Blue Cross Blue Shield Solution 102, a Multi-State PlanSM … · 2017-01-17 · Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan documentat www.bcbstx.com/static/tx/pdf/policy-forms/2017/33602TX0780002-01.pdf or by calling 1-888-697-0683.

Why this Matters:AnswersImportant QuestionsYou must pay all the costs up to the deductible amount before this plan begins to pay for coveredservices you use. Check your policy or plan document to see when the deductible starts over

Network: $3,750 Individual/$11,250 Family.Out-of-Network: $15,000Individual/$45,000 Family.Doesn’t apply to non-specialtyprescription drugs, or to the

What is the overalldeductible?

(usually, but not always, January 1st). See the chart starting on page 3 for how much you payfor covered services after you meet the deductible.

following services fromParticipating providers: preventivecare, first two Primary care officevisits, urgent care, or mentalhealth/substance use disorderoffice visits. Copays andnon-specialty prescription drugcosts don’t count toward theoverall deductible.

You don't have to meet deductibles for specific services, but see the chart starting on page 3for other costs for services this plan covers.

No.Are there otherdeductibles for specificservices?

The out-of-pocket limit is the most you could pay during a coverage period (usually one year)for your share of the cost of covered services. This limit helps you plan for health care expenses.

Yes. Network: $6,500 Individual/$13,700 Family.Out-of-Network: UnlimitedIndividual/Unlimited Family.

Is there an out-of-pocketlimit on my expenses?

Even though you pay these expenses, they don't count toward the out-of-pocket limit.Premiums, balance-billed charges,and health care this plan doesn’tcover.

What is not included inthe out-of-pocket limit?

If you use an in-network doctor or other health care provider, this plan will pay some or all ofthe costs of covered services. Be aware, your in-network doctor or hospital may use an

Yes. For a list of Networkproviders please call1-888-697-0683 or see www.bcbstx.com.

Does this plan use anetwork of providers?

out-of-network provider for some services. Plans use the term in-network, preferred, orparticipating for providers in their network. See the chart starting on page 3 for how thisplan pays different kinds of providers.

1 of 9Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross Blue Shield Solution 102, a Multi-State PlanSM Coverage Period: 01/01/2017-12/31/2017Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: HMO

Why this Matters:AnswersImportant QuestionsThis plan will pay some or all of the costs to see a specialist for covered services but only if youhave the plan's permission before you see the specialist.

Yes. All specialist visits require aPCP referral unless it's for an OB/GYN or for emergency care.

Do I need a referral to seea specialist?

Some of the services this plan doesn't cover are listed on page 6. See your policy or plandocument for additional information about excluded services.

Yes.Are there services this plandoesn't cover?

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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the healthplan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven'tmet your deductible.The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowedamount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)The plan may encourage you to use Network providers by charging you lower deductibles, copayments, and coinsurance amounts.

Limitations & ExceptionsYour Cost If You Usean Out-of-Network

Provider

Your Cost If You Usea Network ProviderServices You May NeedCommon Medical Event

First two Network office visits are nocharge; deductible and coinsuranceapply for subsequent visits.

50% coinsurance20% coinsurancePrimary care visit to treat an injury or illness

If you visit a health careprovider’s office orclinic

---none---50% coinsurance20% coinsuranceSpecialist visitAcupuncture is not covered.Chiropractic care visit limit is 35 per

50% coinsurance20% coinsuranceOther practitioner office visit

benefit period including chiropracticservices for Rehabilitation andHabilitation services.---none---50% coinsuranceNo ChargePreventive care/screening/immunization

---none---

50% coinsuranceHospital – 40%coinsuranceNon-Hospital - 20%coinsurance

Diagnostic test (x-ray, blood work)

If you have a test50% coinsuranceHospital – 40%

coinsuranceNon-Hospital - 20%coinsurance

Imaging (CT / PET scans, MRIs)

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Provider


Lower copay applies at preferredParticipating pharmacies. One copay

Retail – 50%coinsurance plus $5copay/prescription

Retail – No Charge/$5 copay/prescriptionMail – No Charge

Preferred generic drugs

If you need drugs totreat your illness orcondition

per 30-day supply – up to a 90-daysupply for generic and brand drugs, up

More information aboutprescription drugcoverage is available athttps://www.myprime.com/content/dam/prime/memberportal/forms/AuthorForms/IVL/2017/2017_TX_5T_EX.pdf


Retail – $10/$15copay/prescriptionMail – $30 copay/prescription

Non-preferred generic drugs

to a 30-day supply for specialty drugs.Payment of the difference between thecost of a brand name drug and ageneric may also be required if ageneric drug is available. Certainwomen’s preventive services will becovered with no cost to the member.For Out-of-Network drug providers,you are responsible for 50% of the



Preferred brand drugs



Non-preferred brand drugs

eligible amount after the coinsuranceor copay.

