HomeMy WebLinkAboutBlue Shield EPO Plan Document (SPD).pdfClaims Administered by Blue Shield of California
Benefit Booklet
Public Risk Innovation, Solutions and Management (PRISM) -
Small Group Program
ASO EPO Plan
Group Number: W0052149-M0035669
Effective Date: January 1, 2024
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Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Table of contents
Table of contents .......................................................................................................................................2
Summary of Benefits..................................................................................................................................4
Introduction..............................................................................................................................................12
About this Benefit Booklet....................................................................................................................12
About this Plan.......................................................................................................................................13
How to contact Customer Service .....................................................................................................13
Your bill of rights.......................................................................................................................................15
Your responsibilities.................................................................................................................................17
How to access care ................................................................................................................................19
Health care professionals and facilities..............................................................................................19
ID cards ..................................................................................................................................................20
Canceling appointments.....................................................................................................................20
Continuity of care.................................................................................................................................20
Second medical opinion......................................................................................................................21
Care outside of California....................................................................................................................22
Emergency Services..............................................................................................................................22
If you cannot find a Participating Provider........................................................................................22
Other ways to access care..................................................................................................................23
Health advice and education ............................................................................................................25
Medical Management Programs...........................................................................................................26
Prior authorization .................................................................................................................................26
While you are in the Hospital (inpatient utilization review) ..............................................................28
After you leave the Hospital (discharge planning)...........................................................................28
Using your Benefits effectively (care management)........................................................................28
Your payment information......................................................................................................................30
Paying for coverage.............................................................................................................................30
Paying for Covered Services................................................................................................................30
Claims.....................................................................................................................................................34
Your coverage.........................................................................................................................................35
Eligibility for this Plan..............................................................................................................................35
Enrollment and effective dates of coverage....................................................................................36
Plan changes.........................................................................................................................................37
Coordination of benefits......................................................................................................................38
When coverage ends...........................................................................................................................38
Continuation of group coverage .......................................................................................................39
Your Benefits.............................................................................................................................................42
Acupuncture services...........................................................................................................................42
Allergy testing and immunotherapy Benefits.....................................................................................42
Ambulance services.............................................................................................................................43
Bariatric surgery Benefits ......................................................................................................................43
Chiropractic services............................................................................................................................44
Clinical trials for treatment of cancer or life-threatening diseases or conditions Benefits ...........45
Diabetes care services.........................................................................................................................46
Diagnostic X-ray, imaging, pathology, laboratory, and other testing services.............................46
Table of contents 3
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Dialysis Benefits......................................................................................................................................47
Durable medical equipment...............................................................................................................48
Emergency Benefits..............................................................................................................................50
Family planning Benefits.......................................................................................................................50
Home health services ...........................................................................................................................51
Hospice program services....................................................................................................................53
Hospital services....................................................................................................................................54
Medical treatment of the teeth, gums, jaw joints, and jaw bones.................................................54
Mental Health and Substance Use Disorder Benefits........................................................................55
Physician and other professional services..........................................................................................57
PKU formulas and special food products...........................................................................................58
Podiatric services ..................................................................................................................................58
Pregnancy and maternity care ..........................................................................................................58
Preventive Health Services...................................................................................................................59
Reconstructive Surgery Benefits ..........................................................................................................59
Rehabilitative and habilitative services..............................................................................................60
Skilled Nursing Facility (SNF) services...................................................................................................61
Transplant services................................................................................................................................61
Urgent care services.............................................................................................................................62
Exclusions and limitations.......................................................................................................................63
Settlement of Disputes.............................................................................................................................68
Other important information about your Plan.......................................................................................71
Your coverage, continued ..................................................................................................................71
Special enrollment period....................................................................................................................71
Out-of-area services.............................................................................................................................72
Limitation for duplicate coverage......................................................................................................76
Exception for other coverage.............................................................................................................77
Reductions – third-party liability...........................................................................................................77
Coordination of benefits, continued..................................................................................................78
General provisions.................................................................................................................................79
Definitions.................................................................................................................................................81
Notices about your plan.........................................................................................................................96
Notice informing individuals about nondiscrimination and accessibility requirements..................98
Language access services.....................................................................................................................99
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4
Summary of Benefits PRISM/Small Group Program
Effective January 1, 2024
EPO Plan
ASO EPO Plan
This Summary of Benefits shows the amount you will pay for Covered Services under this Claims Administrator
benefit plan. It is only a summary and it is included as part of the Benefit Booklet.1 Please read both
documents carefully for details.
Provider Network:Full PPO Network
This Plan uses a specific network of Health Care Providers, called the Full PPO provider network. Providers
in this network are called Participating Providers. This is an Exclusive Provider Organization (EPO) plan. You
must receive all Covered Services from a Participating Provider, but there are some exceptions. Please
review your Benefit Booklet 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 Claims
Administrator pays for Covered Services under the Plan. The Claims Administrator pays for some Covered
Services before the Calendar Year Deductible is met, as noted in the Benefits chart below.
When using a Participating Provider3
Calendar Year medical Deductible Individual
coverage
$300
Family coverage $300: individual
$600: 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 Notes section at the end of this Summary of Benefits. No Annual or Lifetime Dollar Limit
When using a Participating Provider3
Individual
coverage
$1,300
Family coverage $1,300: individual
$2,600: Family
Under this Plan there is no annual or
lifetime dollar limit on the amount
Claims Administrator will pay for
Covered Services.
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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 $30/visit
Specialist care office visit $30/visit
Physician home visit $0
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 $30/visit
Includes nurse practitioners, physician assistants, and
therapists.
Acupuncture services $30/visit
Combined with chiropractic services, up to 26 visits per
Member, per Calendar Year.
Chiropractic services $30/visit
Combined with acupuncture services, up to 26 visits per
Member, per Calendar Year.
Teladoc consultation $30/consult
Family planning
•Counseling, consulting, and education $0
•Injectable contraceptive $0
•Diaphragm fitting $0
•Intrauterine device (IUD)$0
•Insertion and/or removal of intrauterine device (IUD)$0
•Implantable contraceptive $0
•Tubal ligation $0
•Vasectomy $0
Podiatric services $30/visit
Medical nutrition therapy, not related to diabetes $0
Pregnancy and maternity care
Physician office visits: prenatal and postnatal $0
Physician services for pregnancy termination $0
6
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Emergency Services
Emergency room services $100/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 $30/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 $30/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
Bariatric surgery services, designated California counties
This payment is for bariatric surgery services for residents of
designated California counties. For bariatric surgery services
for residents of non-designated California counties, the
payments for Inpatient facility services/ Hospital services and
stay and Physician inpatient and surgery services apply for
inpatient services; or, if provided on an outpatient basis, the
Outpatient Facility services and outpatient Physician services
payments apply.
Inpatient facility services $0
Outpatient Facility services $30/surgery
Physician services $0
7
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
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 $25/visit
Basic imaging services
Includes plain film X-rays, ultrasounds, and diagnostic
mammography.
•Outpatient radiology center $0
•Outpatient Department of a Hospital $25/visit
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 $25/visit
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 $100/visit
Rehabilitative and Habilitative Services
Includes physical therapy, occupational therapy, and
respiratory therapy.
Office location $30/visit
Outpatient Department of a Hospital $30/visit
Speech Therapy services
Office location $30/visit
Outpatient Department of a Hospital $30/visit
Durable medical equipment (DME)
DME 20%
Breast pump $0
Orthotic equipment and devices 20%
8
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Prosthetic equipment and devices 20%
Home health care services $30/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.
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
Pre-Hospice consultation $0
Routine home care $0
24-hour continuous home care $0
Short-term inpatient care for pain and symptom
management $0
Inpatient respite care $0
Other services and supplies
Diabetes care services
•Devices, equipment, and supplies $0
•Self-management training $30/visit
•Medical nutrition therapy $30/visit
Dialysis services $0
PKU product formulas and special food products $0
Allergy serum billed separately from an office visit $0
9
Mental Health and Substance Use Disorder Benefits Your payment
When using a Participating
Provider3
CYD2
applies
Outpatient services
Office visit, including Physician office visit $30/visit
Teladoc mental health $30/consult
Intensive outpatient care $0
Behavioral Health Treatment in an office setting $0
Behavioral Health Treatment in home or other non-
institutional setting $0
Office-based opioid treatment $0
Partial Hospitalization Program $0
Psychological Testing $0
Inpatient services
Physician inpatient services $0
Hospital services $0
Residential Care $0
Prior Authorization
The following are some frequently-utilized Benefits that require prior authorization:
•Advanced imaging services •Hospice program services
•Outpatient mental health services,
except office visits and office-based
opioid treatment
•Inpatient facility services
Please review the Benefit Booklet for more about Benefits that require prior authorization.
Notes
1 Benefit Booklet:
The Benefit Booklet describes the Benefits, limitations, and exclusions that apply to coverage under this
Plan. Please review the Benefit Booklet for more details of coverage outlined in this Summary of Benefits.
You can request a copy of the Benefit Booklet at any time.
Capitalized terms are defined in the Benefit Booklet. Refer to the Benefit Booklet 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 the Claims Administrator pays for Covered Services under the Plan.
10
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.
Covered Services not subject to the Calendar Year medical Deductible. Some Covered Services received
from Participating Providers are paid by the Claims Administrator before you meet any Calendar Year
medical Deductible. These Covered Services do not have a check mark () next to them in the “CYD
applies” column in the Benefits chart above.
Family coverage has an individual Deductible within the Family Deductible. This means that the Deductible
will be met for an individual with Family coverage who meets the individual Deductible prior to the Family
meeting the Family Deductible within a Calendar Year.
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.
