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HomeMy WebLinkAboutBlue Shield HMO Plan Summary A16205 (1/26) Plan ID: 46029 1 Summary of Benefits PRISM/Small Group Program Effective January 1, 2026 HMO Plan Custom Access+ HMO 15-0 Inpatient This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Medical Provider Network: Access+ HMO Network This Plan uses a specific network of Health Care Providers, called the Access+ HMO provider network. Medical Groups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers. You must select a Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this Plan. You can find Participating Providers in this network at blueshieldca.com. Calendar Year Deductibles (CYD)2 A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Plan. When using a Participating Provider3 Calendar Year medical Deductible Individual coverage $0 Family coverage $0: individual $0: Family Calendar Year Out-of-Pocket Maximum4 An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. No Annual or Lifetime Dollar Limit When using a Participating Provider3 Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. Individual coverage $1,500 Family coverage $1,500: individual $3,000: Family Bl u e S h i e l d o f C a l i f o r n i a i s a n i n d e p e n d e n t m e m b e r o f t h e B l u e S h i e l d A s s o c i a t i o n 2 Benefits5 Your payment When using a Participating Provider3 CYD2 applies Preventive Health Services6 Preventive Health Services $0 California Prenatal Screening Program $0 Physician services Primary care office visit $15/visit Access+ specialist care office visit (self-referral) $30/visit Other specialist care office visit (referred by PCP) $15/visit Physician home visit $15/visit Physician or surgeon services in an Outpatient Facility $0 Physician or surgeon services in an inpatient facility $0 Other professional services Other practitioner office visit $15/visit Includes nurse practitioners, physician assistants, therapists, and podiatrists. Teladoc Health consultation $15/consult Family planning • Counseling, consulting, and education $0 • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. $0 • Tubal ligation $0 • Vasectomy $0 Medical nutrition therapy, not related to diabetes $0 Infertility Services Physician or surgeon services in an Outpatient Facility $0 Artificial Inseminations limited to 6 per lifetime $0 Oocyte (egg) retrieval limited to 3 per lifetime • Ambulatory Surgery Center $0 • Outpatient Department of a Hospital $100/surgery In vitro fertilization (IVF) $0 Embryo transfer • Ambulatory Surgery Center $0 • Outpatient Department of a Hospital $100/surgery Cryopreservation limited to 1 year of storage per lifetime for each of the following: sperm, reproductive tissue, oocytes (eggs), and embryos $0 3 Benefits5 Your payment When using a Participating Provider3 CYD2 applies Pregnancy and maternity care Physician office visits: prenatal and postnatal $0 Abortion and abortion-related services $0 Emergency Services Emergency room services $50/visit If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $0 Urgent care center services $15/visit Ambulance services $50/transport This payment is for emergency or authorized transport. Outpatient Facility services Ambulatory Surgery Center $0 Outpatient Department of a Hospital: surgery $100/surgery Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $0 Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. • Special transplant facility inpatient services $0 • Physician inpatient services $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non- Preventive Health Services, and diagnostic radiological procedures. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory and pathology services Includes diagnostic Papanicolaou (Pap) test. • Laboratory center $0 • Outpatient Department of a Hospital $0 4 Benefits5 Your payment When using a Participating Provider3 CYD2 applies Basic imaging services Includes plain film X-rays, ultrasounds, and diagnostic mammography. • Outpatient radiology center $0 • Outpatient Department of a Hospital $0 Other outpatient non-invasive diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. • Office location $0 • Outpatient Department of a Hospital $0 Advanced imaging services Includes diagnostic radiological and nuclear imaging such as CT scans, MRIs, MRAs, and PET scans. • Outpatient radiology center $0 • Outpatient Department of a Hospital $0 Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $15/visit Outpatient Department of a Hospital $15/visit Durable medical equipment (DME) DME 20% Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $0 Home health care services $15/visit Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. Home infusion and home injectable therapy services Home infusion agency services $0 Includes home infusion drugs, medical supplies, and visits by a nurse. 