go with
^
Providence OptionPLUS HMO plan
Access+ HMO plan
Effective January 1, 2014
ii Blue Shield of California
Go with the plan
that’s right for you
When you go with Blue Shield,
you’re on your way to quality health coverage, large
provider networks, and a wide range of proven programs and services that help you
get the most value from your coverage.
In this booklet, you’ll find the information you need to choose the right health plan
for you and your family, including:
Plan benefits and features
Additional programs and services
available to Blue Shield members
How to find a doctor
Get health plan information anytime, anywhere!
• From a smartphone members can check plan coverage, download their
Blue Shield member ID card, get directions to the nearest urgent care center,
and more. Just enter blueshieldca.com into the mobile browser.
• Our Member Center gives Blue Shield members instant access to their
entire family’s Blue Shield health coverage information from one account.
Just go to blueshieldca.com/providence and select Log in.
• To learn more about Blue Shield through inspiring stories shared by our
members, visit blueshieldca.com/memberstories.
1
Plan choices
During the 2014 open enrollment period, Providence is
offering two HMO plans: Providence OptionPLUS HMO
plan and the Blue Shield Access+ HMO
®plan.
Both HMO plans offer the same comprehensive
Blue Shield benefits and value-added programs and
services. With both plans you’ll need to select your
Personal Physician (primary care physician), who is
responsible for the overall coordination of your care. You
also have the option to self-refer to a specialist within
your Personal Physician’s medical group or Independent
Practice Association (IPA) for a higher copayment using
the Access+ Specialist* referral feature.
The difference between the plans is the provider
network. If you enroll in the Providence OptionPLUS
HMO plan, you will have access to a smaller, specially
selected network of Providence-affiliated medical
groups and affiliated Personal Physicians and specialists
than are available in the Access+ HMO plan. Below
is a list of the Providence Southern California acute
care hospitals that are also included in the Providence
OptionPLUS HMO network:
• Providence Little Company of Mary Medical Center
Torrance
• Providence Little Company of Mary Medical Center
San Pedro
• Providence Holy Cross Medical Center
• Providence Tarzana Medical Center
• Providence Saint Joseph Medical Center
Enrolling in the Blue Shield Access+ HMO or
Providence OptionPLUS HMO plan
When you enroll in either of the HMO plans for the first
time, you will need to select your Personal Physician
(primary care physician), who will be responsible for the
overall coordination of your care, for yourself and your
enrolled dependents. You have the option to choose a
different Personal Physician and medical group for each
enrolled family member. To find out if your doctor is in
the Access+ HMO network, you can search online by
following the steps on page 4.
If you do not select a Personal Physician at the time
of enrollment, Blue Shield will automatically assign a
Personal Physician to you and your enrolled family
members. You can change your Personal Physician by
calling Blue Shield Member Services at (888) 235-1765.
Blue Shield is driven to offering
you the right choices for your
healthcare coverage
*
If your personal physician participates in our access+ specialist program, you may go directly to a specialist in your personal physician’s medical group or ipa without a referral, for a slightly higher copayment. Medical groups and ipas that participate in the access+ specialist program are designated with an a+ in our online and printed directories and on your blue shield member id card.Open enrollment often brings up lots of questions about health plans and
benefits. If you have questions, we’ve got answers. Team Shield is your
dedicated team of experts ready to help you get the right answers, right away.
If you don’t understand particular aspects of your medical coverage, or how
to access all the benefits of your health plan, you can go online and post a
question. We’ll try to find the answers when you need them.
Connect with Team Shield on Facebook or on Twitter @teamshieldbsc.
team
2 Blue Shield of California
Behavioral health benefits
The behavioral health benefits for the Blue Shield
Access+ and Providence OptionPLUS HMO plans include
inpatient and outpatient mental health and substance
abuse care for issues such as:
• Depression
• Alcohol/drug abuse
• Mental illness
• Marriage and family counseling
The services are provided by Blue Shield’s mental health
service administrator (MHSA) network. HMO members
only have access to MHSA network providers.
Care away from home
Through the BlueCard® Program, Blue Shield Access+
and Providence OptionPLUS HMO members can access
emergency and urgent care services across the country
and around the world. You can receive urgent care
services from any provider; however, using the BlueCard
Program can be more cost-effective and eliminate
the need for you to pay for the services when they are
rendered and submit a claim for reimbursement. You
can locate a BlueCard provider at any time by calling
(800) 810-BLUE or by going to the Find a Provider section
of blueshieldca.com.