50% coinsurance30% coinsuranceSpecialty drugsCopay is charged in addition to theoverall deductible. Elective abortion is

$1,500 copay/procedure plus 50%coinsurance

Hospital – $300copay/visit plus 40%coinsuranceNon-Hospital - $300copay/visit plus 20%coinsurance

Facility fee (e.g., ambulatory surgery center)

If you have outpatientsurgery

not covered except in limitedcircumstances. Preauthorizationrequired Out-of-Network; failure topreauthorize will result in reduction ordenial of benefits.50% coinsurance20% coinsurancePhysician/surgeon feesCopay is charged in addition to theoverall deductible and is waived ifadmitted.

$750 copay/visit plus20% coinsurance

$750 copay/visit plus20% coinsurance

Emergency room services

If you need immediatemedical attention

---none---20% coinsurance20% coinsuranceEmergency medical transportation50% coinsurance$20 copay/visitUrgent care

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Provider


Copay is charged in addition to theoverall deductible. Preauthorization

$1,500 copay/admitplus 50% coinsurance

$400 copay/admitplus 20% coinsurance

Facility fee (e.g., hospital room)

If you have a hospitalstay

required Out-of-Network; failure topreauthorize will result in reduction ordenial of benefits. Preauthorizationrequirement waived if admitted fromemergency room.---none---50% coinsurance20% coinsurancePhysician/surgeon feeOutpatient: Preauthorization requiredOut-of-Network for psychological

50% coinsuranceNo charge for officevisits or 20%

Mental/Behavioral health outpatient services

If you have mentalhealth, behavioralhealth, or substanceabuse needs

testing, neuropsychological testing,electroconvulsive therapy, repetitive

coinsurance for otheroutpatient services

transcranial magnetic stimulation,$1,500 copay/admitplus 50% coinsurance


Mental/Behavioral health inpatient servicesintensive outpatient treatment, andAutism Spectrum Disorder.; failure to50% coinsuranceNo charge for office

visits or 20%Substance use disorder outpatient services

preauthorize will result in reduction ordenial of benefits. Inpatient: Copay iscoinsurance for other

outpatient services charged in addition to the overalldeductible. Preauthorization required$1,500 copay/admit

plus 50% coinsurance$400 copay/admitplus 20% coinsurance

Substance use disorder inpatient servicesOut-of-Network; failure topreauthorize will result in reduction ordenial of benefits.No charge for first Participatingprenatal visit (per pregnancy) if one of

50% coinsurance20% coinsurancePrenatal and postnatal care

If you are pregnantfirst two office visits per benefit period;deductible and coinsurance apply forsubsequent visits.Copay is charged in addition to theoverall deductible.

$1,500 copay/admitplus 50% coinsurance


Delivery and all inpatient services

5 of 9


Provider


60 visit maximum per benefit period.50% coinsurance20% coinsuranceHome health care

If you need helprecovering or have otherspecial health needs

35 visit maximum per benefit periodcombined with Chiropractic care.

50% coinsurance20% coinsuranceRehabilitation services50% coinsurance20% coinsuranceHabilitation services

25 day maximum per benefit period.Preauthorization required

50% coinsurance20% coinsuranceSkilled nursing care

Out-of-Network; failure topreauthorize will result in reduction ordenial of benefits.---none---50% coinsurance20% coinsuranceDurable medical equipmentPreauthorization requiredOut-of-Network; failure to

50% coinsurance20% coinsuranceHospice service

preauthorize will result in reduction ordenial of benefits.One visit per year. Reimbursed up to$30 out-of-network. See benefitbooklet for network details.

No ChargeNo ChargeEye exam

If your child needsdental or eye care

One pair of glasses per year. Up to$150 in-network. Reimbursed up to

No ChargeNo ChargeGlasses

$75 frames/$25 single vision lensesout-of-network. See benefit bookletfor network details.---none---Not CoveredNot CoveredDental check-up

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)Routine eye care (Adult)Infertility treatmentAbortions (except where a pregnancy is the result

of rape or incest, or for a pregnancy which, ascertified by a physician, places the woman in dangerof death unless an abortion is performed)

Routine foot care (Except in connection withdiabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)

Long-term careNon-emergency care when traveling outside theU.S.