Teladoc. Teladoc mental health and substance use disorder consultations are provided through Teladoc.
"Allowable Amount" is defined in the Benefit Booklet. In addition:
•Coinsurance is calculated from the Allowable Amount or Benefit maximum, whichever is less.
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,
the Claims Administrator will pay 100% of the Allowable Amount 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 Allowable Amount, and charges for services above any Benefit
maximum.
Any Deductibles count towards the OOPM. Any amounts you pay that count towards the medical
Deductible also count towards the Calendar Year Out-of-Pocket 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.
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 Federal requirements.
11
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Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Introduction
Welcome! We are happy to have you as a Member of the Public Risk Innovation,
Solutions and Management (PRISM) - Small Group Program health Plan (Plan).
This health Plan will help you pay for medical care and provide you with access to a
network of doctors, Hospitals, and other Health Care Providers. The types of services
that are covered, the providers you can see, and your share of cost when you receive
care may vary depending on the terms of the Plan, as described in further detail in this
Benefit Booklet.
About this Benefit Booklet
The Benefit Booklet describes the health care coverage that is provided under the Plan.
The Benefit Booklet tells you:
•Your eligibility for coverage;
•When coverage begins and ends;
•How you can access care;
•Which services are covered under your Plan (Covered Services);
•Which services are not covered under your Plan;
•When and how you must get prior authorization for certain services; and
•Important financial concepts, such as Copayment, Coinsurance, Deductible,
and Out-of-Pocket Maximum.
This Benefit Booklet includes a Summary of Benefits section that lists your Cost Share for
Covered Services. Use this summary to figure out what your cost will be when you
receive care.
Please read this Benefit Booklet carefully. Some topics in this document are complex.
For additional explanation on these topics, you may be directed to a section at the
back of the Benefit Booklet called Other important information about your Plan. Pay
particular attention to sections that apply to any special health care needs you may
have. Be sure to keep this Benefit Booklet in your files for future reference.
Tables and images
In this Benefit Booklet, you will see the following tables and images to highlight key
information:
This table provides easy access to information
Phone numbers and addresses
Answers to commonly-asked questions
Examples to help you better understand important concepts
Introduction 13
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
This box tells you where to find additional information about a
specific topic.
This box alerts you to information that may require you to take
action.
“You” means the Member
In this Benefit Booklet, “you” or “your” means any Member enrolled in the Plan,
including the Participant and all Dependents. “Your Employer” means the
Participant’s Employer.
Capitalized words have a special meaning
Some words and phrases in this Benefit Booklet may be new to you. Key terms with a
special meaning within this Benefit Booklet are capitalized and defined in the
Definitions section.
About this Plan
This is an Exclusive Provider Organization (EPO) plan. In an EPO plan, you can receive
care from the same network of providers as with a PPO plan. However, with an EPO
plan there is no coverage for services from providers who do not participate in the PPO
network. All Covered Services must be received from a Participating Provider in the PPO
network, except:
•For Emergency or Urgent Services;
•Inter-Plan Arrangements, including the BlueCard® and Blue Shield Global®
Core programs described in the Out-of-area services section; and
•When prior authorized by the Claims Administrator.
See the How to access care section for information about Participating Providers.
How to contact Customer Service
If you have questions at any time, we’re here to help. The Claims Administrator’s
website and app are useful resources. Visit blueshieldca.com or use the Claims
Administrator’s mobile app to:
•Download forms;
•View or print a temporary ID card;
•Access recent claims;
•Find a doctor or other Health Care Provider; and
•Explore health topics and wellness tools.
The Claims Administrator’s contact information appears at the bottom of every page.
Introduction 14
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Contacting Customer Service
If you need information about You should contact
Medical Benefits, including prior
authorization and claims submission
Customer Service:
1-855-599-2650
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
Prior authorization of radiological services National Imaging Associates:
(888) 642-2583
If you are hearing impaired, you may contact Customer Service through the Claims
Administrator’s toll-free TTY number: 711.
Introduction 15
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Your bill of rights
As a Member, you have the right to:
1 Receive considerate and courteous care with respect for your right to personal
privacy and dignity.
2 Receive information about all health services available to you, including a clear
explanation of how to obtain them.
3 Receive information about your rights and responsibilities.
4 Receive information about your Plan, the services we offer you, and the Physicians
and other Health Care Providers available to care for you.
5 Have reasonable access to appropriate medical and mental health services in
accordance with the terms of your Plan.
6
Participate actively with your Physician in decisions about your medical and
mental health care. To the extent the law permits, you also have the right to refuse
treatment.
7 A candid discussion of appropriate or Medically Necessary treatment options for
your condition, regardless of cost or Benefit coverage.
8
An explanation of your medical or mental health condition, and any proposed,
appropriate, or Medically Necessary treatment alternatives from your Physician,
so you can make an informed decision before you receive treatment. This
includes available success/outcomes information, regardless of cost or Benefit
coverage.
9 Receive Preventive Health Services.
10 Know and understand your medical or mental health condition, treatment plan,
expected outcome, and the effects these have on your daily living.
11
Have confidential health records, except when the law requires or permits
disclosure. With adequate notice, you have the right to review your medical
record with your Physician.
12 Communicate with, and receive information from, Customer Service in a
language you can understand.
13 Know about any transfer to another Hospital, including information as to why the
transfer is necessary and any alternatives available.
Introduction 16
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
As a Member, you have the right to:
14 Be fully informed about the complaint and grievance process and understand
how to use it without the fear of an interruption in your health care.
15 Voice complaints or grievances about your Plan or the care provided to you.
16 Make recommendations on the Claims Administrator’s Member rights and
responsibilities policies.
Introduction 17
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Your responsibilities
As a Member, you have the responsibility to:
1
Carefully read all plan materials, including this Benefit Booklet, immediately after
you are enrolled so you understand how to:
•Use your Benefits;
•Minimize your out-of-pocket costs; and
•Follow the provisions of your Plan as explained in the Benefit Booklet.
2 Maintain your good health and prevent illness by making positive health choices
and seeking appropriate care when you need it.
3 Provide, to the extent possible, information needed for you to receive
appropriate care.
4 Understand your health problems and take an active role in developing
treatment goals with your Physician, whenever possible.
5
Follow the treatment plans and instructions you and your Physician agree to and
consider the potential consequences if you refuse to comply with treatment
plans or recommendations.
6 Ask questions about your medical or mental health condition and make certain
that you understand the explanations and instructions you are given.
7 Make and keep medical and mental health appointments and inform your
Health Care Provider ahead of time when you must cancel.
8 Communicate openly with your Physician so you can develop a strong
partnership based on trust and cooperation.
9 Offer suggestions to improve the Plan.
10
Help the Claims Administrator maintain accurate and current records by
providing timely information regarding changes in your address, family status,
and other plan coverage.
11 Notify the Claims Administrator as soon as possible if you are billed
inappropriately or if you have any complaints or grievances.
12 Treat all Plan personnel respectfully and courteously.
13 Pay your Participant Contributions, Copayments, Coinsurance, and charges for
non-Covered Services in full and on time.
Introduction 18
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
As a Member, you have the responsibility to:
14 Follow the provisions of the Claims Administrator’s Medical Management
Programs.
19
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
How to access care
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR
WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
Health care professionals and facilities
This Plan covers care from Participating Providers. You do not need a referral. However,
some services do require prior authorization. See the Medical Management Programs
section for information about prior authorization.
Participating Providers
Participating Providers have a contract with the Claims Administrator and agree to
accept the Claims Administrator’s Allowable Amount as payment in full for Covered
Services. With an EPO plan, there is generally no coverage for services from Non-
Participating Providers.
If a provider leaves this Plan’s network, the status of the provider will change from
Participating to Non-Participating. See the Continuity of Care section for more
information on how to continue treatment with a former Participating Provider.
Visit blueshieldca.com or use the Claims Administrator’s mobile
app and click on Find a Doctor for a list of your plan’s
Participating Providers.
Non-Participating Providers
Non-Participating Providers do not have a contract with the Claims Administrator to
accept the Claims Administrator’s Allowable Amount as payment in full for Covered
Services. You may be responsible for the total amount billed by a Non-Participating
Provider. All Covered Services must be received from a Participating Provider in the
Claims Administrator’s PPO network, except:
•For Emergency or Urgent Services;
•Inter-Plan Arrangements, including the BlueCard® and Blue Shield Global®
Core programs described in the Out-of-area services section; and
•When prior authorized by the Claims Administrator.
Except for Emergency Services and services received at a Participating Provider
facility (Hospital, Ambulatory Surgical Center, laboratory, radiology center,
imaging center, or certain other outpatient settings) under certain conditions,
you will pay more for Covered Services from a Non-Participating Provider.
Non-Participating Providers at a Participating Provider Hospital or Ambulatory
Surgical Center
When you receive care at one of these types of Participating Provider
facilities, some Covered Services may be provided by a Non-Participating
How to access care 20
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Provider. Your Cost Share will be the same as the amount due to a
Participating Provider under similar circumstances, and you will not be
responsible for additional charges above the Allowable Amount, unless the
Non-Participating Provider provides you written notice of what they may
charge and you consent to those terms.
Common types of providers
Primary Care Physicians (PCPs)
Other primary care providers, such as nurse practitioners and physician assistants
Physician Specialists, such as dermatologists and cardiologists
Physical, occupational, and speech therapists
Mental health providers, such as psychiatrists, psychologists, and licensed clinical
social workers
Hospitals
Freestanding labs and radiology centers
Ambulatory Surgery Centers
ID cards
The Claims Administrator will provide the Participant and any enrolled Dependents with
identification cards (ID cards). Only you can use your ID card to receive Benefits. Your
ID card is important for accessing health care, so please keep it with you at all times.