The Away From Home Care® program gives students,
long-term travelers, workers on extended out-of-state
assignments, and families living apart the convenience
and flexibility of coverage for extended periods across
the country. To learn more about Away From Home
Care and whether your family is eligible, call your
Blue Shield Member Services team at (888) 235-1765.
Please note that Away From Home Care is not available
in all areas and states, and benefits from the host
plan may differ from the Access+ HMO or Providence
OptionPLUS HMO plan.
A website designed just for you!
You have convenient 24-hour access to
information about your health benefits
at blueshieldca.com/providence. Here
you can find a wide range of resources
in one centralized location, including:
• Medical Benefits – Learn about your
medical plan features and benefits.
• Find a Provider – Search for doctors
and hospitals easily.
• NurseHelp 24/7
SM– Get health advice
from a registered nurse day or night.
• Programs and Services – Find information
on programs and services including
prenatal and condition management.
Visit blueshieldca.com/providence today!
blueshieldca.com/providence 3
To learn more about these plans, please
see the benefit summaries that begin
on page 7.
Providence OptionPLUS
HMO plan and Access+
HMO plan benefits
Providence OptionPLUS HMO plan and Access+ HMO plan
Annual deductible
None
Annual out-of-pocket maximum
or copayment maximum
$1,500 per individual/$4,500 per family
Member copayment
Physician office visit
$15 per visit
Specialist office visit
$15 per physician and specialist office visit
$30 per Access+ Specialist visit*
Preventive health benefits
No charge
Pregnancy and maternity
care benefits
†No charge
†Outpatient X-ray, pathology,
and laboratory
No charge
Hospital care
(inpatient non-emergency facility services)
No charge at a Providence Health facility
20% per admission for all other facilities
Rehabilitation benefits
(physical, occupational and
respiratory therapy)
$15 per visit
Emergency room services
(not resulting in admission)
$150 per visit
Mental health and substance abuse
(outpatient physician visit)
$15 per visit
* To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by an MHSA network participating provider.
6 Blue Shield of California
Search for a network provider online
It’s fast and easy to find a network provider online:
• Go to blueshieldca.com/providence.
• Select Find a Provider.
• Choose the type of provider you would like
to search for.
How to find a Personal Physician
(Primary Care Physician)
Go to blueshieldca.com/providence and choose Find a
Provider
. Follow the instructions listed under the Access+
HMO or Providence OptionPLUS HMO plan.
Find out your provider’s quality
of care rankings
You can easily access quality scores, efficiency
indicators, patient satisfaction scores, and cost
information for many individual physicians, HMO medical
groups, and hospitals. To see a provider’s performance
profile, simply click on the name of the doctor, HMO
medical group, or hospital from your search results.
Find a network provider
If you don’t have access to the Internet or
need help, simply contact your dedicated
Blue Shield Member Services team at
(888) 235-1765 for personal assistance
blueshieldca.com/providence 5
Your green light to added benefits,
programs, and services
As a member, you can find more information about these programs by going to blueshieldca.com/providence and
selecting Log in. If you don’t have a username and password, you can select Register for an online account.
NurseHelp 24/7 – Speak with registered nurses anytime,
day or night, and get answers to your health-related
questions, or go online to have a one-on-one personal
chat with a registered nurse anytime. The NurseHelp
24/7
SMphone number is conveniently located on the
back of your member ID card.
LifeReferrals 24/7 – Call anytime to talk with a team
of experienced professionals ready to assist you with
personal, family, and work issues. Get referrals for three
face-to-face visits (in a six-month period) with a licensed
therapist at no cost to you (available only in California).
Telephonic counseling sessions with a licensed therapist
are available for members outside of California. The
LifeReferrals 24/7
SMphone number is located on the back
of your member ID card.
Prenatal Program – This program gives expectant
parents 24/7 access to experienced maternity nurses
as well as prenatal information including a popular
pregnancy or parenting book at no additional cost.
Some materials are also available in Spanish.
Condition management programs – These programs
offer nurse support as well as education and
self-management tools for members with asthma, diabetes,
coronary artery disease, heart failure, and chronic
obstructive pulmonary disease.
Wellness discount programs – Blue Shield offers a variety
of member discounts on popular weight loss, fitness,
vision, and health and wellness programs
1that can help
you save money and get healthier.