Acupuncture Private-duty nursing (Except when determined tobe Medically Necessary and ordered or authorizedby the PCP)

Bariatric surgeryWeight loss programsDental Care (Adult and Child)

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Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)Hearing aids (Limited to one for each ear everythree years)

Cosmetic surgery (Only for the correction ofcongenital deformities or for conditions resultingfrom accidental injuries, scars, tumors or diseases.When Medically Necessary.)

Chiropractic care

Your Rights to Continue Coverage:

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions,however, such as if:

You commit fraudThe insurer stops offering services in the StateYou move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at 1-888-697-0683. You may also contact your state insurance department athttp://www.tdi.texas.gov..

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions aboutyour rights, this notice, or assistance, you can contact: Texas Department of Insurance at (800) 578-4677 or visit www.tdi.texas.gov. The MSP Program ExternalReview Process enables every MSP enrollee to obtain an additional, independent level of review of any adverse benefit determination. More information is availableat http://www.opm.gov/healthcare-insurance/multi-state-plan-program/external-review/. You may also call OPM toll free at (855) 318-0714 if you needhelp with your request for External Review.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provideminimum essential coverage.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-888-697-0683.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-697-0683.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-697-0683.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-697-0683.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

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About These CoverageExamples:

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

Having a baby(normal delivery)

Amount owed to providers: $7,540 Amount owed to providers: $5,400These examples show how this plan might covermedical care in given situations. Use these Plan pays $2,920Plan pays $2,840

Patient pays $4,700 Patient pays $2,480examples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.

Sample care costs:Sample care costs:$2,900Prescriptions$2,700Hospital charges (mother)$1,300Medical Equipment and Supplies$2,100Routine obstetric care

This is not acostestimator.

$700Office Visits and Procedures$900Hospital charges (baby)$300Education$900Anesthesia$100Laboratory tests$500Laboratory tests$100Vaccines, other preventive$200Prescriptions

$5,400Total$200RadiologyDon’t use these examples toestimate your actual costs under $40Vaccines, other preventive

$7,540Total Patient pays:the plan. The actual care youreceive will be different from these $2,400Deductibles

$0CopaysPatient pays:examples, and the cost of that carealso will be different. $3,800Deductibles $0Coinsurance

$0Copays $80Limits or exclusionsSee the next page for importantinformation about these examples.

$2,480Total$700Coinsurance$200Limits or exclusions

$4,700Total

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Questions and answers about Coverage Examples:

What are some of the assumptionsbehind the Coverage Examples?

Costs don’t include premiums.Sample care costs are based on nationalaverages supplied by the U.S. Department ofHealth and Human Services, and aren’tspecific to a particular geographic area orhealth plan.The patient’s condition was not an excludedor preexisting condition.All services and treatments started and endedin the same coverage period.There are no other medical expenses for anymember covered under this plan.Out-of-pocket expenses are based only ontreating the condition in the example.The patient received all care from in-networkproviders. If the patient had received carefrom out-of-network providers, costs wouldhave been higher.

What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. It alsohelps you see what expenses might be left up toyou to pay because the service or treatment isn’tcovered or payment is limited.

Does the Coverage Examplepredict my own care needs?

No. Treatments shown are just examples. Thecare you would receive for this condition couldbe different based on your doctor’s advice,your age, how serious your condition is, andmany other factors.

Does the Coverage Examplepredict my future expenses?

No. Coverage Examples are not costestimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Your owncosts will be different depending on the careyou receive, the prices your providers charge,and the reimbursement your health planallows.

Can I use Coverage Examples tocompare plans?

Yes. When you look at the Summary ofBenefits and Coverage for other plans, you’llfind the same Coverage Examples. When youcompare plans, check the “Patient Pays” boxin each example. The smaller that number,the more coverage the plan provides.

Are there other costs I shouldconsider when comparing plans?

Yes. An important cost is the premium youpay. Generally, the lower your premium, themore you’ll pay in out-of-pocket costs, suchas copayments, deductibles, and coinsurance.You should also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements (FSAs)or health reimbursement accounts (HRAs)that help you pay out-of-pocket expenses.

9 of 10Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.

