, subject to in-network deductible, 10% coinsurance and $100 copay. Copay is waived if member is admitted as an inpatient. When emergency criteria are not met, subject to $100 copay, out-ofnetwork deductible and 30% coinsurance. Urgent Care Emergency Ambulance ADDITIONAL SERVICES Skilled nursing facility services (120 days/year) Home Health Care (out-of-network 50 visits/year) Transplant Services from a BCBSA-Approved Blue Quality Center for Transplant Facility ($10,000 per transplant episode for travel, lodging and meals) Subject to $50 copay, innetwork deductible and 10% coinsurance. Subject to in-network deductible and 10% coinsurance. 10%** 10%** 10%** Subject to $50 copay, outof-network deductible and 30% coinsurance. Subject to in-network deductible and 10% coinsurance. 30%** 30%** 30%** Hospice Care ($50,000 lifetime), Includes Residential Hospice Care Home Medical Equipment (including oxygen) Prosthetics (Other Than Wigs) and Orthotics Wigs (limited to a $300/year maximum) Outpatient Therapy Services Speech and Occupational (each service limited to 30 visits/year) Physical (30 visits/calendar year) Chemotherapy, Dialysis, Radiation, Respiratory (unlimited) Manipulation Therapy (limited to 10 visits per calendar year) 10%** 10%** 10%** 10%** 10%** 10%** 10%** 10%** 10%** 30%** 30%** 30%** 30%** 30%** 30%** 30%** 30%** 30%** 14

19 WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK MENTAL HEALTH CARE SERVICES Inpatient Services Partial Hospitalization Outpatient Services 10%** 10%** $15/visit when provided by all professional providers*** 30%** 30%** 30%** BENEFITS SUMMARY SUBSTANCE ABUSE SERVICES Detoxification-Inpatient Rehabilitation-Inpatient Rehabilitation-Outpatient PHYSICIAN & OUTPATIENT SERVICES Physician Office Visits* (*includes Outpatient Therapy evaluations.) Preventive Care Services, pediatric and adult, (includes physical examinations*, immunizations and tests as well as specific women s preventive services as required by law) *Preventive visits are subject to the applicable office visit copayment when a medical condition is diagnosed by the provider. 10%** 10%** $15/visit when provided by all professional providers*** $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician*** $30/visit when provided by all other professional providers*** $0 Cost Share 30%** 30%** 30%** 100% 15

20 BENEFITS SUMMARY WHAT YOU PAY BENEFIT IN-NETWORK OUT-OF-NETWORK Contraceptives (Limited to coverage for those prescribed contraceptive products or devices as mandated by law, including but not limited to contraceptive implants such as intrauterine devices (IUD). Refer to your prescription medication booklet for contraceptive coverage under your drug plan.) $0 Cost Share 100% \ Infertility (limited testing & treatment) Surgical Services Hospital Visits and Consultations Diagnostic Services 30%** 10%** 10%** 10%** 50%** 30%** 30%** 30%** * In-network deductible/out-of-pocket amounts do not accumulate towards out-ofnetwork deductible/out-of-pocket amounts. Out-of-network deductible/out-of-pocket amounts do not accumulate towards in-network deductible/out-of-pocket amounts. ** You must first pay the deductible, after which you are responsible for this percentage, which is applied to the plan allowance. A network provider cannot bill you for the difference between the plan allowance and his or her actual charge. A non-network provider may bill you for the difference between the plan allowance and the actual charge. *** You pay this copayment amount each time you visit the provider's office. Copayment amounts do not apply towards the deductible amount. 16