• 24 Hour Fitness – Enjoy waived enrollment,
processing, and initiation fees and discounts
on monthly membership dues.
• Weight Watchers – Get discounts on three- and
12-month subscriptions, monthly passes, and
at-home kits.
• ClubSport and Renaissance ClubSport – Obtain a 60%
discount on enrollments when joining with a
month-to-month agreement. Enrollment fees are waived
when joining with a 12-month agreement. (There is a
one-time $25 processing fee when you enroll.)
• Alternative Care Discount Program – Get 25% off
usual and customary fees for acupuncture, massage
therapy, and chiropractic services, plus get discounts
on health and wellness products, with free shipping
on most items.
• Discount Provider Network
2– Take 20% off the
published retail prices when you use a participating
provider in the Discount Vision Program network for
exams, frames, lenses,
and more.
• MESVision Optics –Take advantage of competitive
prices on contact lenses,
3sunglasses, readers, and
eyecare accessories, with free shipping on orders
over $50.
• QualSight LASIK – Save on LASIK surgery at more than
45 surgery centers in California. Services include
pre-screening, a pre-operative exam, and
post-operative visits.
• NVISION Laser Eye Centers – Receive a 15% discount
on LASIK surgery from experienced surgeons with
offices in Southern California and Sacramento.
• My2020EyesDirect – Get a 20% discount on
6 Blue Shield of California
1 These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. Discount program services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan.
The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products.
Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program.
Members who are not satisfied with products or services received from the discount program may use Blue Shield’s grievance process described in the Grievance Process section of the Evidence of Coverage. Blue Shield reserves the right to terminate this program at any time without notice.
Discount programs administered by or arranged through the following independent companies:
• Alternative Care Discount Program – American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc. • Discount Provider Network and MESVisionOptics.com – MESVision
• Weight control – Weight Watchers North America
• Fitness facilities – 24 Hour Fitness, ClubSport, and Renaissance ClubSport
• LASIK – Laser Eye Care of California, LLC; QualSight, Inc.; and NVISION Laser Eye Centers • My2020EyesDirect.com – Advanced Digital Eyewear Inc.
Note: No genetic information, including family medical history, is gathered, shared, or used from these programs.
2 The Discount Provider Network is available throughout California. Coverage in other states may be limited. Find participating providers by going to blueshieldca.com/fap.
3 Requires a prescription from your doctor or licensed optical professional.
Providence OptionPLUS HMO
®
Plan
Benefit Summary (For groups of 300 and above)
(Uniform Health Plan Benefits and Coverage Matrix)
THIS MATRIX IS INTENDED TO BE USED TO HELP
YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE
AND PLAN CONTRACT SHOULD BE CONSULTED FOR
A DETAILED DESCRIPTION OF COVERAGE BENEFITS
AND LIMITATIONS.
Blue Shield of California
Effective January 1, 2014
Calendar Year Facility Deductible
None
Calendar Year Copayment Maximum
(For many covered services)$1,500 per Individual /
$4,500 per Family
LIFETIME BENEFIT MAXIMUM
None
Covered Services
Member Copayment
PROFESSIONAL SERVICES
Professional (Physician) Benefits
•
Physician and specialist office visits
(Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services)
$15 per visit
•
Outpatient X-ray, pathology and laboratory
No Charge
Allergy Testing and Treatment Benefits
•
Office visits (includes visits for allergy serum injections)
$15 per visit
Access+ Specialist
SMBenefits
2•
Office visit, Examination or Other Consultation
(Self-referred office visits and consultationsonly)
$30 per visit
Preventive Health Benefits
•
Preventive Health Services
(As required by applicable federal and California law.)No Charge
OUTPATIENT SERVICES
Hospital Benefits (Facility Services)
•
Outpatient surgery performed at an Ambulatory Surgery Center
3No Charge
•
Outpatient surgery in a hospital
No Charge
•
Outpatient Services for treatment of illness or injury and necessary supplies
(Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")
No Charge
HOSPITALIZATION SERVICES
Hospital Benefits (Facility Services)
•
Inpatient Physician Services
No Charge
•
Inpatient Non-emergency Providence Health Facility Services
(Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)•
Inpatient Non-emergency Facility Services
(Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)No Charge
20% per admission
•
Inpatient Medically Necessary skilled nursing Services including Subacute Care at
a Providence Health Facility
4•
Inpatient Medically Necessary skilled nursing Services including Subacute Care
4, 5No Charge
20% per admission
EMERGENCY HEALTH COVERAGE
•
Emergency room facility services
(The ER copayment does not apply if the member is directlyadmitted to the hospital for inpatient services)
$150 per visit
•
Emergency room Physician Services
No Charge
AMBULANCE SERVICES
Review benefit summaries
Providence OptionPLUS HMO
®
Plan
Benefit Summary (For groups of 300 and above)
(Uniform Health Plan Benefits and Coverage Matrix)
THIS MATRIX IS INTENDED TO BE USED TO HELP
YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE
AND PLAN CONTRACT SHOULD BE CONSULTED FOR
A DETAILED DESCRIPTION OF COVERAGE BENEFITS
AND LIMITATIONS.