Temporary ID cards are available at blueshieldca.com or on the Claims Administrator’s
mobile app.
Canceling appointments
If you are unable to keep an appointment, you should notify the provider at least 24
hours before your scheduled appointment. Some offices charge a fee for missed
appointments unless it is due to an emergency or you give 24-hour advance notice.
Continuity of care
Continuity of care with a Former Participating Provider may be available if your provider
leaves the Claims Administrator network or the Claims Administrator no longer contracts
with your Participating Provider for the services you are receiving.
Continuity of care may also be available to you when your Employer terminates its
contract with the Claims Administrator and contracts with a new third-party
How to access care 21
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
administrator (TPA) that does not include the Claims Administrator’s Participating
Provider in its network.
If your Former Participating Provider is no longer available to you for one of the reasons
noted above, the Claims Administrator will notify you of the option to continue
treatment with your Former Participating Provider.
You can request to continue treatment with your Former Participating Provider in the
situations described above if you are currently receiving the following care:
Continuity of care with a Former Participating Provider
Qualifying condition Timeframe
•Ongoing treatment for a serious
and complex condition;
•Ongoing institutional or inpatient
care;
•Ongoing pregnancy care,
including care immediately after
giving birth;
•Scheduled, nonelective surgery,
including postoperative care; or
•Treatment for a terminal illness
90 days from the date you were notified
that the Former Participating Provider is
no longer available to you or until the
treatment concludes, whichever is sooner
To request continuity of care with a Former Participating Provider, visit blueshieldca.com
and fill out the Continuity of Care Application. The Claims Administrator will confirm your
eligibility and may review your request for Medical Necessity.
The Former Participating Provider must accept the Claims Administrator’s Allowable
Amount as payment in full for your ongoing care. Once the provider accepts and your
request is authorized, you may continue to see the Former Participating Provider at the
Participating Provider Cost Share.
See the Your payment information section for more information about the Allowable
Amount.
Second medical opinion
You can consult a Participating Provider for a second medical opinion in situations
including but not limited to:
•You have questions about the reasonableness or necessity of the treatment
plan;
•There are different treatment options for your medical condition;
•Your diagnosis is unclear;
•Your condition has not improved after completing the prescribed course of
treatment;
•You need additional information before deciding on a treatment plan; or
How to access care 22
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
•You have questions about your diagnosis or treatment plan.
You do not need prior authorization from the Claims Administrator or your Physician for
a second medical opinion.
Care outside of California
If you need medical care while traveling outside of California, you’re covered. The
Claims Administrator has relationships with health plans in other states, Puerto Rico, and
the U.S. Virgin Islands through the BlueCard® Program. The Blue Cross Blue Shield
Association can help you access care in those geographic areas.
See the Out-of-area services section for more information
about receiving care while outside of California. To find
participating providers while outside of California, visit
bcbs.com.
Emergency Services
If you have a medical emergency, call 911 or seek immediate
medical attention at the nearest hospital.
The Benefits of this Plan will be provided anywhere in the world for treatment of an
Emergency Medical Condition. Emergency Services are covered at the Participating
Provider Cost Share, even if you receive treatment from a Non-Participating Provider.
After you receive care, the Claims Administrator will review your claim for Emergency
Services to determine if your condition was in fact an Emergency Medical Condition. If
you did not require Emergency Services and did not reasonably believe an emergency
existed, you will be responsible for the services provided at a Participating Provider
facility at the applicable Participating Provider Cost Share. Services provided at a Non-
Participating Provider facility will not be covered.
If you cannot find a Participating Provider
Call Customer Service if you need help finding a Participating Provider who can
provide the care you need close to home. If a Participating Provider is not available,
you can ask to see a Non-Participating Provider at the Participating Provider Cost
Share. If the services cannot reasonably be obtained from a Participating Provider, we
will approve your request and you will only be responsible for the Participating Provider
Cost Share.
How to access care 23
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Other ways to access care
For non-emergencies, it may be faster and easier to access care in one of the following
ways. For more information, visit blueshieldca.com or use the Claims Administrator’s
mobile app.
Retail-based health clinics
Retail-based health clinics are conveniently located within stores and pharmacies.
They are staffed with nurse practitioners who can provide basic medical care on a
walk-in basis.
The Cost Share for Covered Services at a Participating retail-based health clinic is the
same as the Cost Share at your Physician’s office.
Teladoc
Teladoc provides health consultations by phone or secure online video. Teladoc
general medical Physicians can diagnose and treat basic non-emergency medical
conditions, and can also prescribe certain medication. Teladoc mental health
consultations are available for Members age 13 and older. Members under age 13
may obtain telebehavioral health services for Mental Health and Substance Use
Disorders from a mental health professional. Teladoc is a supplemental service that is
not intended to replace care from your Physician or mental health professional.
How to access care 24
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
How to access Teladoc
Teladoc service Ways to access Availability
General medical Phone: 1-800-835-2362
Online:
blueshieldca.com/teladoc
24 hours a day, 7 days
a week by phone or
secure online video
Consultations can be
requested on-demand
or by scheduled
appointment
Mental health Phone: 1-800-835-2362
Online:
blueshieldca.com/teladoc
7 a.m. to 9 p.m., 7
days a week by
scheduled
appointment only
Consultations must be
scheduled online and
cannot be requested
by phone
Telebehavioral health services
Online telebehavioral health services for Mental Health and Substance Use Disorder
Conditions are available through the Claims Administrator. Telebehavioral health
includes counseling services, psychotherapy, and medication management with a
mental health provider.
Urgent care centers
Urgent care centers are free-standing facilities that provide many of the same basic
medical services as a doctor's office, often with extended hours but similar Cost
Share.
If your condition is not an emergency, but you need treatment that cannot be
delayed, you can visit an urgent care center to receive care that is typically faster
and costs less than an emergency room visit.
Ambulatory Surgery Centers
Many of the more common, uncomplicated, outpatient surgical procedures can be
performed at an Ambulatory Surgery Center. Your cost at an Ambulatory Surgery
Center may be less than it would be for the same outpatient surgery performed at a
Hospital.
How to access care 25
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Health advice and education
Your Plan provides several ways for you to get health advice and access to health
education and wellness services. These resources are available to you at no extra cost.
NurseHelp 24/7SM
You can contact a registered nurse 24 hours a day, seven days a week through the
NurseHelp 24/7SM program. Nurses are available to help you select appropriate care
and answer questions about:
•Symptoms you are experiencing;
•Minor illnesses and injuries;
•Medical tests and medications;
•Chronic conditions; and
•Preventive care.
Call (877) 304-0504 or log in to your account at blueshieldca.com and use the chat
feature to connect with a nurse. This service is free and confidential.
NurseHelp 24/7 SM is not meant to replace the advice and care you receive from your
Physician or other health care professional.
Health and wellness resources
Your Plan gives you access to a variety of health education and wellness services,
such as:
•Prenatal and other health education programs;
•Healthy lifestyle programs to help you get more active, quit smoking, lower
stress, and much more; and
•A health update newsletter.
Visit blueshieldca.com to explore these resources.
26
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Medical Management Programs
The Medical Management Programs are services that can help you coordinate your
care and treatment. They include utilization management and care management. The
Claims Administrator uses utilization management to help you and your providers
identify the most appropriate and cost-effective way to use the Benefits of this plan.
Care management and palliative care can help you access the care you need to
manage serious health conditions and complex treatment plans.
For written information about the Claims Administrator’s
Utilization Management Program, visit blueshieldca.com.
Prior authorization
Coverage for some Benefits requires pre-approval from the Claims Administrator. This
process is called prior authorization. Prior authorization requests are reviewed for
Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior
authorization process also verifies that the selected provider is a Participating Provider.
Your provider must obtain prior authorization when required. When prior authorization is
required but not obtained, the Claims Administrator may deny payment to your
provider. You are not responsible for the Claims Administrator’s portion of the Allowable
Amount if this occurs, only your Cost Share.
You do not need prior authorization for Emergency Services or emergency Hospital
admissions. For non-emergency inpatient services, your provider should request prior
authorization at least five business days before admission.
Visit blueshieldca.com and click on Prior Authorization List for more details about
medical and surgical services and select prescription Drugs that require prior
authorization.
Medical Management Programs 27
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Frequently-utilized services that require prior authorization
Benefit Services that require prior authorization
Medical •Surgery
•Prescription Drugs administered by a Health Care
Provider
•Non-emergency inpatient facility services, such as
Hospitals and Skilled Nursing Facilities
•Non-emergency ambulance services
•Routine patient care received while enrolled in a
clinical trial
•Hospice program enrollment
Advanced imaging •CT (Computerized Tomography) scan
•MRI (Magnetic Resonance Imaging)
•MRA (Magnetic Resonance Angiography)
•PET (Positron Emission Tomography) scan
•Diagnostic cardiac procedure utilizing nuclear
medicine
Mental health and
substance use
disorder
•Non-emergency mental health or substance use
disorder Hospital admissions, including acute and
residential care
•Behavioral Health Treatment
•Electroconvulsive therapy
•Psychological testing
•Partial Hospitalization Program
•Intensive Outpatient Program
•Transcranial magnetic stimulation
When a decision will be made about your prior authorization request
Prior authorization or exception request Time for decision
Routine medical and mental health and substance use
disorder requests
Within five business days
Expedited medical and mental health and substance use
disorder requests
Within 72 hours
Expedited requests include urgent medical requests. Once the decision is made, your
provider will be notified within 24 hours. Written notice will be sent to you and your
provider within two business days.