21 IV. How PPO Works Who Is Eligible? The Air Products Medical Plan Summary Plan Description fully defines all aspects of eligibility and enrollment. To enroll or change coverage, contact the Air Products Employee Help Center at How Do I Obtain Benefits? IDENTIFICATION CARD HOW PPO WORKS Your PPO Program identification card must be used to receive health care benefits under the program. When you receive your identification card, you should verify the information appearing on it. Contact the Customer Service Department if your PPO identification card contains incorrect information. You should always carry your identification card with you and present it when you receive health care services. The identification card identifies the member's name and other information that assists health care professionals in submitting claims. As a member, you are responsible for the proper use of the identification card and are accountable for any fraudulent use. ID Card Information If you lose your identification card, please call the Customer Service Department immediately at Member s name. This identification number is generally the Air Products employee-member s identification number, preceded by the letters AIR. Group ID and Plan are used to identify the employee or retiree s group and also identifies the cardholder as a member of this PPO Program. The ID card for those members residing within Capital s service area will receive ID cards with the name Capital BlueCross in the upper left hand corner next to Capital s logo. For those members residing outside Capital s service area the name BlueCross will appear in the upper left hand corner next to Capital s logo. 17

22 HOW PPO WORKS How Does The Clinical Management Program Work? The Clinical Management Program is part of your PPO coverage. Clinical Management is comprised of three major components: Utilization Management, Case Management and Disease Management. Because these components can affect your coverage, it is important that you understand Clinical Management before receiving care and services. Utilization Management Preauthorization and medical necessity reviews are functions of the utilization management portion of the program. Although the Utilization Management Program does not require extensive effort on your part, you will be responsible for notifying your physician that certain services may require preauthorization and treatment plan review. Preauthorization To obtain preauthorization services, call (in or out of Pennsylvania) Certain services, listed below, require preauthorization before full benefits will be paid. Your identification card contains a notation concerning preauthorization and brief instructions on how to obtain this service. All requests for preauthorization may be directed to the Utilization Management Unit at Capital. Preauthorization requests may be submitted by: Telephone - (Monday through Friday 8 a.m. to 6 p.m. E.S.T.) (in or out of Pennsylvania) Fax Or mail Capital BlueCross Utilization Management Department PO Box Harrisburg, PA Services Requiring Preauthorization All elective inpatient facility admissions including hospitals, skilled nursing facilities and rehabilitation hospitals. Preauthorization of scheduled elective admissions and selected outpatient services should be obtained at least seven days prior to the date of service. Preauthorization requirements do not apply to services provided by a hospital emergency room provider. If services are provided on an emergency basis or admission results from an emergency room visit, notification should occur within forty-eight (48) hours or within two (2) business days following such services. Most in-network providers will perform the necessary notification. However, you or the responsible party acting on behalf of the member is responsible for the notification. 18

23 Home Health and Home Infusion Treating provider/suppliers will be required to submit treatment plans for authorization of home health and home infusion services. Treatment plans for home health and home infusion should be submitted after providing an initial visit and one follow-up visit. Authorization for subsequent visits will be dependent upon an evaluation of the treatment plan, medically necessity and appropriateness of setting based on skilled needs, when required. Home Medical Equipment Preauthorization is required in all settings for home medical equipment (HME) if the estimated cost is greater than $300 per item. This includes rental of HME that would cost greater than $300 if purchased. HOW PPO WORKS Orthotics and Prosthetics Orthotics and prosthetics require preauthorization if the cost is greater than $300 per item. Non-emergency air/non-emergency ground Ambulance/Transports Any reconstructive surgery for treatment of medical disease, accident, injury or congenital anomaly. Outpatient Rehabilitation Therapies, including physical therapy, occupational therapy, speech therapy, and spinal manipulations. Treatment plans are required for outpatient rehabilitation therapies. Authorizations and the submission of a treatment plan are required after the first six visits. Transplant evaluation and services Preauthorization is required prior to initiating a referral for any transplant evaluation, with the exception of cornea transplants. In addition to providing preauthorization for transplant services, Capital's nurses will provide referral assistance to the Blue Quality Centers for Transplants (BQCT) network if appropriate. The Blue Quality Centers for Transplants (BQCT) offers members access to more than 45 health care institutions selected for participation based on their clinical criteria and experience. The institutions selected for participation in the BQCT have been chosen by panels of nationally recognized transplant researchers and providers retained by the Blue Cross and Blue Shield Association. Our clinicians can also assist the provider and the member with coordination of a pre-transplant evaluation, including arrangements for travel and lodging in the event services are provided outside of our service area. 19