Blue Shield of California
Effective January 1, 2014
Calendar Year Facility Deductible
None
Calendar Year Copayment Maximum
(For many covered services)$1,500 per Individual /
$4,500 per Family
LIFETIME BENEFIT MAXIMUM
None
Covered Services
Member Copayment
PROFESSIONAL SERVICES
Professional (Physician) Benefits
•
Physician and specialist office visits
(Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services)
$15 per visit
•
Outpatient X-ray, pathology and laboratory
No Charge
Allergy Testing and Treatment Benefits
•
Office visits (includes visits for allergy serum injections)
$15 per visit
Access+ Specialist
SMBenefits
2•
Office visit, Examination or Other Consultation
(Self-referred office visits and consultationsonly)
$30 per visit
Preventive Health Benefits
•
Preventive Health Services
(As required by applicable federal and California law.)No Charge
OUTPATIENT SERVICES
Hospital Benefits (Facility Services)
•
Outpatient surgery performed at an Ambulatory Surgery Center
3No Charge
•
Outpatient surgery in a hospital
No Charge
•
Outpatient Services for treatment of illness or injury and necessary supplies
(Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")
No Charge
HOSPITALIZATION SERVICES
Hospital Benefits (Facility Services)
•
Inpatient Physician Services
No Charge
•
Inpatient Non-emergency Providence Health Facility Services
(Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)•
Inpatient Non-emergency Facility Services
(Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)No Charge
20% per admission
•
Inpatient Medically Necessary skilled nursing Services including Subacute Care at
a Providence Health Facility
4•
Inpatient Medically Necessary skilled nursing Services including Subacute Care
4, 5No Charge
20% per admission
EMERGENCY HEALTH COVERAGE
•
Emergency room facility services
(The ER copayment does not apply if the member is directlyadmitted to the hospital for inpatient services)
$150 per visit
•
Emergency room Physician Services
No Charge
AMBULANCE SERVICES
•
Emergency or authorized transport
No Charge
8 Blue Shield of California
Covered Services
Member Copayment
PRESCRIPTION DRUG COVERAGE
Outpatient Prescription Drug Benefits
Provided by Express Scripts
(800) 711-0917
PROSTHETICS/ORTHOTICS
•
Prosthetic equipment and devices
(Separate office visit copay may apply)No Charge
•
Orthotic equipment and devices
(Separate office visit copay may apply)No Charge
DURABLE MEDICAL EQUIPMENT
•
Breast pump
No Charge
•
Other Durable Medical Equipment
(member share is based upon allowed charges)No Charge
MENTAL HEALTH SERVICES (PSYCHIATRIC)
6•
Inpatient Hospital Services
No Charge
•
Outpatient Mental Health Services
$15 per visit
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)
7Please see footnote 9
•
Chemical dependency and substance abuse services
Not Covered
HOME HEALTH SERVICES
•
Home health care agency Services
(up to 100 visits per Calendar Year)$15 per visit
•
Medical supplies
(See "Prescription Drug Coverage" for specialty drugs)No Charge
OTHER
Hospice Program Benefits
•
Routine home care
No Charge
•
Inpatient Respite Care
No Charge
•
24-hour Continuous Home Care
No Charge
•
General Inpatient care
No Charge
Pregnancy and Maternity Care Benefits
•
Prenatal and postnatal Physician office visits
(For inpatient hospital services, see "Hospitalization Services.")
No Charge
Family Planning and Infertility Benefits
•
Counseling and consulting
8No Charge
•
Infertility Services
(member share is based upon allowed charges)(Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT).