Medical Management Programs 28
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
While you are in the Hospital (inpatient utilization review)
When you are admitted to the Hospital, your stay will be monitored for continued
Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient
level of care, the Claims Administrator will send a written notice to you, your provider,
and the Hospital. If you choose to stay in the Hospital past the date indicated in this
notice, you will be financially responsible for all inpatient charges after that date.
Exceptions to inpatient utilization review include maternity and mastectomy care.
For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal
delivery and 96 hours for a C-section. The provider and mother together may decide
that a shorter length of stay is adequate.
For mastectomy, you and your provider determine the Medically Necessary length of
stay after the surgery.
After you leave the Hospital (discharge planning)
You may still need care at home or in another facility after you are discharged from the
Hospital. The Claims Administrator will work with you, your provider, and the Hospital’s
discharge planners to determine the most appropriate and cost-effective way to
provide this care.
Using your Benefits effectively (care management)
Care management helps you coordinate your health care services and make the most
efficient use of your Plan Benefits. Its goal is to help you stay as healthy as possible while
managing your health condition, to avoid unnecessary emergency room visits and
repeated hospitalizations, and to help you with the transition from Hospital to home. A
Claims Administrator care management nurse may contact you to see how we might
help you manage your health condition. You may also request care management
support by calling Customer Service. A case manager can:
•Help you identify and access appropriate services;
•Instruct you about self-management of your health care conditions; and
•Identify community resources to lend support as you learn to manage a
chronic health condition.
Alternative services may be offered when they are medically appropriate and only
utilized when you, your provider, and the Claims Administrator mutually agree. The
availability of these services is specific to you for a set period of time based on your
health condition. The Claims Administrator does not give up the right to administer your
Benefits according to the terms of this Benefit Booklet or to discontinue any alternative
services when they are no longer medically appropriate. The Plan is not obligated to
cover the same or similar alternative services for any other Member in any other
instance.
Medical Management Programs 29
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Managing a serious illness (palliative care services)
The Claims Administrator covers palliative care services if you have a serious illness.
Palliative care provides relief from the symptoms, pain, and stress of a serious illness to
help improve the quality of life for you and your family.
Palliative care services include access to Physicians and case managers who are
specially trained to help you:
•Manage your pain and other symptoms;
•Maximize your comfort, safety, autonomy, and well-being;
•Navigate a course of care;
•Make informed decisions about therapy;
•Develop a survivorship plan; and
•Document your quality-of-life choices.
30
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Your payment information
Paying for coverage
The Employer is responsible for funding the payment of claims for Benefits under this
Plan.
Paying for Covered Services
Your Cost Share is the amount you pay for Covered Services. It is your portion of the
Claims Administrator’s Allowable Amount.
Your Cost Share includes any:
•Deductible;
•Copayment amount; and
•Coinsurance amount.
See the Summary of Benefits section for your Cost Share for
Covered Services.
Allowable Amount
The Allowable Amount is the lower of either the Claims Administrator’s Agreed
Amount, or the Claims Administrator’s Reasonable Amount.
Participating Providers agree to accept the Allowable Amount as payment in full for
Covered Services, except as stated in the Exception for other coverage and
Reductions – third party liability sections. When you see a Participating Provider, you
are responsible for your Cost Share.
Generally, the Claims Administrator will pay its portion of the Allowable Amount and
you will pay your Cost Share. If there is a payment dispute between the Claims
Administrator and a Participating Provider over Covered Services you receive, the
Participating Provider must resolve that dispute with the Claims Administrator. You
are not required to pay for the Claims Administrator’s portion of the Allowable
Amount. You are only required to pay your Cost Share for those services.
Non-Participating Providers do not agree to accept the Allowable Amount as
payment in full for Covered Services. When you see a Non-Participating Provider, you
are responsible for:
•Your Cost Share; and
•All charges over the Allowable Amount.
Calendar Year Deductible
The Deductible is the amount you pay each Calendar Year for Covered Services
before the Claims Administrator begins payment. The Claims Administrator will pay
for some Covered Services before you meet your Deductible.
Your payment information 31
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Amounts you pay toward your Deductible count toward your Out-of-Pocket
Maximum.
Some plans do not have a Deductible. For plans that do, there may be separate
Deductibles for an individual Member and an entire Family.
If your Plan has Family coverage, there is an individual Deductible within the Family
Deductible. This means an individual family member can meet the individual
Deductible before the entire Family meets the Family Deductible.
If your Plan has individual coverage and you enroll a Dependent, your Plan will have
Family coverage. Any amount you have paid toward the Deductible for your Plan
with individual coverage will be applied to both the individual Deductible and the
Family Deductible for your new Plan.
See the Summary of Benefits section for details on which Covered Services are
subject to the Deductible and how the Deductible works for your plan.
Prior carrier Deductible credit
If you pay all or part of a Deductible for another Employer-sponsored health plan
in the same Calendar Year you enroll in this plan, that amount will be applied to
this plan’s Deductible if:
•You were enrolled in an Employer-sponsored health plan with another
carrier during the same Calendar Year this contract becomes effective
and you enroll as of the original effective date of coverage under this
contract;
•You were enrolled in another Claims Administrator plan sponsored by the
same Employer which this plan is replacing; or
•You were enrolled in another Claims Administrator plan sponsored by the
same Employer and you are transferring to this plan during open
enrollment.
Last Quarter Carry Over
If charges for Covered Services received during the last three months of the
Calendar Year are applied to the Deductible, the Deductible for the next
Calendar Year will be reduced by that amount.
Copayment and Coinsurance
A Covered Service may have a Copayment or a Coinsurance. A Copayment is a
specific dollar amount you pay for a Covered Service. A Coinsurance is a
percentage of the Allowable Amount you pay for a Covered Service.
Your provider will ask you to pay your Copayment or Coinsurance at the time of
service. For Covered Services that are subject to your plan’s Deductible, you are also
responsible for all costs up to the Allowable Amount until you reach your Deductible.
You will continue to pay the Copayment or Coinsurance for each Covered Service
you receive until you reach your Out-of-Pocket Maximum.
Your payment information 32
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Calendar Year Out-of-Pocket Maximum
The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for
Covered Services in a Calendar Year. Your Cost Share includes any applicable
Deductible, Copayment, and Coinsurance and these amounts count toward your
Out-of-Pocket Maximum, except as listed below. Once you reach your Out-of-
Pocket Maximum, the Claims Administrator will pay 100% of the Allowable Amount
for Covered Services for the rest of the Calendar Year. If you want information about
your Out-of-Pocket Maximum, you can call Customer Service.
If your Plan has Family coverage, you will have a separate Out-of-Pocket Maximum
for each individual Member and one for the entire Family.
If your Plan has Family coverage, there is an individual Out-of-Pocket Maximum
within the Family Out-of-Pocket Maximum. This means an individual family member
can meet the individual Out-of-Pocket Maximum before the entire Family meets the
Family Out-of-Pocket Maximum.
If your Plan has individual coverage and you enroll a Dependent, your Plan will have
Family coverage. Any amount you have paid toward the Out-of-Pocket Maximum
for your Plan with individual coverage will be applied to both the individual Out-of-
Pocket Maximum and the Family Out-of-Pocket Maximum for your new Plan.
The following do not count toward your Out-of-Pocket Maximum:
•Charges for services that are not covered; and
•Charges over the Allowable Amount.
You will continue to be responsible for these costs even after you reach your Out-of-
Pocket Maximum.
See the Summary of Benefits section for details on how the Out-of-Pocket Maximum
works for your Plan.
Your payment information 33
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Cost Share concepts in action
To recap, you are responsible for all costs for Covered Services until you reach any
applicable Deductible. Once you reach any applicable Deductible, the Claims
Administrator will pay the Allowable Amount for Covered Services, minus your
Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum.
Once you reach your Out-of-Pocket Maximum, the Claims Administrator will pay
100% of the Allowable Amount for Covered Services. Exceptions are described
above.
EXAMPLE
Cost to visit the doctor
Now that you know the basics, here is an example of how your Cost Share
works. Please note, the DOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES
ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.
Example: You visit the doctor for a sore throat. You have received Covered
Services throughout the year and have already met your $500 Deductible.
However, you have not yet met your $1,000 Out-of-Pocket Maximum.
Deductible: $500
Amount paid to date toward Deductible: $500
Out-of-Pocket Maximum: $1,000
Amount paid to date toward Out-of-Pocket Maximum: $500
Participating Provider Copayment: $30
The Claims Administrator’s Allowable Amount for the doctor’s visit: $100
Participating Provider
You pay $30
($30 Copayment)
The Claims Administrator
pays
$70
(Allowable Amount
minus
your Cost Share)
Total payment to the
doctor
$100
(Allowable Amount)
In this example, because you have already met your Deductible, you are only
responsible for the Participating Provider Copayment.
Your payment information 34
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Claims
When you receive health care services, a claim must be submitted to request payment
for Covered Services. A claim must be submitted even if you have not yet met your
Deductible. The Claims Administrator uses claims information to track dollar amounts
that count toward your Deductible and Out-of-Pocket Maximum.
When you see a Participating Provider, your provider submits the claim to the Claims
Administrator. However, you may need to submit the claim to the Claims Administrator
for the following services when received from a Non-Participating Provider:
•For Emergency or Urgent Services; and
•Inter-Plan Arrangements, including the BlueCard® and Blue Shield Global®
Core programs described in the Out-of-area services section.
Claim forms are available at blueshieldca.com. Please submit your claim form and
medical records within one year of the service date.
See the Out-of-Area services section in the Other important information about your plan
section for more information on claims outside of California.
35
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Your coverage
This section explains eligibility and enrollment for this Plan. It also describes the terms of
your coverage, including information about effective dates and the different ways your
coverage can end.
