Special Care SM A Guaranteed Issue Health Insurance Plan for Individuals Helping lower-income individuals and families afford health care benefits Basic hospitalization issued by Capital BlueCross; medical surgical and major medical issued by Capital Advantage Insurance Company, a Capital BlueCross subsidiary. Independent licensees of the BlueCross BlueShield Association.
Welcome to Special Care 1 Helping Lower-income Individuals and Families Afford Health Care Benefits Special Care is an affordable benefit program for individuals and families who earn too much money to qualify for Medicaid but not enough to afford standard health insurance coverage. Today, more than ever, Special Care can provide the peace of mind you need. Your eligibility for Special Care is based on your family s pretax income from the previous year and the number of family members living in your home (including yourself and your spouse and dependent children under age 26). Only the member s and spouse s income are considered. To qualify for Special Care: Your family s annual income cannot exceed the Special Care income guidelines (calculated each year based on federal poverty levels) You must reside in the Capital BlueCross 21-county service area You cannot be eligible for Medicare, Medical Assistance, or Children s Health Insurance Program (CHIP) You cannot be enrolled in an employer group health plan Coverage for Dependent Children If you apply for Special Care for a dependent under the age of 26, we will review the application to see if your child meets the enrollment guidelines for CHIP or Medical Assistance. If your child is found to be eligible, he/she will be enrolled in CHIP or referred to Medical Assistance. 1 Not affiliated with Special Care, Inc., a home health care company.
Freedom to Choose Coverage The Special Care plan gives you access to one of the largest provider networks in Central Pennsylvania and the Lehigh Valley. You have the freedom to choose the provider you want to see. However, you maximize your benefits and have the lowest out-of-pocket costs when you use a participating provider. You also have access to providers outside our 21-county service area through the BlueCard network. Special Care requires you to use a participating provider to receive nonemergency services. When you use a participating provider, there are no claims to file. Your provider takes care of the paperwork for you. If you choose to see doctors or hospital providers who are not in the network for nonemergency services, you will be required to pay the cost of the services. If you choose to see a nonparticipating provider, you may have to submit the bill and claim form to be reimbursed for eligible emergency expenses. Your Special Care plan allows you to use any of our providers in our 21-county service area. To find a participating provider in the Capital BlueCross 21-county service area, search our online directory at capbluecross.com. With Special Care, you have access to thousands of BlueCard participating doctors and hospitals outside our 21-county area, across the country, and around the world. To find a BlueCard participating provider anywhere outside our service area, you can search the Blue Cross and Blue Shield Association s online directory at bcbs.com. You can also call 800.810.BLUE, or, when traveling outside of the country, you can call collect at 804.673.1177 for assistance 24 hours a day, seven days a week.
Special Care Benefits Overview The Special Care plan covers mandated preventive care and other important health care services. Services may be subject to copayments. You do not need a referral to see a specialist; however, some services require a preauthorization. Please refer to your Contract or Outline of Coverage or check your benefits online by logging in to capbluecross.com. Amounts you are responsible for Service Hospitalization* benefits Medical-Surgical* benefits Preventive Care Adult routine physical exams and preventive care (age X and over) Not covered Covered in full Pediatric routine physical exams and preventive care (includes well-baby care) Not covered Covered in full Childhood immunizations Covered in full Covered in full Annual mammogram, age 40 and over Covered in full Covered in full Annual gynecological exam and pap test Covered in full Covered in full Physician Services Office visits for illness or injury (limited to four visits per benefit period) $20 copay per visit** $20 copay per visit** Maternity and newborn care Covered in full Covered in full Inpatient visits, surgery, and anesthesia Covered in full Covered in full Lab tests, x rays, and high-end imaging Covered, $25 copayment Covered, $25 copayment Other Provider Services Outpatient physical medicine Not covered Not covered Manipulation therapy Not covered Not covered Occupational, speech, and respiratory therapy Not covered Not covered Home health care Not covered Not covered Hospice Not covered Not covered Outpatient Hospital Services Professional fees and facility services, including: labs, x rays, preadmission tests, radiation therapy, chemotherapy, kidney Covered in full Covered in full dialysis, anesthesia, and surgery Inpatient Hospital Services Covered, limited to 21 days, renewable after a period of Professional fees and facility services, including: room and 90 days in which member board, and other covered services has not received Inpatient Covered in full benefits** Emergency Services Emergency care Covered, $100 copayment, waived if admitted Covered, $100 copayment, waived if admitted Urgent care Covered, $35 copayment Covered, $35 copayment Ambulance services for emergency care Covered in full Covered in full Durable Medical Equipment, Supplies, Prosthetics and Orthotics Not covered Not covered Mental Health Care Inpatient care Not covered Not covered Psychiatric partial hospitalization (included as part of inpatient days) Not covered Not covered Outpatient psychiatric services Not covered Not covered Substance Abuse Inpatient care Not covered Not covered Outpatient care Not covered Not covered *Some nonparticipating providers are not covered. **Nonparticipating providers are not covered. Inpatient admissions as well as certain other services and equipment may require preauthorization. Please refer to your Contract for detailed description of all benefits, limitations, definitions of terms, and exclusions that apply to your plan.