If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 888-697-0683

العربيةArabic

مترجم فوري، اتصل على الرقم إن كان لديك أو لدى شخص تساعده أسئلة، فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع

0683-697-888.

繁體中文 Chinese

如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助和訊息。洽詢一位翻譯員, 請撥電話號碼

888-697-0683.

Français French

Si vous, ou quelqu’un que vous êtes en train d’aider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 888-697-0683.

Deutsch German

Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 888-697-0683 an.

ગજુરાતી Gujarati

જો તમને અથવા તમે મદદ કરી રહ્યા હોય એવી કોઈ બીજી વ્યક્તતને એસ.બી.એમ. કાયયક્રમ બાબતે પ્રશ્નો હોય, તો તમને વવના ખરે્ચ, તમારી ભાષામાાં મદદ અને માહહતી મેળવવાનો હક્ક છે. દુભાવષયા સાથે વાત કરવા માટે આ નાંબર 888-697-0683 પર કૉલ કરો.

ह िंदी Hindi

यहद आपके, या आप जिसकी स ायता कर र े ैं उसके, प्रश्न ैं, तो आपको अपनी भाषा में ननिःशुल्क स ायता और िानकारी प्राप्त करने का अधिकार

ै। ककसी अनुवादक से बात करने के लिए 888-697-0683 पर कॉि करें।.

日本語 Japanese

ご本人様、またはお客様の身の回りの方でも、ご質問がございましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場合、888-697-0683 までお電話ください。

한국어 Korean

만약 귀하 또는 귀하가 돕는 사람이 질문이 있다면 귀하는 무료로 그러한 도움과 정보를 귀하의 언어로 받을 수 있는 권리가

있습니다. 통역사가 필요하시면 888-697-0683 로 전화하십시오.

ພາສາລາວ

Laotian

ຖ້າທ້ານ້ຫ້້້ຄ້ນທ້້ທ້ານກ້າລ້ງໃຫ້ການຊ້ວຍເຫ້້ອມ້ຄ້າຖາມ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ , ທ້ານມ້ສ້ດຂ້ເອ້າການຊ້ວຍເຫ້້ອ້ແລະ້ຂ້້້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້້ ້ ້ ້້ ້ມ້ນເປ້ນນພາສາຂອງທ້ານໄດ້ໂດຍບ້້ມ້ຄ້າໃຊ້ຈ້າຍ.້ເພ້້ອລ້ມກ້ບນາຍແປພາສາ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້້້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ ້ , ໃຫ້ໂທຫາເບ້້້ ້ ້ ້ ້ ້ ້ ້ ້888-697-0683.

Diné Navajo

T’11 ni, 47 doodago [a’da b7k1 an1n7lwo’7g77, na’7d7[kidgo, ts’7d1 bee n1 ah00ti’i’ t’11 n77k’e n7k1 a’doolwo[ d00 b7na’7d7[kid7g77 bee ni[

hodoonih. Ata’dahalne’7g77 bich’8’ hod77lnih kwe’4 888-697-0683.

bcbstx.com

فارسیPersian

گفتگو با يک جهت. فت نماييداگر شما، يا کسی که شما به او کمک مي کنيد، سؤالی داشته باشيد، حق اين را داريد که به زبان خود، به طور رايگان کمک و اطالعات دريا

.تماس حاصل نماييد 0683-697-888مترجم شفاهی،با شمار

Русский Russian

Если у вас или человека, которому вы помогаете, возникли вопросы, у вас есть право на бесплатную помощь и информацию, предоставленную на вашем языке. Чтобы связаться с переводчиком, позвоните по телефону 888-697-0683.

Español Spanish

Si usted o alguien a quien usted está ayudando tiene preguntas, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 888-697-0683.

Tagalog Tagalog

Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa 888-697-0683.

اردوUrdu

سے مترجم ہے۔ حق كا كرنے حاصل معلومات اور مدد مفت ميں زبان اپنی كو آپ تو، ہے درپيش سوال كوئی ہيں، كررہے مدد آپ كی جس كو فرد ايسے كسی يا كو، آپ اگر كريں۔ كال پر 0683-697-888 ليے، كے كرنے بات

Tiếng Việt Vietnamese

Nếu quý vị, hoặc người mà quý vị đang giúp đỡ, có câu hỏi, thì quý vị có quyền được giúp và nhận thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 888-697-0683.

Documents

Blue Cross Blue Shield Solution 102, a Multi-State PlanSM … · 2017-01-17 · Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when