50%
•
Tubal ligation
Not Covered
•
Elective abortion
Not Covered
•
Vasectomy
Not Covered
Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy)
•
Office location
(Copayment applies to all places of services, including professional and facility settings)$15 per visit
Speech Therapy Benefits
•
Office Visit - Services by licensed speech therapists
(Copayment applies to all places ofservices, including professional and facility settings)
$15 per visit
Diabetes Care Benefits
•
Devices, equipment, and non-testing supplies
(member share is based upon allowed charges)No Charge
•
Diabetes self-management training
(by a registered dietician or registered nurse that are certifieddiabetes educators)
$15 per visit
Hearing Aid Benefits
•
Hearing examination
•
Hearing aid and ancillary equipment
(Plan payment up to maximum of $5,000 per member every 24 months)$15 per visit
No Charge
Urgent Care Benefits
(BlueCard® Program)•
Urgent Services outside your Personal Physician Service Area
$15 per visit
Optional Benefits
1Optional dental, vision, hearing aid, infertility, substance abuse, chiropractic or chiropractic and acupuncture
benefits are available. If your employer purchased any of these benefits, a description of the benefit is
provided separately.
Plan designs may be modified to ensure compliance with state and federal requirements.
A15818 (1/14)
ML091313 BH092013 BH092413 ML092613 BH1001013
1 Copayments/Coinsurance marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments/Coinsurance and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. This amount could be substantial. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.
2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider.
3 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits.
4 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met.
5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of
severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract. 7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization
services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield HMO providers. 8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women.
9 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as
"Additional Substance Abuse Treatment Benefits."
10 Blue Shield of California
Providence OptionPLUS HMO plan
Substance Abuse Treatment Benefits
Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix)
How the Plan Works
In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional
(physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial
hospitalization/day treatment.
1All services must be medically necessary. Blue Shield of California has contracted with a
Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these
services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of
California does not provide benefits for services provided by non-participating providers.
Coverage Details
Residential care is not covered.
Covered Services
Member Copayment
2MHSA Participating Provider
Inpatient Hospitalization No Charge
Professional (Physician) Services - Inpatient and Outpatient Physician Visit
Physician Visit Copay Applies
Partial Hospitalization/Day Treatment Ambulatory Surgery Copay Applies
1.
Except for emergencies, benefits are covered only when pre-authorized by the MHSA.2.
Please refer to the Medical Benefit Summary for applicable copayment responsibility.This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and
Evidence of Coverage for the exact terms and conditions of coverage.
Access+ HMO
®
Plan
Benefit Summary (For groups of 300 and above)
(Uniform Health Plan Benefits and Coverage Matrix)
THIS MATRIX IS INTENDED TO BE USED TO HELP
YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE
AND PLAN CONTRACT SHOULD BE CONSULTED FOR
A DETAILED DESCRIPTION OF COVERAGE BENEFITS
AND LIMITATIONS.
Blue Shield of California
Effective January 1, 2014
Calendar Year Facility Deductible
None
Calendar Year Copayment Maximum
(For many covered services)$1,500 per Individual /
$4,500 per Family
LIFETIME BENEFIT MAXIMUM
None
Covered Services
Member Copayment
PROFESSIONAL SERVICES
Professional (Physician) Benefits
•
Physician and specialist office visits
(Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services)
$15 per visit
•
Outpatient X-ray, pathology and laboratory
No Charge
Allergy Testing and Treatment Benefits
•
Office visits (includes visits for allergy serum injections)
$15 per visit
Access+ Specialist
SMBenefits
2•
Office visit, Examination or Other Consultation
(Self-referred office visits and consultationsonly)
$30 per visit
Preventive Health Benefits
•
Preventive Health Services
(As required by applicable federal and California law.)No Charge
OUTPATIENT SERVICES
Hospital Benefits (Facility Services)
•
Outpatient surgery performed at an Ambulatory Surgery Center
3No Charge
•
Outpatient surgery in a hospital
No Charge
•
Outpatient Services for treatment of illness or injury and necessary supplies
(Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")
No Charge
HOSPITALIZATION SERVICES
Hospital Benefits (Facility Services)
•
Inpatient Physician Services
•
Inpatient Non-emergency Providence Health Facility Services
(Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)No Charge
No Charge
•
Inpatient Non-emergency Facility Services
(Semi-private room and board, andmedically-necessary Services and supplies, including Subacute Care)
20% per admission
•
Inpatient Medically Necessary skilled nursing Services including Subacute Care at
a Providence Health Facility
4No Charge
•
Inpatient Medically Necessary skilled nursing Services including Subacute Care
4, 520% per admission
EMERGENCY HEALTH COVERAGE
•
Emergency room facility services
(The ER copayment does not apply if the member is directlyadmitted to the hospital for inpatient services)
$150 per visit
•
Emergency room Physician Services
No Charge
AMBULANCE SERVICES
•
Emergency or authorized transport
No Charge
PRESCRIPTION DRUG COVERAGE
Outpatient Prescription Drug Benefits
Provided by Express Scripts
(800) 711-0917
PROSTHETICS/ORTHOTICS
•
Prosthetic equipment and devices
(Separate office visit copay may apply)No Charge
•
Orthotic equipment and devices
(Separate office visit copay may apply)No Charge
Access+ HMO
®
Plan
Benefit Summary (For groups of 300 and above)
(Uniform Health Plan Benefits and Coverage Matrix)
THIS MATRIX IS INTENDED TO BE USED TO HELP
YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE
AND PLAN CONTRACT SHOULD BE CONSULTED FOR
A DETAILED DESCRIPTION OF COVERAGE BENEFITS
AND LIMITATIONS.