Eligibility for this Plan
To be eligible for coverage as a Participant, you must meet all of your Employer’s
eligibility requirements and complete any waiting period established by your Employer.
Dependent eligibility
To be eligible for coverage as a Dependent, you must:
•Be listed on the enrollment form completed by the Participant; and
•Be the Participant’s spouse, Domestic Partner, or be under age 26 and the
child of the Participant, spouse, or Domestic Partner.
o For the Participant’s spouse to be eligible for this Plan, the Participant and
spouse must not be legally separated.
o For the Participant’s Domestic Partner to be eligible for this Plan, the
Participant and Domestic Partner must meet all the following
requirements:
▪Both partners are 18 years of age or older;
▪The partners have chosen to share one another’s lives in an intimate
and committed relationship of mutual caring;
▪The partners are:
•not currently married to someone else or a member of another
domestic partnership, and
•not so closely related by blood that legal marriage or registered
domestic partnership is prohibited;
▪Both partners are capable of consenting to the domestic partnership;
and
▪If required under your Plan Sponsor’s eligibility requirements, provide a
declaration of domestic partnership.
o “Child” includes a stepchild, newborn, child placed for adoption, child
placed in foster care, and child for whom the Participant, spouse, or
Domestic Partner is the legal guardian. It does not include a grandchild
unless the Participant, spouse, or Domestic Partner has adopted or is the
legal guardian of the grandchild.
o A child age 26 or older can remain enrolled as a Dependent if the child is
disabled, incapable of self-support because of a mental or physical
disability, and chiefly dependent on the Participant for economic support.
▪The Dependent child’s disability must have begun before the period
he or she would become ineligible for coverage due to age.
▪The Claims Administrator will send a notice of termination due to loss of
eligibility 90 days before the date coverage will end.
▪The Participant must submit proof of continued eligibility for the
Dependent at the Claims Administrator’s request. The Claims
Administrator may not request this information again for two years after
Your coverage 36
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
the initial determination. The Claims Administrator may request this
information no more than once a year after that. The Participant’s
failure to provide this information could result in termination of a
Dependent’s coverage.
If both partners in a marriage or Domestic Partnership are eligible Employees and
Participants, both are eligible for Dependent Benefits. You may enroll a child as a
Dependent of either or of both parents.
A child will be considered adopted for the purpose of Dependent eligibility when
one of the following happens:
•The child is legally adopted;
•The child is placed for adoption and there is evidence of the Participant,
spouse, or Domestic Partner’s right to control the child’s health care; or
•The Participant, spouse, or Domestic Partner is granted legal authority to
control the child’s health care.
The child’s eligibility as a Dependent will continue while waiting for a legal decree of
adoption unless the child is removed from the Participant, spouse, or Domestic
Partner’s home before the decree is issued.
Enrollment and effective dates of coverage
As the Participant, you can enroll in coverage for yourself and your Dependents during
your initial enrollment period, your Employer’s annual open enrollment period, or if you
qualify for a special enrollment period.
You are eligible for coverage as a Participant on the day following the date you
complete any applicable waiting period established by your Employer. Coverage starts
at 12:01 a.m. Pacific Time on the effective date of coverage. The Benefits of this plan
are not available before the effective date of coverage.
Annual open enrollment
An annual open enrollment period will be available for any Member or Dependent
who failed to enroll:
•during the first period in which he or she was eligible to enroll, or during any
subsequent special enrollment period; or
•during any previous annual open enrollment period; or
•within 31 days after the termination date, if the individual was previously covered
under the Plan but elected to terminate the coverage.
To qualify for enrollment during the annual open enrollment period, the Member or
Dependent:
•must meet the eligibility requirements described in the Plan, including satisfaction
of any applicable waiting period; and
•may not be covered under an alternate medical expense coverage offered by
the Employer, unless the annual open enrollment period happens to coincide with
a separate open enrollment period established for coverage election.
Your coverage 37
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
The effective date for any qualified individual requesting coverage during the annual
open enrollment period will be the day immediately following the completion of the
annual open enrollment period.
Special enrollment period
A special enrollment period is a time outside open enrollment when you can apply
for coverage or change coverage. A special enrollment period begins with a
Qualifying Event.
A special enrollment period gives you at least 30 days from a Qualifying Event to
apply for or change coverage for yourself or your Dependents. See the Special
enrollment period section for more information. You should notify your Employer as
soon as possible if you experience a Qualifying Event that requires a change in your
coverage.
If you or your Dependent request enrollment after the first period in which you or your
Dependent were eligible to enroll but during a special enrollment event due to a
family status change (newborn, child placed for adoption, child acquired by legal
guardianship, new spouse or Domestic Partner, newly hired or newly transferred
Employees), you or your Dependent will be a special enrollee and will not be
considered a Late Enrollee.
If the Employer offers different Benefit options, a Benefit option transfer may also be
made on any contribution due date if your request is due to a special enrollment event
and you complete the appropriate enrollment form within the time specified for a
special enrollment event due to a family status change (newborn, child placed for
adoption, child acquired by legal guardianship, new spouse or Domestic Partner,
newly hired or newly transferred Employees).
If a request for contributory coverage is made more than 31 days after the date an
individual is eligible but during a special enrollment event due to a family status
change, coverage for such individual will become effective as described within in
this section.
Common Qualifying Events
Change in Dependents
Loss of coverage under another employer health plan or other health
insurance
Loss of eligibility in a government program
For a complete list of Qualifying Events, see Special enrollment
period on page 71 in the Other important information about
your plan section.
Your coverage 38
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Effective date of coverage for most special enrollment periods
If enrolled during initial enrollment or open enrollment, a Dependent will have
the same effective date of coverage as the Participant. However, a Dependent
may have a different effective date of coverage if added during a special
enrollment period. Generally, if the Employee or Dependents qualify for a special
enrollment period, coverage will begin no later than the 1st of the month
following the date the Claims Administrator receives the request for special
enrollment from your Employer.
Effective date of coverage for a new Dependent child
Coverage starts immediately for a:
•Newborn;
•Adopted child;
•Child placed for adoption;
•Child placed in foster care; or
•Child for whom the Participant, spouse, or Domestic Partner is the court-
appointed legal guardian.
For coverage to continue beyond 31 days for a newborn,
adopted child, or child placed for adoption, the Participant
must notify your Employer within 31 days of birth, adoption, or
placement for adoption.
Plan changes
The Plan Sponsor has the right to change the Benefits and terms of this Plan as the law
permits. This includes, but is not limited to, changes to:
•Terms and conditions;
•Benefits;
•Cost Shares;
•Participant Contributions; and
•Limitations and exclusions.
Benefits provided after the effective date of any change will be subject to the change.
There is no vested right to obtain the original Benefits.
Coordination of benefits
When you are covered by more than one group health plan, payments for allowable
expenses will be coordinated between the two plans. Coordination of benefits
determines which plan will pay first when both plans have responsibility for paying the
medical claim. For more information, see the Coordination of benefits, continued
section.
Your coverage 39
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When coverage ends
Your coverage will end if:
•You are no longer eligible for coverage in this Plan;
•Your Employer terminates or discontinues the Plan;
•The Participant cancels coverage; or
•The Claims Administrator cancels or rescinds coverage.
There is no right to receive the Benefits of this Plan after coverage ends, except as
described in the Continuity of Care and Continuation of group coverage sections.
If your Employer terminates or discontinues the Plan
Your Employer may terminate or discontinue the Plan at any time.
If the Participant cancels coverage
If the Participant decides to cancel coverage, coverage will end at 11:59 p.m.
Pacific Time on a date determined by your Employer.
Reinstatement
If the Participant voluntarily cancels coverage, the Participant can contact the
Employer for reinstatement options.
If the Claims Administrator cancels coverage
The Claims Administrator can cancel your coverage if you or your Dependent
commit fraud or intentional misrepresentation of material fact.
Cancellation or rescission for fraud or intentional misrepresentation of material
fact
The Claims Administrator may cancel or rescind your coverage if you or your
Dependent commit fraud or intentional misrepresentation of material fact. The
Claims Administrator will send the Notice of Cancellation, Rescission or Nonrenewal
to your Employer prior to any rescission. Your Employer must provide you with a copy
of the Notice of Cancellation, Rescission or Nonrenewal. Rescission voids the
coverage as if it never existed. Cancellation or rescission is effective on the date
specified in the Notice of Cancellation, Rescission or Nonrenewal and the Notice of
End of Coverage.
Continuation of group coverage
Please examine your options carefully before declining this coverage.
You can continue coverage under this Plan when your Employer is subject to Title X of
the Consolidated Omnibus Budget Reconciliation Act (COBRA), as amended.
Your benefits under the group continuation of coverage provisions will be identical to
the Benefits you would have received as an active Employee if the qualifying event
had not occurred. Any changes in the coverage available to active Employees will also
apply to group continuation coverage.
Your coverage 40
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COBRA
You may elect to continue group coverage under this Plan if you would otherwise
lose coverage because of a COBRA qualifying event. Please contact your Employer
for detailed information about COBRA continuation coverage, including eligibility,
election of coverage, and COBRA dues.
COBRA qualifying event
A qualifying event is defined as a loss of coverage as a result of any one of the
following occurrences.
•With respect to the Employee:
o the termination of employment (other than by reason of gross
misconduct); or
o the reduction of hours of employment to less than the number of hours
required for eligibility.