24 HOW PPO WORKS The Preauthorization Process Most in-network providers of health care will make the necessary contacts with the Utilization Management Department. However, you are ultimately responsible to be sure that preauthorization is obtained by in-network and out-of-network providers, when required. If a procedure, service, or supply is not preauthorized when required you will be subject to a penalty. Preauthorization approvals generally are handled by your physician and the Utilization Management staff. The process involves the following steps: The preauthorization requirement is noted in the top right hand corner of your identification card. You should remind your physician or treating provider of the preauthorization requirements. In most situations, your physician or treating provider will notify the Utilization Management Department. All inpatient admissions require preauthorization before they are performed. The Utilization Management Department staff reviews the information provided by the physician or other treating provider to determine if the care and services to be provided are medically necessary. They may find it necessary to ask the physician or treating provider to provide additional medical documentation. After the review, they may suggest an alternate treatment plan. If your provider does not notify the Utilization Management Department you are ultimately responsible to notify the Utilization Management Department. In the case of maternity and emergency admissions, notification should be made within two (2) working days following the admission. The preauthorization staff of the Utilization Management Department will notify you and your health care provider in writing of all denied care or services. The individual requesting authorization will be notified of the approval and an authorization number will be assigned. For approved admissions, the Utilization Management staff assigns a length of stay. All reviews are made with quality, cost-effective care being the top priority. This program endeavors to ensure that health care is provided in the most advantageous setting at the least cost. Please note that if the Utilization Management Department denies a request for coverage of care or services, it does not mean that you must cancel or postpone care or services. The final decision rests with you and your physician. However, when care and services requiring preauthorization are provided without the required approval, you may be responsible for some or all of the associated costs. Also note that preauthorization of care and services does not guarantee reimbursement. All claim payments are subject to the specific terms and conditions of the group contract, including its eligibility requirements. How Benefits Subject to Preauthorization Are Paid When a member obtains preauthorization of required services, benefits will be paid in the same manner as that described in Your Benefits section of this booklet. PENALTY When a member fails to obtain preauthorization of any service requiring preauthorization, he or she must pay a $300 penalty per episode. If the cost of the care or services is less than $300, the member may be held responsible for the entire cost. 20

25 If an in-network provider (within the Capital service area) is properly advised of the need to obtain preauthorization by the member presenting his or her identification card to the provider and the provider fails to obtain or fails to follow the preauthorization process, the member will not be financially responsible for the penalty amount. It is the member's responsibility to obtain preauthorization for services and care provided by an out-of-network provider (located outside of Capital's service area) and the member is held responsible for the penalty. Additionally, the provider may bill the member for the balance of charges not covered by this plan. How To Appeal A Preauthorization Determination HOW PPO WORKS If you disagree with a preauthorization determination, you may submit an appeal in writing to: Medical Appeals Capital BlueCross PO Box Harrisburg, PA You or your physician on your behalf with your written consent, must submit your appeal no later than one-hundred and eighty (180) days from the date you are notified of the decision and should include copies of all information in support of your claim. The Appeals staff will review the appeal, make a final decision and notify you of the decision within sixty (60) days of receiving your appeal. In the event that your physician believes that the adverse determination has placed your health at eminent risk, you may request an expedited appeal. To request an expedited appeal, please contact the Customer Service Department. The Appeals staff will notify you of the decision within seventy-two (72) hours of receiving your appeal. If you do not understand the process or the decision, please contact Customer Service at for any information you may need. Case Management Case Management helps members suffering from catastrophic or chronic conditions to receive the maximum benefits from their coverage and treatment support systems designed to prevent repeated hospitalizations. The goal of the Case Management Program is to help the patient receive the most appropriate level of care in a setting most conducive to recovery. The Case Management Program employs experienced professionals, generally a registered nurse, to work with physicians, patients, and families to coordinate services to facilitate the provision of medically necessary and appropriate health care. Please note that the decision to participate in the Case Management Program always rests with the patient and the physician. The Case Management Process Cases that could benefit from Case Management can be identified and referred either by Capital - through the preauthorization process - you, your family members, other support persons, or by health care providers. 21