Blue Shield of California
Effective January 1, 2014
Calendar Year Facility Deductible
None
Calendar Year Copayment Maximum
(For many covered services)$1,500 per Individual /
$4,500 per Family
LIFETIME BENEFIT MAXIMUM
None
Covered Services
Member Copayment
PROFESSIONAL SERVICES
Professional (Physician) Benefits
•
Physician and specialist office visits
(Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services)
$15 per visit
•
Outpatient X-ray, pathology and laboratory
No Charge
Allergy Testing and Treatment Benefits
•
Office visits (includes visits for allergy serum injections)
$15 per visit
Access+ Specialist
SMBenefits
2•
Office visit, Examination or Other Consultation
(Self-referred office visits and consultationsonly)
$30 per visit
Preventive Health Benefits
•
Preventive Health Services
(As required by applicable federal and California law.)No Charge
OUTPATIENT SERVICES
Hospital Benefits (Facility Services)
•
Outpatient surgery performed at an Ambulatory Surgery Center
3No Charge
•
Outpatient surgery in a hospital
No Charge
•
Outpatient Services for treatment of illness or injury and necessary supplies
(Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")
No Charge
HOSPITALIZATION SERVICES
Hospital Benefits (Facility Services)
•
Inpatient Physician Services
•
Inpatient Non-emergency Providence Health Facility Services
(Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)No Charge
No Charge
•
Inpatient Non-emergency Facility Services
(Semi-private room and board, andmedically-necessary Services and supplies, including Subacute Care)
20% per admission
•
Inpatient Medically Necessary skilled nursing Services including Subacute Care at
a Providence Health Facility
4No Charge
•
Inpatient Medically Necessary skilled nursing Services including Subacute Care
4, 520% per admission
EMERGENCY HEALTH COVERAGE
•
Emergency room facility services
(The ER copayment does not apply if the member is directlyadmitted to the hospital for inpatient services)
$150 per visit
•
Emergency room Physician Services
No Charge
AMBULANCE SERVICES
•
Emergency or authorized transport
No Charge
PRESCRIPTION DRUG COVERAGE
Outpatient Prescription Drug Benefits
Provided by Express Scripts
(800) 711-0917
PROSTHETICS/ORTHOTICS
•
Prosthetic equipment and devices
(Separate office visit copay may apply)No Charge
•
Orthotic equipment and devices
(Separate office visit copay may apply)No Charge
12 Blue Shield of California
Covered Services
Member Copayment
DURABLE MEDICAL EQUIPMENT
•
Breast pump
No Charge
•
Other Durable Medical Equipment
(member share is based upon allowed charges)No Charge
MENTAL HEALTH SERVICES (PSYCHIATRIC)
6•
Inpatient Hospital Services
No Charge
•
Outpatient Mental Health Services
$15 per visit
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)
7Please see footnote 9
•
Chemical dependency and substance abuse services
Not Covered
HOME HEALTH SERVICES
•
Home health care agency Services
(up to 100 visits per Calendar Year)$15 per visit
•
Medical supplies
(See "Prescription Drug Coverage" for specialty drugs)No Charge
OTHER
Hospice Program Benefits
•
Routine home care
No Charge
•
Inpatient Respite Care
No Charge
•
24-hour Continuous Home Care
No Charge
•
General Inpatient care
No Charge
Pregnancy and Maternity Care Benefits
•
Prenatal and postnatal Physician office visits
(For inpatient hospital services, see "Hospitalization Services.")