•With respect to the Dependent spouse or Dependent Domestic Partner*
and Dependent children (children born to or placed for adoption with the
Participant or Domestic Partner during a COBRA continuation period may
be immediately added as Dependents, provided the Employer is properly
notified of the birth or placement for adoption, and such children are
enrolled within 30 days of the birth or placement for adoption):
*Note: Domestic Partners and Dependent children of Domestic Partners
cannot elect COBRA on their own, and are only eligible for COBRA if the
Participant elects to enroll.
o the death of the Participant; or
o the termination of the Participant’s employment (other than by reason
of such Participant’s gross misconduct); or
o the reduction of the Participant’s hours of employment to less than the
number of hours required for eligibility; or
o the divorce or legal separation of the Participant from the Dependent
spouse or termination of the domestic partnership; or
o the Participant’s entitlement to benefits under Title XVIII of the Social
Security Act (“Medicare”); or
o a Dependent child’s loss of Dependent status under this Plan.
•With respect to a Participant who is covered as a retiree, that retiree’s
Dependent spouse and Dependent children, the Employer's filing for
reorganization under Title XI, United States Code, commencing on or after
July 1, 1986.
•With respect to any of the above, such other qualifying event as may be
added to Title X of COBRA.
Notification of a qualifying event
You are responsible for notifying your Employer of divorce, legal separation, or a
child’s loss of Dependent status under this Plan, within 60 days of the date of the
Your coverage 41
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599-2650.
later of the qualifying event or the date on which coverage would otherwise
terminate under this Plan because of a qualifying event.
The Employer is responsible for notifying its COBRA administrator (or Plan
Administrator if the Employer does not have a COBRA administrator) of the
Member’s death, termination, or reduction of hours of employment, the
Member’s Medicare entitlement or the Employer’s filing for reorganization under
Title XI, United States Code.
When the COBRA administrator is notified that a Qualifying Event has occurred,
the COBRA administrator will, within 14 days, provide written notice to you by first
class mail of your right to continue group coverage under this Plan. You must
then notify the COBRA administrator within 60 days of the later of (1) the date of
the notice of your right to continue group coverage or (2) the date coverage
terminates due to the qualifying event.
If you do not notify the COBRA administrator within 60 days, your coverage will
terminate on the date you would have lost coverage because of the qualifying
event.
Duration and extension of group continuation coverage
In no event will continuation of group coverage under COBRA be extended for
more than 3 years from the date the qualifying event has occurred which
originally entitled you to continue group coverage under this Plan.
Note: Domestic Partners and Dependent children of Domestic Partners cannot
elect COBRA on their own, and are only eligible for COBRA if the Participant
elects to enroll.
Payment of COBRA dues
COBRA dues for the Member continuing coverage shall be 102 percent of the
applicable group dues rate, except for the Member who is eligible to continue
group coverage to 29 months because of a Social Security disability
determination, in which case, the dues for months 19 through 29 shall be 150
percent of the applicable group premium rate.
If you are contributing to the cost of coverage, the Employer shall be responsible
for collecting and submitting all dues contributions to the Claims Administrator in
the manner and for the period established under this Plan.
Effective date of the continuation of group coverage
The continuation of coverage will begin on the date your coverage under this
Plan would otherwise terminate due to the occurrence of a qualifying event and
it will continue for up to the applicable period, provided that coverage is timely
elected and so long as COBRA dues are timely paid.
Termination of group continuation coverage
The continuation of group coverage will cease if any one of the following events
occurs prior to the expiration of the applicable period of continuation of group
coverage:
Your coverage 42
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599-2650.
•Termination of the Plan (if your Employer continues to provide any group
health benefit plan for Employees, you may be able to continue coverage
with another plan);
•Failure to pay COBRA dues in full and on time to the Claims Administrator.
Coverage will end as of the end of the period for which COBRA dues were
paid;
•You become covered under another group health plan;
•You become entitled to Medicare; or
•You commit fraud or deception in the use of the services of this Plan.
Continuation of group coverage while on leave
Employers are responsible to ensure compliance with state and federal laws
regarding leaves of absence, including the Family and Medical Leave Act and the
Uniformed Services Employment and Re-employment Rights Act.
Family leave
The federal Family and Medical Leave Act of 1993 allow you to continue your
coverage under this Plan while you are on family leave. Your Employer is solely
responsible for notifying their Employee of the availability and duration of family
leaves.
Military leave
The Uniformed Services Employment and Re-employment Rights Act of 1994
(USERRA) allows you to continue your coverage under this Plan while you are on
military leave. If you are planning to enter the Armed Forces, you should contact
your Employer for information about your rights under the (USERRA).
43
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2650.
Your Benefits
This section describes the Benefits your plan covers. They are listed in alphabetical order
so they are easy to find. All Covered Services must be received from a Participating
Provider in the Claims Administrator’s PPO network, except:
•For Emergency or Urgent Services;
•Inter-Plan Arrangements, including the BlueCard® and Blue Shield Global®
Core programs described in the Out-of-area services section; and
•When prior authorized by the Claims Administrator.
The Claims Administrator provides coverage for Medically Necessary services and
supplies only. Experimental or Investigational services and supplies are not covered.
All Benefits are subject to:
•Your Cost Share;
•Any Benefit maximums;
•The provisions of the Medical Management Programs; and
•The terms, conditions, limitations, and exclusions of this Plan.
You can receive many outpatient Benefits in a variety of settings, including your home,
a Physician’s office, an urgent care center, an Ambulatory Surgery Center, or a
Hospital. The Claims Administrator’s Medical Management Programs work with your
provider to ensure that your care is provided safely and effectively in a setting that is
appropriate to your needs. Your Cost Share for outpatient Benefits may vary depending
on where you receive them.
See the Exclusions and limitations section for more information about Benefit exclusions
and limitations.
See the Summary of Benefits section for your Cost Share for
Covered Services.
Acupuncture services
Benefits are available for acupuncture evaluation and treatment. Acupuncture services
must be provided by a Physician, licensed acupuncturist, or other appropriately
licensed or certified Health Care Provider.
Contact the Claims Administrator with questions about acupuncture services or
acupuncture Benefits.
Allergy testing and immunotherapy Benefits
Benefits are available for allergy testing and immunotherapy services.
Benefits include:
•Allergy testing on and under the skin such as prick/puncture, patch and
scratch tests;
•Preparation and provision of allergy serum; and
Your Benefits 44
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599-2650.
•Allergy serum injections.
This Benefit does not include:
•Blood testing for allergies.
Ambulance services
Benefits are available for ambulance services provided by a licensed ambulance or
psychiatric transport van.
Benefits include:
•Emergency ambulance transportation (surface and air) when used to
transport you from the place of illness or injury to the closest medical facility
that can provide appropriate medical care; and
•Non-emergency, prior-authorized ambulance transportation (surface and air)
from one medical facility to another.
Air ambulance services are covered at the Participating Provider Cost Share, even if
you receive services from a Non-Participating Provider.
Bariatric surgery Benefits
Benefits are available for bariatric surgery services. These Benefits include facility and
Physician services for the surgical treatment of morbid obesity.
Services for residents of designated California counties
The Claims Administrator has a network of Participating Providers for bariatric surgery
services in certain designated counties within California. If you live in a designated
county, services are only covered if you receive them from one of these Participating
Providers.
Bariatric surgery services designated counties
Imperial Orange San Diego
Kern Riverside Santa Barbara
Los Angeles San Bernardino Ventura
Travel expense reimbursement for residents of designated counties
You may be eligible for reimbursement of your travel expenses for bariatric
surgery services if you meet the following conditions:
•Live in a designated county;
•Live at least 50 miles away from the nearest Bariatric Surgery Services
Provider in the network;
•Receive prior authorization for travel expense reimbursement; and
Your Benefits 45
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599-2650.
•Submit receipts and any other documentation of your expenses to the
Claims Administrator.
Reimbursable bariatric surgery travel expenses
Expense type Maximum
reimbursement Limitations & exclusions
Transportation to
and from the
facility
$130/roundtrip •Maximum of 3 roundtrips
(pre-surgery, surgery, follow-
up)
•1 companion is covered for
a maximum of 2 roundtrips
(surgery & surgery follow-up)
Hotel
accommodations
$100/day •Maximum of 2 trips, 2
days/trip (pre-surgery &
post-surgery follow-up) for
you and 1 companion
•1 companion alone may be
reimbursed for a maximum
of 4 days during your
surgery admission
•Hotel stays are limited to 1
double-occupancy room.
Only the room is covered.
All other hotel expenses are
excluded
Related
reasonable
expenses
$25/day/Member •Maximum of 4 days/trip
•Expenses for tobacco,
alcohol, drugs, phone,
television, delivery, and
recreation are excluded
Services for residents of non-designated counties
If you do not reside in a designated county, bariatric surgery services are covered
like other surgery services. See the Hospital services and Physician and other
professional services sections for more information.
The Claims Administrator does not reimburse travel expenses associated with
bariatric surgery services for residents of non-designated counties.
Chiropractic services
Benefits are provided for chiropractic services performed by a chiropractor or other
appropriately licensed or certified Health Care Provider. The chiropractic Benefit
includes the initial examination, subsequent office visits, adjustments, and plain film X-
ray services in a chiropractor’s office.
Your Benefits 46
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599-2650.
Benefits are limited to a per Member per Calendar Year visit maximum as shown on the
Summary of Benefits.
Clinical trials for treatment of cancer or life-threatening diseases or
conditions Benefits
Benefits are available for routine patient care when you have been accepted into an
approved clinical trial for treatment of cancer or a life-threatening disease or condition.
A life-threatening disease or condition is a disease or condition that is likely to result in
death unless its progression is interrupted.
The clinical trial must have therapeutic intent and the treatment must meet one of the
following requirements:
•Your Participating Provider determines that your participation in the clinical
trial would be appropriate based on either the trial protocol or medical and
scientific information provided by you; or
•You provide medical and scientific information establishing that your
participation in the clinical trial would be appropriate.