26 HOW PPO WORKS Referrals to the Case Management Program are screened to determine whether or not the patient may benefit from Case Management services. Once it is determined that a member may benefit from Case Management, a Case Manager will contact the member to explain the program and determine whether or not the member wishes to participate. Once a desire to participate is established, the Case Manager will conduct an assessment and develop the plan of care. The plan of care is developed by the Case Manager jointly with the member and in collaboration with the member's physician and other appropriate members of the health care team, as well as the member's family and other support persons. The Case Manager will perform periodic evaluations of the member's progress. Disease Management The Disease Management Program is a collaborative program between Capital and members that assesses the health needs of members with a chronic condition and provides education, counseling, and information designed to increase the member s selfmanagement of this condition. The goals of Capital s Disease Management Program are to maintain and improve the overall health status of members with specific diseases through the provision of comprehensive education, monitoring and support for healthy self-management techniques. The Disease Management Program is especially beneficial for members who have complex health care needs or who require additional assistance and support. Participation in Capital s Disease Management Program is voluntary and involves no additional cost to our members. Members should refer to the Disease/Condition Management Programs attachment to this handbook for a description of Disease Management Programs available to them. How Are Benefits Administered? IN-NETWORK PROVIDERS In-network providers are any providers who have signed a PPO agreement with Capital pertaining to payment for covered services. When you receive covered services from an in-network provider, they will bill Capital directly, and in turn be paid directly. If you choose health care providers who are in-network, benefits are payable at a higher level. In-network providers accept an agreed upon plan allowance established by Capital for each service they provide to you. You are responsible for the amount of any deductible, copayments, coinsurance, penalties, or maximums, but not for any difference between what the provider might typically charge and the agreed-upon plan allowance. Outside of the Capital service area you can receive care at the in-network reimbursement level through the BlueCard program by choosing a provider that participates with the local Blue Cross Blue Shield plan that services the geographic area where the care is delivered. To locate a BlueCard participating provider call BLUE or visit the BlueCard Web site at OUT-OF-NETWORK PROVIDERS Out-of-network providers do not have an agreement to accept the PPO plan allowance for covered services. Members can be billed the difference between the provider s total charge and the plan allowance, in addition to the deductible, 22

27 copayments, coinsurance, penalties, or maximums. If you choose a provider that does not participate be sure you fully understand the potential financial liability of that decision, including any balance billing for charges in excess of the PPO plan allowance. The difference between the provider s total charge and the plan allowance can be significant. When you obtain covered services from an eligible out-of-network professional provider, payment is made up to the plan allowance less your coinsurance percentage (after you meet your deductible). The plan allowance for an out-of-network provider is the same allowance that an in-network provider would receive in the service area. When you obtain covered services from an eligible out-of-network facility provider, payment is made up to the plan allowance less your coinsurance percentage (after you meet your deductible). You are responsible for any remaining balance of the provider s charge. The coinsurance and payment percentage are based on the PPO benefit option you have selected. HOW PPO WORKS The following eligible out-of-network facility providers are paid at your PPO option's payment percentage (listed below) of the plan allowance: Ambulatory Surgical Facilities Birthing Facility Freestanding Dialysis Facilities Home Health Care Agencies Hospital Rehabilitation Hospital Skilled Nursing Facility Hospice The Blue Cross Core PPO option and the Blue Cross Basic PPO option pay most out-ofnetwork providers at 60% of the plan allowance. The Blue Cross Premium PPO option pays most out-of-network providers at 70% of the plan allowance. Capital makes payment to the member. The member is then responsible for reimbursing the provider, as well as for paying coinsurances, deductibles, and any remaining balances between the plan allowance as determined by Capital and the provider s actual charge. These remaining balances are not eligible for payment under this program. No payment will be made by the program for out-of-network Freestanding Outpatient Facilities. Payment for Anesthesia, Radiology, Emergency Room Physicians and Pathologists In some cases, you may have health care services at an in-network facility and with an In-network professional provider, but services for anesthesia, radiology, emergency room and pathology are provided by an out-of-network provider. If these services are received in Capital's service area, payment is based on the plan allowance and is made directly to the member less any applicable in-network deductible and coinsurance. If you are balance billed for amounts between what the provider normally charges and the in-network plan allowance (less any applicable in-network deductible and coinsurance), please call Customer Service for an adjustment to your claims. If these services are received outside Capital's service area, reimbursement is made directly to the member. PPO pays most of these services based on the in-network plan allowance. You pay any applicable in-network deductible and coinsurance and the coinsurance percentage you pay, is a percentage of the plan allowance. Out-ofnetwork deductible and coinsurance are waived for these services. If you are paid at 23

