Premier Blue. State of Kansas 2002 Health Care Benefits

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1 December 31, 2001 S Questions: Contact your Professional Relations Representative, or the Professional Relations Hotline in Topeka at or OUR WEB ADDRESS: The Blue Shield Report is published by your Professional Relations Department. Communication Coordinator Larry Callahan Inside This Issue: State of Kansas Benefits...Pg. 1 Premier Blue...Pg. 1 Kansas Choice...Pg. 3 Kansas Senior Plan C...Pg. 6 Who to Call for State of Kansas Employee Group Questions...Pg. 7 State of Kansas 2002 Health Care Benefits Some changes to State of Kansas (SOK) benefits will take effect January 1, Kansas Choice and Premier Blue will continue to be offered, along with the introduction of Kansas Senior Plan C, but Blue Select will be terminated. Additionally, school groups have joined the State of Kansas group for health benefits. For Kansas providers, if you are a contracting CAP (Competitive Allowance Program) provider, then you are in the Blue Choice network. Out of network providers are Kansas providers that do not contract with Blue Cross and Blue Shield of Kansas (BCBSKS). Kansas Choice uses the Blue Choice network. In the proceeding sections, you will find a quick summary of changes for 2002, followed by a more detail description of product benefits. Premier Blue Alpha prefix for SOK Premier Blue is XSP. All services require prior approval or referral by the participant s PCP (Primary Care Physician) except when indicated otherwise. Summary of Changes for Premier Blue 2002: Deductibles: Inpatient services increase from $0 to $200 annually. Copayments: Outpatient surgery increases from $0 to $100 per occurrence. Miscellaneous: Home Medical Equipment limit changed from $2,000/person to 80 percent coverage, up to $4,000 maximum of allowable charges (per benefit year).

2 Blue Shield Report S December 31, 2001 Page 2 Deductible: Detailed Description of SOK Premier Blue 2002 Benefits Alpha prefix for SOK Premier Blue is XSP. $200 per person/$400 per family annually for inpatient services Copayment: $100 per occurrence for outpatient surgery Members are responsible for all costs associated with venipuncture Premier Blue Inpatient Services (Hospital care, surgery, anesthesia, physicians, hospital visits, etc.,) Upon satisfying $200 annual deductible, covered in full for unlimited general days when using a contracting hospital. Newborns must be added to coverage within 31 days of birth. Inpatient hospital treatment for non-biologically based mental health and alcohol/ substance abuse is limited to 60 days per plan year per person. Partial days may be substituted if approved by specific HMO. Biologically based mental illnesses have the same coverage as medical. Hospital Copayment: Not applicable. Home Health Care, Private Duty Nursing, and Home Hospice Care: Covered at 100 percent of maximum allowable payment (MAP). Outpatient Physician Services: (office visits, lab, x-ray, immunizations, routine physicals, and chiropractors) Covered, subject to a $10 copayment per office visit. No copay for immunizations for children under the age of 72 months. Obstetrical care is a $10 copayment for initial prenatal visit and no copay for subsequent care. Annual well woman exam is a $10 copayment per exam.

3 Blue Shield Report S December 31, 2001 Page 3 Premier Blue Kansas Choice Outpatient Mental Health (non-biologically based) and Alcohol/ Substance Abuse: The first 3 outpatient visits will be covered at 100 percent of the maximum allowable payment. The next 22 visits are subject to a $25 office visit copayment and additional visits are covered at 50 percent. Group therapy sessions count as one-half visit. Biologically based mental illnesses have the same coverage as medical. All mental health services must be authorized by HMS/Value Options at Emergency Care: Emergency room services are covered subject to a $50 copayment unless hospitalized within 24 hours. Vision Care: Covered for one eye exam for refraction per covered person per plan year, subject to a $10 copayment. Home Medical Equipment: If medically necessary, covered at 80 percent up to $4,000 maximum in covered charges per person per plan year. Summary of Changes for 2002 Kansas Choice (Alpha Prefix KSE) Deductibles (annual): In network increases from $0 (single and family) to $300 (single) and $600 (family). Out of network increases from $200 (single) / $400 (family) to $600 (single) and $1,200 (family). Inpatient changes from a maximum of $50 a day for 5 days to be included above. Out of Pocket Maximums (annual): Outpatient/in network maximums increase from $500 (single) / $1000 (family) to $2,000 (single) / $4,000 (family). Self-referral/out of Network increases from $1,000 (single) / $2,000 (family) to $4,000 (single) / $8,000 (family). Copayments: Emergency room increases from $25 per visit, plus deductible/coinsurance to $75 per visit plus deductible/coinsurance. Copay waived if hospitalized within 24 hours. If hospitalized, services are subject to deductible and coinsurance. Miscellaneous: Gatekeeper requirement (PCP) is no longer applicable.