Coverage for routine patient care received while participating in a clinical trial requires
prior authorization. Routine patient care is care that would otherwise be covered by the
Plan if those services were not provided in connection with an approved clinical trial.
The Summary of Benefits section lists your Cost Share for Covered Services. These Cost
Share amounts are the same whether or not you participate in a clinical trial. Routine
patient care does not include:
•The investigational item, device, or service itself;
•Drugs or devices not approved by the U.S. Food and Drug Administration
(FDA);
•Travel, housing, companion expenses, and other non-clinical expenses;
•Any item or service that is provided solely to satisfy data collection and
analysis needs and that is not used in the direct clinical management of the
patient;
•Services that, except for the fact that they are being provided in a clinical
trial, are specifically excluded under the Plan;
•Services normally provided by the research sponsor free for any enrollee in
the trial; or
•Any service that is clearly inconsistent with widely accepted and established
standards of care for a particular diagnosis.
Approved clinical trial means a phase I, phase II, phase III, or phase IV clinical trial
conducted in relation to the prevention, detection, or treatment of cancer or other life-
threatening diseases or conditions, and the study or investigation meets one of the
following requirements:
•It is a drug trial conducted under an investigational new drug application
reviewed by the FDA;
•It is a drug trial exempt under federal regulations from a new drug
application; or
•It is federally funded or approved by one or more of the following:
o One of the National Institutes of Health;
Your Benefits 47
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599-2650.
o The Centers for Disease Control and Prevention;
o The Agency for Health Care Research and Quality;
o The Centers for Medicare & Medicaid Services; or
o A designated Agency affiliate or research entity as described in the
Affordable Care Act, including the Departments of Veterans Affairs,
Defense, or Energy if the study has been reviewed and approved
according to Health and Human Services guidelines.
Diabetes care services
Benefits are available for devices, equipment, supplies, and self-management training
to help manage your diabetes. Services will be covered when provided by a Physician,
registered dietician, registered nurse, or other appropriately-licensed Health Care
Provider who is certified as a diabetes educator.
Devices, equipment, and supplies
Covered diabetic devices, equipment, and supplies include:
•Blood glucose monitors, including continuous blood glucose monitors and
those designed to help the visually impaired, and all related necessary
supplies;
•Insulin pens, syringes, pumps and all related necessary supplies;
•Disposable hypodermic needles and syringes needed for administration of
insulin and glucagon;
•Blood and urine testing strips and tablets;
•Lancets and lancet puncture devices;
•Podiatric footwear and devices to prevent or treat diabetes-related
complications;
•Medically Necessary foot care; and
•Visual aids, excluding eyewear and video-assisted devices, designed to help
the visually impaired with proper dosing of insulin.
Your Plan also covers the replacement of a covered item after the expiration of its life
expectancy. Insulin and glucagon may be covered under the Prescription Drug Rider, if
your Employer selected it as an optional Benefit.
Self-management training and medical nutrition therapy
Benefits are available for outpatient training, education, and medical nutrition
therapy when directed or prescribed by your Physician. These services can help you
manage your diabetes and properly use the devices, equipment, and supplies
available to you. With self-management training, you can learn to monitor your
condition and avoid frequent hospitalizations and complications.
Diagnostic X-ray, imaging, pathology, laboratory, and other testing
services
Benefits are available for imaging, pathology, and laboratory services for preventive
screening or to diagnose or treat illness or injury.
Your Benefits 48
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599-2650.
Benefits include:
•Basic diagnostic imaging services, such as plain film X-rays, ultrasounds, and
mammography;
•Advanced diagnostic radiological and nuclear imaging, including CT, PET,
MRI, and MRA scans;
•COVID-19 diagnostic testing, screening testing, and related healthcare
services. Medical Necessity requirements do not apply for COVID-19
screening testing;
•Reimbursement for over-the-counter at-home COVID-19 tests. The
reimbursement is allowed for up to 8 tests per Member per month. See the
Claims section for information about how to submit a claim for repayment for
this Benefit;
•Clinical pathology services;
•Laboratory services;
•Other areas of non-invasive diagnostic testing, including respiratory,
neurological, vascular, cardiological, genetic, cardiovascular and
cerebrovascular; and
•Prenatal diagnosis of genetic disorders of the fetus in cases of high-risk
pregnancy.
Laboratory or imaging services performed as part of a preventive health screening are
covered under the Preventive Health Services Benefit.
For services provided by Participating Providers, the Claims Administrator will waive Cost
Shares for COVID-19 diagnostic testing, screening testing, and related services.
The Claims Administrator encourages Members to seek services from Participating
Providers to avoid paying extra fees. Some Non-Participating Providers may charge
extra fees that are not covered by the Claims Administrator. Any fees not covered by
the Claims Administrator will be the Member’s responsibility. See the How to access
care section for information about Participating and Non-Participating Providers.
Dialysis Benefits
Benefits are available for dialysis services at a freestanding dialysis center, in the
Outpatient Department of a Hospital, in a physician office setting, or in your home.
Benefits include:
•Renal dialysis;
•Hemodialysis;
•Peritoneal dialysis; and
•Self-management training for home dialysis.
Benefits do not include:
•Comfort, convenience, or luxury equipment; or
•Non-medical items, such as generators or accessories to make home dialysis
equipment portable.
Your Benefits 49
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599-2650.
Durable medical equipment
Benefits are available for durable medical equipment (DME) and supplies needed to
operate the equipment. DME is intended for repeated use to treat an illness or injury, to
improve the function of movable body parts, or to prevent further deterioration of your
medical condition. Items such as orthotics and prosthetics are only covered when
necessary for Activities of Daily Living.
Benefits include:
•Mobility devices, such as wheelchairs;
•Peak flow meter for the self-management of asthma;
•Glucose monitor, including continuous blood glucose monitors, and all
related necessary supplies for the self-management of diabetes;
•Apnea monitors for the management of newborn apnea;
•Home prothrombin monitor for specific conditions;
•Oxygen and respiratory equipment;
•Disposable medical supplies used with DME and respiratory equipment;
•Required dialysis equipment and medical supplies;
•Medical supplies that support and maintain gastrointestinal, bladder, or
bowel function, such as ostomy supplies;
•DME rental fees, up to the purchase price; and
•Breast pumps.
Benefits do not include:
•Environmental control and hygienic equipment, such as air conditioners,
humidifiers, dehumidifiers, or air purifiers;
•Exercise equipment;
•Routine maintenance, repair, or replacement of DME due to loss or misuse,
except when authorized;
•Self-help or educational devices;
•Speech or language assistance devices, except as specifically listed;
•Wigs;
•Adult eyewear;
•Video-assisted visual aids for diabetics;
•Generators;
•Any other equipment not primarily medical in nature; or
•Backup or alternate equipment.
See the Diabetes care services section for more information about devices, equipment,
and supplies for the management and treatment of diabetes. Self-applied continuous
blood glucose monitors are also covered under the Prescription Drug Benefits Rider, if
your Employer selected it as an optional Benefit.
Orthotic equipment and devices
Benefits are available for orthotic equipment and devices you need to perform
Activities of Daily Living. Orthotics are orthopedic devices used to support, align,
prevent, or correct deformities or to improve the function of movable body parts.
Your Benefits 50
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Benefits include:
•Shoes only when permanently attached to orthotic devices;
•Special footwear required for foot disfigurement caused by disease, disorder,
accident, or developmental disability;
•Knee braces for postoperative rehabilitation following ligament surgery,
instability due to injury, and to reduce pain and instability for patients with
osteoarthritis;
•Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist
and used to treat mechanical problems of the foot, ankle, or leg by
preventing abnormal motion and positioning when improvement has not
occurred with a trial of strapping or an over-the-counter stabilizing device;
•Device fitting and adjustment;
•Device replacement at the end of its expected lifespan; and
•Repair due to normal wear and tear.
Benefits do not include:
•Orthotic devices intended to provide additional support for recreational or
sports activities;
•Orthopedic shoes and other supportive devices for the feet, except as listed;
•Backup or alternate items; or
•Repair or replacement due to loss or misuse.
Prosthetic equipment and devices
Benefits are available for prosthetic appliances and devices used to replace a part
of your body that is missing or does not function, and related supplies.
Benefits include:
•Tracheoesophageal voice prosthesis (e.g. Blom-Singer device) and artificial
larynx for speech after a laryngectomy;
•Artificial limbs and eyes;
•Internally-implanted devices such as pacemakers, intraocular lenses,
cochlear implants, osseointegrated hearing devices, and hip joints, if surgery
to implant the device is covered;
•Contact lenses to treat eye conditions such as keratoconus or keratitis sicca,
aniridia, or to treat aphakia following cataract surgery when no intraocular
lens has been implanted;
•Supplies necessary for the operation of prostheses;
•Device fitting and adjustment;
•Device replacement at the end of its expected lifespan; and
•Repair due to normal wear and tear.
Benefits do not include:
•Speech or language assistance devices, except as listed;
•Dental implants;
•Backup or alternate items; or
•Repair or replacement due to loss or misuse.
Your Benefits 51
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599-2650.
Emergency Benefits
Benefits are available for Emergency Services received in the emergency room of a
Hospital or other emergency room licensed under state law. The Emergency Benefit
also includes Hospital admission when inpatient treatment of your Emergency Medical
Condition is Medically Necessary. You can access Emergency Services for an
Emergency Medical Condition at any Hospital, even if it is a Non-Participating Hospital.
If you have a medical emergency, call 911 or seek immediate
medical attention at the nearest hospital.
Benefits include:
•Physician services;
•Emergency room facility services; and
•Inpatient Hospital services to stabilize your Emergency Medical Condition.