No Charge
Family Planning and Infertility Benefits
•
Counseling and consulting
8No Charge
•
Infertility Services
(member share is based upon allowed charges)(Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT).
50%
•
Tubal ligation
Not Covered
•
Elective abortion
Not Covered
•
Vasectomy
Not Covered
Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy)
•
Office location
(Copayment applies to all places of services, including professional and facility settings)$15 per visit
Speech Therapy Benefits
•
Office Visit - Services by licensed speech therapists
(Copayment applies to all places ofservices, including professional and facility settings)
$15 per visit
Diabetes Care Benefits
•
Devices, equipment, and non-testing supplies
(member share is based upon allowed charges)No Charge
•
Diabetes self-management training
(by a registered dietician or registered nurse that are certifieddiabetes educators)
$15 per visit
Hearing Aid Benefits
•
Hearing examination
•
Hearing aid and ancillary equipment
(Plan payment up to maximum of $5,000 per member every 24 months)$15 per visit
No Charge
Urgent Care Benefits
(BlueCard® Program)•
Urgent Services outside your Personal Physician Service Area
$15 per visit
Optional Benefits
1Optional dental, vision, hearing aid, infertility, substance abuse, chiropractic or chiropractic and acupuncture
benefits are available. If your employer purchased any of these benefits, a description of the benefit is
provided separately.
Plan designs may be modified to ensure compliance with state and federal requirements.
A15818 (1/14)
ML091313 BH092013 BH092413 ML092613
1 Copayments/Coinsurance marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments/Coinsurance and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. This amount could be substantial. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.
2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider.
3 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits.
4 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met.
5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of
severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract. 7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization
services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield HMO providers. 8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women.
9 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as
Plan designs may be modified to ensure compliance with state and federal requirements.
A15818 (1/14)
ML091313 BH092013 BH092413 ML092613
1 Copayments/Coinsurance marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments/Coinsurance and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. This amount could be substantial. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.
2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider.
3 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits.
4 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met.
5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of
severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract. 7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization
services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield HMO providers. 8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women.
9 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as
"Additional Substance Abuse Treatment Benefits."
14 Blue Shield of California
Access+ HMO Plan
Substance Abuse Treatment Benefits
Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix)
How the Plan Works
In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional
(physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial
hospitalization/day treatment.
1All services must be medically necessary. Blue Shield of California has contracted with a
Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these
services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of
California does not provide benefits for services provided by non-participating providers.
Coverage Details
Residential care is not covered.
Covered Services
Member Copayment
2MHSA Participating Provider
Inpatient Hospitalization No Charge
Professional (Physician) Services - Inpatient and Outpatient Physician Visit
Physician Visit Copay Applies
Partial Hospitalization/Day Treatment Ambulatory Surgery Copay Applies
1.
Except for emergencies, benefits are covered only when pre-authorized by the MHSA.2.
Please refer to the Medical Benefit Summary for applicable copayment responsibility.This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and
Notice on the availability of language assistance services to accompany
vital documents issued in English
IMPORTANT: Can you read this letter? If not, we can have somebody help
you read it.
You may also be able to get this letter written in your language. For free
help, please call right away at the Member/Customer Service telephone
number on the back of your Blue Shield ID card, or (866) 346-7198.
IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien
le ayude a leerla. También puede recibir esta carta en su idioma. Para
ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios
al miembro/cliente que se encuentra al reverso de su tarjeta de
identificación de Blue Shield o al (866) 346-7198.
(Spanish)
重要通知：您能讀懂這封信嗎？
如果不能，我們可以請人幫您閱讀。
這封信也可以用您所講的語言書寫。
如需幫助，請立即撥打登列在您的
Blue
Shield ID
卡背面上的會員
/
客戶服務部的電話，或者撥打電話
866-346-7198
。
(Chinese)
QUAN TR
Ọ
NG: Quý v
ị có thể đọc lá thư này không? Nếu không, chúng tôi
có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này
được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi
ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue
Shield của quý vị hoặc theo số 866-346-7198.
(Vietnamese)
16 Blue Shield of California
blueshieldca.com/providence 17