4 Blue Shield Report S December 31, 2001 Page 4 Detailed Description of SOK Kansas Choice 2002 Benefits Alpha Prefix for SOK Kansas Choice KSE Deductible: In network: Insured pays first $300 per person per plan year $600 per family per plan year Out of network: Insured pays first $600 per person per plan year $1,200 per family per plan year Coinsurance: Kansas Choice In network: (80/20) Insured pays 20 percent of allowable charges to a maximum of $2,000 per person/$4,000 per family per plan year. Out of network: (70/30) Insured pays 30 percent of allowable charges to a maximum of $4,000 per person/$8,000 per family per plan year. Inpatient Services: (Hospital Care, Surgery, Anesthesia, Physician s Hospital Visits, etc.): Covered unlimited general days subject to deductibles and coinsurance. Newborns must be added to coverage within 31 days of birth. Inpatient hospital treatment for mental health and alcohol substance abuse is limited to: In network: 60 days per plan year per person (may substitute partial hospital days). Out of network: 30 days per plan year per person. Home Health Care and Home Hospice Care: Covered in full up to MAP. Home health care is subject to an annual maximum benefit of $2,500 per person. Home hospice care subject to a lifetime maximum benefit of $5,000 per person. Outpatient Physician Services (office visits, lab, X-ray, surgery, immunizations, routine physicals, and chiropractic services): Covered services subject to deductibles and coinsurance.

5 Blue Shield Report S December 31, 2001 Page 5 Mental Health parity: (biologically based conditions) In network: up to 25 visits per plan year; visits 1-3 will be covered at 100 percent of the allowable charge; visits 4-25 will have a $25 copayment per visit. Out of network: up to 25 visits per plan year at 50 percent of the allowable charge. Services must be approved by Health Management Services/Value Options at and related to the following biologically based conditions before the member is eligible for parity benefits: Kansas Choice Schizophrenia, schizo affective disorder, schizophreniform disorder, brief reactive psychosis, paranoid or delusional disorder, atypical psychosis Major affective disorders (bipolar and major depression), cyclothymic and dysthymic disorders; Obsessive compulsive disorder; Panic disorder; Pervasive developmental disorder, including autism; Attention deficit disorder and attention deficit hyperactive disorder. Outpatient Mental Health and Alcohol/Substance Abuse: (Non-Parity; Nonbiologically based conditions) Each covered person is entitled to 25 outpatient visits per plan year, combined network and nonnetwork. In network: The first three outpatient visits will be covered at 100 percent of the maximum allowable payment. The next 22 visits are subject to a $25 office visit copayment. Out of network: First 3 visits are covered at 100 percent of the maximum allowable payment, the next 22 visits are covered at 50 percent of the allowable charge. Emergency Room Services: Covered services subject to a $75 copayment unless hospitalized within 24 hours; then subject to deductibles and coinsurance. Vision Care: Annual eye exam for refraction covered subject to deductible and coinsurance. Eyeglasses and contact lenses are not covered except for initial purchase following cataract removal. Home Medical Equipment: Covered subject to deductible and coinsurance. Benefits limited to $2,500 per person per plan year.

6 Blue Shield Report S December 31, 2001 Page 6 Kansas Senior Plan C Alpha prefix for SOK Kansas Senior Plan C is XSM. A new package is available through the SOK group plan for Medicare eligible retirees and their Medicare eligible dependents. Kansas Senior Plan C is a self-funded group product offering the same medical benefits as the Medicare Supplemental Plan C. Kansas Senior Plan C is group rated, rather than individually age rated. In addition, the medical benefits are designed to coordinate with traditional Medicare coverage. Eligibility: To enroll in Kansas Senior Plan C, the retiree and all covered dependents must be eligible for and enrolled in Medicare Part A and Medicare Part B. Physician Selection: To receive maximum benefits, the beneficiary should use a contracting Medicare provider. Hospital Selection: To receive maximum benefits, the beneficiary should use a contracting Medicare hospital. Summary of Benefits: Medical coverage is determined by Medicare. If a service is not covered by Medicare, it is also not covered by Kansas Senior Plan C. Kansas Senior Plan C will cover the remaining balance of whatever Medicare approves but doesn t pay. This means that the following are covered in full: Basic Medical Benefits: Medicare Part A deductible Medicare Part A coinsurance Medicare Part B deductible Medicare Part B coinsurance Medicare Parts A and B blood Skilled nursing facility coinsurance days Extra Medical Benefits Additional 365 hospital days per lifetime Foreign Travel Emergency: $250 deductible, then the plan will pay 80 percent to a lifetime maximum of $50,000.

7 Blue Shield Report S December 31, 2001 Page 7 Kansas Senior Plan C Prescription Drug Coverage: The prescription drug coverage does not include any medications and supplies already covered by Medicare. Medicare should be billed for these items, with any remaining balance of covered items billed to the Kansas Senior Plan C. This includes any drugs related to organ transplants or chemotherapy covered under Medicare. The prescription drug card can be used for the medications that Medicare does not cover at all, such as insulin, high blood pressure medications, etc. The prescription plan will work very much like the prescription plan for active state employees, except for those items that Medicare will cover. Dental Coverage: The dental benefits offered with Kansas Senior Plan C are the same benefits for the rest of the SOK group. Dental coverage is for all enrolled participants, including dependents. Who To Call? Questions regarding the State of Kansas employee group are directed to: Premier Blue Customer Service Center Topeka (785) Toll Free State Customer Service Center Topeka (785) Toll Free