5 Benefits5 Your payment When using a Participating Provider3 CYD2 applies Hemophilia home infusion services $0 Includes blood factor products. Skilled Nursing Facility (SNF) services Up to 100 days per Member, per benefit period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF $0 Hospital-based SNF $0 Hospice program services $0 Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Other services and supplies Diabetes care services • Devices, equipment, and supplies 20% • Self-management training $15/visit • Medical nutrition therapy $15/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum billed separately from an office visit 50% Mental Health and Substance Use Disorder Benefits Your payment When using a Participating Provider3 CYD2 applies Outpatient services Office visit, including Physician office visit $15/visit Teladoc Health mental health $15/consult Other outpatient services, including intensive outpatient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility setting, and office-based opioid treatment $0 Partial Hospitalization Program $0 Psychological Testing $0 Inpatient services Physician inpatient services $0 6 Mental Health and Substance Use Disorder Benefits Your payment When using a Participating Provider3 CYD2 applies Hospital services $0 Residential Care $0 Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this Plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time. Capitalized terms are defined in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of Benefits. 2 Calendar Year Deductible (CYD): Calendar Year Deductible explained. A Calendar Year Deductible is the amount you pay each Calendar Year before Blue Shield pays for Covered Services under the Plan. If this Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a check mark () in the Benefits chart above. 3 Using Participating Providers: Participating Providers have a contract to provide health care services to Members. When you receive Covered Services from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar Year Deductible has been met. 4 Calendar Year Out-of-Pocket Maximum (OOPM): Calendar Year Out-of-Pocket Maximum explained. The Out-of-Pocket Maximum is the most you are required to pay for Covered Services in a Calendar Year. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges for services that are not covered, charges above the Allowed Charges, and charges for services above any Benefit maximum. Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for an individual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM within a Calendar Year. 5 Separate Member Payments When Multiple Covered Services are Received: Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance) for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example, you may owe an office visit payment in addition to an allergy serum payment when you visit the doctor for an allergy shot. 7 Notes 6 Preventive Health Services: If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit, you may have a Copayment or Coinsurance for the visit. Plans may be modified to ensure compliance with State and Federal requirements. PENDING REGULATORY APPROVAL lg082225 A17273 (1/26) Plan ID: 46034 1 Acupuncture and Chiropractic Services Rider Group Rider Effective January 1, 2026 HMO/POS PRISM/Small Group Program Chiropractic and Acupuncture Benefits Summary of Benefits This Summary of Benefits shows the amount you will pay for Covered Services under this acupuncture and chiropractic services Benefit. Benefits Your Payment Covered Services must be determined as Medically Necessary by American Specialty Health Plans of California, Inc. (ASH Plans). Up to 30 visits per Member, per Calendar Year. The 30 visit maximum is for acupuncture and chiropractic services combined. Services are not subject to the Calendar Year Deductible and do count towards the Calendar Year Out-of-Pocket Maximum. When using an ASH Participating Provider When using a Non-Participating Provider Acupuncture Services Office visit $10/visit Not covered Chiropractic Services Office visit $10/visit Not covered Chiropractic Appliances All charges above $50 Not covered Benefit Plans may be modified to ensure compliance with State and Federal Requirements. Bl u e S h i e l d o f C a l i f o r n i a i s a n i n d e p e n d e n t m e m b e r o f t h e B l u e S h i e l d A s s o c i a t i o n A17273 (1/26) Plan ID: 46034 2 Introduction In addition to the Benefits listed in your Evidence of Coverage, your rider provides coverage for acupuncture and chiropractic services as described in this supplement. The Benefits covered under this rider must be received from an American Specialty Health Plans of California, Inc. (ASH Plans) Participating Provider. These acupuncture and chiropractic Benefits are separate from your health Plan, but the general provisions, limitations, and exclusions described in your Evidence of Coverage do apply. A referral from your Primary Care