Your Member Identification Card Show this card each time you seek medical services. The following is important information about the identification card (ID card): Your ID card is the key to accessing the benefits provided under Special Care. MEMBER NAME ID # YWB80012345600 OV $$ ER $$ Preauthorization: A clinical program in which our nurses work with physicians to approve and monitor certain health care services prior to the delivery of services. The purpose of preauthorization is to ensure that all members receive medically appropriate treatment to meet their individual needs. Certain medical and therapy services and all nonemergency inpatient hospital admissions require preauthorization. Refer to the Preauthorization section of your Contract for more information. Copayments: The specified dollar amount that you are required to pay directly to your provider at the time a service is rendered. The abbreviations stand for: OV $$ office visit copayment ER $$ emergency room copayment Special Care Suitcase Symbol: This symbol lets you know that your coverage includes BlueCard and BlueCard Worldwide. With both programs, you have access to BlueCard participating providers nationwide and worldwide. The back of the ID card has important information such as: Toll-free telephone numbers. General instructions for filing claims. Emergency care information. Remember to destroy old ID cards and use only your current ID card. Please contact Customer Service at the phone number that appears on your ID card if any information on your card is incorrect or if you have questions.
Preexisting Conditions Pharmacy Discount Program Mail Order Service Special Care includes a 12-month waiting period for preexisting conditions. A preexisting condition is a health problem that exists or was treated before the date your insurance becomes effective. If you received a diagnosis and/or treatment for a medical condition during the one-year period before your first day of coverage, services related to that medical condition will not be eligible for benefits during the first 12 months of your coverage. You may enroll in Special Care without the preexisting condition limitations, if your previous health coverage was provided under a Capital BlueCross group plan or from a Blue Cross or Blue Shield plan outside our service area. The preexisting condition limitations period will not be imposed on a child less than nineteen (19) years of age. The Rx Savings Plus SM is a discount prescription card issued to Special Care members at no additional cost. You can use this card to save money on certain prescription drugs purchased at a participating retail pharmacy. Present your card at any participating pharmacy and receive a discount. Over 60,000 pharmacies participate nationwide, including most chain drug stores and many independent pharmacies right in your neighborhood. You can even use your Rx Savings Plus card to receive discounts on prescription drugs through our mail order service. Through the mail order service, you will receive additional savings on a 90-day supply of medications. This is a great benefit for members using a maintenance drug, like those taken for diabetes or high blood pressure. It is convenient and is often a less expensive way to fill prescriptions you take on a regular basis. To take advantage of the mail order discount, simply reference the information provided on the back of the discount card.
Great Ways to become a better health care consumer... When you take the time to become a better health care consumer, you are doing your part to help keep health care affordable. And as a member of the Capital BlueCross family of companies, you will have access to the information and tools to assist you in making better decisions about your health and well-being. Register for a secure personal account at capbluecross.com. Take your FREE Better Health Works Personal Profile. If you haven t already set up a capbluecross.com secure personal account, register on our website to establish a user ID and password. Your secure account is a valuable tool that can help you make the most of your health care benefits. Here s how: When you login to capbluecross.com you can: Check the status of a claim. Compare hospital quality and treatment costs. Print a temporary proof of coverage. Access the Simply Well SM member newsletter. View your Explanation of Benefits (EOB) for the past two years. And much more! The Better Health Works Personal Profile starts by asking you questions about yourself and the way you live. Based on the answers you provide, you ll receive customized recommendations for your health situation. And to help you follow through on those recommendations, we provide you with the support you need to make positive health changes. For more information, go to capbluecross.com or call 866.802.4781 (TTY: 800.242.4816).
Call Nurse Line 24 hours a day, 7 days a week When your doctor is out, Nurse Line is always in. Nurse Line is staffed by experienced Registered Nurses who provide information and support for any health-related concern, at no cost to you. Call 800.452.BLUE (TTY: 800.855.2880). Blue365 Take control of the quality and cost of your health care. At Capital BlueCross, we want to help you take care of your health through all the stages of life. With this in mind, we offer Blue365 to encourage members and their families to get up, get out and get active. Blue365 offers discounts on gym memberships, fitness apparel, and other products and services. Use MyCare Advisor SM to research and compare average cost and quality information for many of the most common elective surgical and treatment procedures to maximize your health care dollar. Log in to capbluecross.com to access this valuable tool before deciding where and how much you spend on your procedure.
Special Care Monthly rates as of January 1, 2013. Rates are subject to change. Plan Single Husband/Wife Parent/Child Parent/Children Family Special Care $211.16 $422.34 $355.85 $355.85 $567.03 Special Care Income Levels It s Simple To Enroll In Special Care Three ways to pay: Income limits are subject to change. Income Limit One Family Member $22,980 Two Family Members $31,020 Three Family Members $39,060 Four Family Members $47,100 Five Family Members $55,140 Six Family Members $63,180 If you would like to enroll for new coverage or change your existing coverage, complete an Application for Health Insurance Coverage for Uninsured Children and Adults and return it to: Capital BlueCross PO Box 772612 Harrisburg PA 17177-2612 Remember to sign and date your application before returning it to us. Incomplete applications will be returned. Do not send your payment with this application. If your application is approved, you will be billed for your first month s premium. Pay through your bank s bill payer program Capital BlueCross participates with most banks and credit unions to receive payments electronically from your financial institution. 1. Enroll in your bank s bill payer program 2. Add Capital BlueCross to your payee list 3. Follow your bank s instructions to set up a payment Check It Out An automated payment option that will deduct your premium directly from your bank account. Simply complete the enrollment form, attach a voided check for account confirmation, and return the information to Capital BlueCross. Visit capbluecross.com to download an enrollment form. Monthly Paper Billing Do not send your first payment with your application. You will receive a bill for your premium payment in the mail.
Thank you for considering Capital BlueCross If you have any questions about benefits, eligibility or completing the application, visit us online at capbluecross.com or call us at: 800.962.2242 (TTY 800.242.4816) Monday through Friday 8 a.m. to 6 p.m. Do you have a smart phone? Scan this barcode to automatically visit our website. /capbluecross @capbluecross capitalbluestore.com/blog Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. NF-774 (5/2013)