28 HOW PPO WORKS the out-of-network level or are balance billed for amounts between what the provider normally charges and the in-network plan allowance, please call Customer Service for an adjustment to your claims. IN-NETWORK AND OUT-OF-NETWORK DEDUCTIBLE The PPO option you are enrolled in will pay the level of coverage described in this handbook, in most situations, only after your deductible is satisfied. If you are enrolled under the "Blue Cross Core PPO option"; as an individual, you have a deductible of $400 per year for covered services provided by in-network providers; and a $750 per year deductible for covered services provided by out-of-network providers. These deductibles are separate. The individual plus one aggregate deductible is $800 for innetwork services per year and a separate $1,500 individual plus one aggregate deductible for out-of-network services per year. The family aggregate deductible is $1200 for in-network services per year and a separate $2,250 family aggregate deductible for out-of-network services per year. The family aggregate deductible will be satisfied only if one member of your family meets the individual deductible; the balance of the family deductible may then be fully satisfied by any other family members meeting all or a portion of the individual deductible (up to the family aggregate deductible amount.) If you are enrolled under the "Blue Cross Basic PPO option"; as an individual, you have a deductible of $600 per year for covered services provided by in-network providers and a $1,250 per year deductible for covered services provided by out-of-network providers. These deductibles are separate. The individual plus one aggregate deductible is $1,200 for in-network services per year and a separate $2,500 individual plus one aggregate deductible for out-of-network services per year. The family aggregate deductible is $1,800 for in-network services per year and a separate $3,750 family aggregate deductible for out-of-network services per year. The family aggregate deductible will be satisfied only if one member of your family meets the individual deductible first, the balance of the family deductible may then be fully satisfied by any other family members meeting all or a portion of the individual deductible (up to the family aggregate deductible amount.) If you are enrolled under the "Blue Cross Premium PPO option"; as an individual, you have a deductible of $250 per year for covered services provided by in-network providers; and a $500 per year deductible for covered services provided by out-of-network provider. These deductibles are separate. The individual plus one aggregate deductible is $500 for in-network services per year and a separate $1,000 individual plus one aggregate deductible for out-of-network services per year. The family aggregate deductible is $750 for in-network services per year and a separate $1,500 family aggregate deductible for out-of-network services per year. The family aggregate deductible will be satisfied only if one member of your family meets the individual deductible first, the balance of the family deductible may then be fully satisfied by any other family members meeting all or a portion of the individual deductible (up to the family aggregate deductible amount.) Payments for in-network services will not be applied to the out-of-network deductible. Payments for out-of-network services will not be applied to the in-network deductible. 24