Physician is not required. All Covered Services, except for (1) the initial examination and treatment by an ASH Participating Provider; and (2) Emergency Services, must be determined as Medically Necessary by ASH Plans. Note: ASH Plans will respond to all requests for Medical Necessity review within five business days from receipt of the request. Covered Services received from providers who are not ASH Participating Providers will not be covered except for Emergency Services and in certain circumstances, in counties in California in which there are no ASH Participating Providers. If ASH Plans determines Covered Services from a provider other than a Participating Provider are Medically Necessary, you will be responsible for the Participating Provider Copayment amount. Benefits Acupuncture Services Benefits are available for Medically Necessary acupuncture services for the treatment of Musculoskeletal and Related Disorders. Benefits include an initial examination, acupuncture and adjunctive therapy, and subsequent office visits for the treatment of:  headaches (tension-type and migraines);  hip or knee joint pain associated with osteoarthritis (OA);  other extremity joint pain associated with OA or mechanical irritation;  other pain syndromes involving the joints and associated soft tissues;  back and neck pain; and  nausea associated with pregnancy, surgery, or chemotherapy. Chiropractic Services Benefits are available for Medically Necessary chiropractic services for the treatment of Musculoskeletal and Related Disorders. Benefits include an initial examination, subsequent office visits and the following services:  spinal and extra-spinal joint manipulation (adjustments);  adjunctive therapy such as electrical muscle stimulation or therapeutic exercises;  plain film x-ray services; and  chiropractic supports and appliances. 3 Visits for acupuncture and chiropractic services are limited to a per Member per Calendar Year maximum as shown on the Summary of Benefits. Benefits must be provided in an office setting. You will be referred to your Primary Care Physician for evaluation of conditions not related to a Musculoskeletal and Related Disorder and for other services not covered under this rider such as diagnostic imaging (e.g. CAT scans or MRIs). Note: You should exhaust the Benefits covered under this rider before accessing the same services through the "Alternative Care Discount Program," which is a wellness discount program. For more information about the Alternative Care Discount Program, visit www.blueshieldca.com. See the Grievance Process portion of your EOC for information on filing a grievance, your right to seek assistance from the Department of Managed Health Care, and your rights to independent medical review. Member Services For all acupuncture and chiropractic services, Blue Shield of California has contracted with ASH Plans to act as the Plan’s acupuncture and chiropractic services administrator. Contact ASH Plans with questions about acupuncture and chiropractic services, ASH Participating Providers, or acupuncture and chiropractic Benefits. Contact ASH Plans at: 1-800-678-9133 American Specialty Health Plans of California, Inc. P.O. Box 509002 San Diego, CA 92150-9002 ASH Plans can answer many questions over the telephone. Exclusions Acupuncture services do not include:  treatment of asthma;  treatment of addiction (including without limitation smoking cessation); or  vitamins, minerals, nutritional supplements (including herbal supplements), or other similar products. See the Grievance Process portion of your EOC for information on filing a grievance, your right to seek assistance from the Department of Managed Health Care, and your rights to independent medical review. Definitions American Specialty Health Plans of California, Inc. (ASH Plans) ASH Plans is a licensed, specialized health care service plan that has entered into an agreement with Blue Shield of California to arrange for the delivery of acupuncture and chiropractic services. ASH Participating Provider An acupuncturist or a chiropractor under contract with ASH Plans to provide Covered Services to Members. 4 Musculoskeletal and Related Disorders Musculoskeletal and Related Disorders are conditions with signs and symptoms related to the nervous, muscular, and/or skeletal systems. Musculoskeletal and Related Disorders are conditions typically categorized as: structural, degenerative, or inflammatory disorders; or biomechanical dysfunction of the joints of the body and/or related components of the muscle or skeletal systems (muscles, tendons, fascia, nerves, ligaments/capsules, discs and synovial structures) and related manifestations or conditions. Musculoskeletal and Related Disorders include Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders and subluxation. Please be sure to retain this document. It is not a contract but is a part of your EOC.