29 COPAYMENTS Copayments under each PPO program will apply to the following covered services in the amounts specified: SERVICE Home, Office and Other Outpatient Visits Emergency Room Services Urgent Care Services COPAYMENT $15/visit when provided by a Family Practitioner, General Practitioner, Internist, or Pediatrician $30/visit when provided by all other professional providers $100 (copayment is waived if the member is admitted as an inpatient) $50 (copayment is waived if the member is admitted as an inpatient) HOW PPO WORKS Copayments are not credited toward deductible or out-of-pocket limits. What Is My Level Of Coverage? (Note: For employees on International Global assignment, all covered medical services received outside the United States are paid at the in-network level). COINSURANCE If you are enrolled under the "Blue Cross Core option" and "Blue Cross Basic PPO option": For covered services received from in-network providers, after the deductible has been satisfied, the program pays 80% of the plan allowance. For out-of-network facility and professional providers, after the deductible has been satisfied, the PPO program pays 60% of the plan allowance. You are responsible for the remaining 40% of the covered expenses and for any amount between the plan allowance and the provider's charge. Note: You pay 50% for covered in-network infertility services and 70% for covered outof-network infertility services. If you are enrolled under the "Blue Cross Premium PPO option": For covered services received from in-network providers, after the deductible has been satisfied, the program pays 90% of the plan allowance. For out-of-network facility and professional providers, after the deductible has been satisfied, the PPO program pays 70% of the plan allowance. You are responsible for the remaining 30% of the covered expenses and for any amount between the plan allowance and the provider's charge. Note: You pay 30% for covered in-network infertility services and 50% for covered outof-network infertility services. 25

30 HOW PPO WORKS IN-NETWORK AND OUT-OF-NETWORK OUT-OF-POCKET LIMIT The out-of-pocket limit is the maximum amount of coinsurance expense that must be incurred by you and your participating dependents in a calendar year before coverage increases to 100% for most covered services. The following amounts are not included in calculating your out-of-pocket limit: The deductible Any copayments Charges in excess of plan allowance Expenses incurred after benefit maximums have been exhausted Preauthorization penalty amounts Charges for infertility services Any amount applied to the in-network out-of-pocket will not be applied to the out-ofnetwork out-of-pocket. Any amount applied to the out-of-network out-of-pocket will not be applied to the in-network out-of-pocket. If you are enrolled under the "Blue Cross Core PPO option": This program will pay 100% of the plan allowance on most covered services rendered for any one person during the remainder of the calendar year when that person's out-of-pocket limit of $1,250 has been paid for covered services provided by in-network providers, or the individual out-of-pocket limit of $2,250 has been paid for covered services provided by outof-network providers, during that period. In addition to the individual out-of-pocket limit, the program will pay 100% of the plan allowance on most covered services rendered during the remainder of the calendar year when you have paid a family aggregate out-of-pocket limit of $2,500 for covered services provided by in-network providers, or a family aggregate outof-pocket limit of $4,500 for covered services provided by out-of-network providers, during that period. If you are enrolled under the "Blue Cross Basic PPO option": This program will pay 100% of the plan allowance on most covered services rendered for any one person during the remainder of the calendar year when that person's out-of-pocket limit of $1,500 has been paid for covered services provided by in-network providers, or the individual out-of-pocket limit of $2,750 has been paid for covered services provided by outof-network providers, during that period. In addition to the individual out-of-pocket limit, the program will pay 100% of the plan allowance on most covered services rendered during the remainder of the calendar year when you have paid a family aggregate out-of-pocket limit of $3,000 for covered services provided by in-network providers, or a family aggregate outof-pocket limit of $5,500 for covered services provided by out-of-network providers, during that period. If you are enrolled under the "Blue Cross Premium PPO option": This program will pay 100% of the plan allowance on most covered services rendered for any one person during the remainder of the calendar year when that person's out-ofpocket limit of $1000 is paid for covered services provided by in-network providers, or the individual out-of-pocket limit of $1,750 has been paid for covered services provided by out-of-network providers, during that period. In addition to the individual out-of-pocket limit, the program will pay 100% of the plan allowance on most covered services rendered during the remainder of the calendar year when you have paid a family aggregate out-of-pocket limit of $2,000 for covered services provided by innetwork providers, or a family aggregate out-of-pocket limit of $3,500 for covered services provided by out-of-network providers, during that period. 26