After your condition stabilizes
Once your Emergency Medical Condition has stabilized, it is no longer considered an
emergency. Upon stabilization, you may:
•Be released from the emergency room if you do not need further treatment;
•Receive additional inpatient treatment at the Participating Hospital; or
•Transfer to a Participating Hospital for additional inpatient treatment if you
received treatment of your Emergency Medical Condition at a Non-
Participating Hospital.
Stabilization is medical treatment necessary to assure, with reasonable medical
probability, that no material deterioration of the condition is likely to result from, or
occur during, your release from medical care or transfer from a facility. With respect
to a pregnant woman who is having contractions, when there is inadequate time to
safely transfer her to another Hospital before delivery or the transfer may pose a
threat to the health or safety of the woman or unborn child, stabilize means delivery,
including the placenta. Post-stabilization care is Medically Necessary treatment
received after the treating Physician determines the Emergency Medical Condition is
stabilized.
If you are admitted to the Hospital for Emergency Services, you should notify the
Claims Administrator within 24 hours or as soon as possible after your condition has
stabilized.
Family planning Benefits
Family planning
Benefits are available for family planning services without illness or injury.
Benefits include:
•Counseling, consulting, and education;
Your Benefits 52
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599-2650.
•Office-administered contraceptives;
•Physician office visits for office-administered contraceptives;
•Tubal ligation; and
•Vasectomy.
Benefits do not include family planning services from Non-Participating Providers.
Home health services
Benefits are available for home health services. These services include home health
agency services, home infusion and injectable medication services, and hemophilia
home infusion services.
Home health agency services
Benefits are available from a Participating home health care agency for diagnostic
and treatment services received in your home under a written treatment plan
approved by your Physician.
Benefits include:
•Intermittent home care for skilled services from:
o Registered nurses;
o Licensed vocational nurses;
o Physical therapists;
o Occupational therapists;
o Speech and language pathologists;
o Licensed clinical social workers; and
o Home Health Aides.
•Related medical supplies.
Intermittent home care is for skilled services you receive:
•Fewer than seven days per week; or
•Daily, for fewer than eight hours per day, up to 21 days.
Benefits are limited to a visit maximum as shown in the Summary of Benefits section
for home health agency visits. For this Benefit, coverage includes:
•Up to four visits per day, two hours maximum per visit, with a registered nurse,
licensed vocational nurse, physical therapist, occupational therapist, speech
and language pathologist, or licensed clinical social worker. A visit of two
hours or less is considered one visit. Nursing visits cannot be combined to
provide Continuous Nursing Services.
•Up to four hours maximum per visit with a Home Health Aide. A visit of four
hours or less is considered one visit.
Benefits do not include:
•Continuous Nursing Services provided by a registered nurse or a licensed
vocational nurse, on a one-to-one basis, in an inpatient or home setting.
These services may also be described as “shift care” or “private-duty nursing.”
Your Benefits 53
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599-2650.
Home infusion and injectable medication services
Benefits are available through a Participating home infusion agency for home
infusion, enteral, and injectable medication therapy.
Benefits include:
•Home infusion agency Skilled Nursing visits;
•Infusion therapy provided in an infusion suite associated with a Participating
home infusion agency;
•Administration of parenteral nutrition formulations and solutions;
•Administration of enteral nutrition formulas and solutions;
•Medical supplies used during a covered visit; and
•Medications injected or administered intravenously.
See the PKU formulas and special food products section for more information.
There is no Calendar Year visit maximum for home infusion agency services.
This Benefit does not include:
•Insulin;
•Insulin syringes; and
•Services related to hemophilia, which are described below.
Hemophilia home infusion services
Benefits are available for hemophilia home infusion products and services for the
treatment of hemophilia and other bleeding disorders. Benefits must be prior
authorized and provided in the home or in an infusion suite managed by a
Participating Hemophilia Home Infusion Provider.
Benefits include:
•24-hour service;
•Home delivery of hemophilia infusion products;
•Blood factor product;
•Supplies for the administration of blood factor product; and
•Nursing visits for training or administration of blood factor products.
There is no Calendar Year visit maximum for hemophilia home infusion agency
services.
Benefits do not include:
•In-home services to treat complications of hemophilia replacement therapy;
or
•Self-infusion training programs, other than nursing visits to assist in
administration of the product.
Your Benefits 54
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599-2650.
Most Participating home health care and home infusion agencies are not
Participating Hemophilia Home Infusion Providers. A list of Participating Hemophilia
Home Infusion Providers is available at blueshieldca.com.
Hospice program services
Benefits are available through a Participating Hospice Agency for specialized care if
you have been diagnosed with a terminal illness with a life expectancy of one year or
less. When you enroll in a Hospice program, you agree to receive all care for your
terminal illness through the Hospice Agency. Hospice program enrollment is prior
authorized for a specified period of care based on your Physician’s certification of
eligibility. The period of care begins the first day you receive Hospice services and ends
when the specified timeframe is over or you choose to receive care for your terminal
illness outside of the Hospice program.
The authorized period of care is for two 90-day periods followed by unlimited 60-day
periods, depending on your diagnosis. Your Hospice care continues through to the next
period of care when your Physician recertifies that you have a terminal illness. The
Hospice Agency works with your Physician to ensure that your Hospice enrollment
continues without interruption. You can change your Participating Hospice Agency only
once during each period of care.
A Hospice program provides interdisciplinary care designed to ease your physical,
emotional, social, and spiritual discomfort during the last phases of life, and support
your primary caregiver and your family. Hospice services are available 24 hours a day
through the Hospice Agency.
While enrolled in a Hospice program, you may continue to receive Covered Services
that are not related to the care and management of your terminal illness from the
appropriate Health Care Provider. However, all care related to your terminal illness must
be provided through the Hospice Agency. You may discontinue your Hospice
enrollment when an acute Hospital admission is necessary, or at any other time. You
may also enroll in the Hospice program again when you are discharged from the
Hospital, or at any other time, with Physician recertification.
Benefits include:
•Pre-Hospice consultation to discuss care options and symptom management;
•Advance care planning;
•Skilled Nursing Services;
•Medical direction and a written treatment plan approved by a Physician;
•Continuous Nursing Services provided by registered or licensed vocational
nurses, eight to 24 hours per day;
•Home Health Aide services, supervised by a nurse;
•Homemaker services, supervised by a nurse, to help you maintain a safe and
healthy home environment;
•Medical social services;
•Dietary counseling;
•Volunteer services by a Hospice agency;
•Short-term inpatient, Hospice house, or Hospice care, if required;
•Drugs, medical equipment, and supplies;
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•Physical therapy, occupational therapy, and speech-language pathology
services to control your symptoms or help your ability to perform Activities of
Daily Living;
•Respiratory therapy;
•Occasional, short-term inpatient respite care when necessary to relieve your
primary caregiver or family members, up to five days at a time;
•Bereavement services for your family; and
•Social services, counseling, and spiritual services for you and your family.
Benefits do not include:
•Services provided by a Non-Participating Hospice Agency, except in certain
circumstances where there are no Participating Hospice Agencies in your
area and services are prior authorized.
Hospital services
Benefits are available for inpatient care in a Hospital.
Benefits include:
•Room and board, such as:
o Semiprivate Hospital room, or private room if Medically Necessary;
o Specialized care units, including adult intensive care, coronary care,
pediatric and neonatal intensive care, and subacute care;
o General and specialized nursing care; and
o Meals, including special diets.
•Other inpatient Hospital services and supplies, including:
o Operating, recovery, labor and delivery, and other specialized
treatment rooms;
o Anesthesia, oxygen, medicines, and IV solutions;
o Clinical pathology, laboratory, radiology, and diagnostic services and
supplies;
o Dialysis services and supplies;
o Blood and blood products;
o Medical and surgical supplies, surgically implanted devices,
prostheses, and appliances;
o Radiation therapy, chemotherapy, and associated supplies;
o Therapy services, including physical, occupational, respiratory, and
speech therapy;
o Acute detoxification;
o Acute inpatient rehabilitative services; and
o Emergency room services resulting in admission.
Medical treatment of the teeth, gums, jaw joints, and jaw bones
Benefits are available for outpatient, Hospital, and professional services provided for
treatment of the jaw joints and jaw bones, including adjacent tissues.
Benefits include:
•Treatment of odontogenic and non-odontogenic oral tumors (benign or
malignant);
Your Benefits 56
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599-2650.
•Stabilization of natural teeth after traumatic injury independent of disease,
illness, or any other cause;
•Surgical treatment of temporomandibular joint syndrome (TMJ);
•Non-surgical treatment of TMJ;
•Orthognathic surgery to correct a skeletal deformity;
•Dental and orthodontic services directly related to cleft palate repair;
•Dental services to prepare the jaw for radiation therapy for the treatment of
head or neck cancers; and
•General anesthesia and associated facility charges during dental treatment
due to the Member’s underlying medical condition or clinical status when:
o The Member is younger than seven years old; or
o The Member is developmentally disabled; or
o The Member’s health is compromised and general anesthesia is
Medically Necessary.
Benefits do not include:
• Diagnostic dental services such as oral examinations, oral pathology, oral
medicine, X-rays, and models of the teeth, except when related to surgical
and non-surgical treatment of TMJ;
•Preventive dental services such as cleanings, space maintainers, and habit
control devices except as covered under the Preventive Health Services
Benefit;
•Periodontal care such as hard and soft tissue biopsies and routine oral surgery
including removal of teeth;
•Reconstructive or restorative dental services such as crowns, fillings, and root
canals;
•Orthodontia for any reason other than cleft palate repair;
•Dental implants for any reason other than cleft palate repair;
•Any procedure to prepare the mouth for dentures or for the more
comfortable use of dentures;
•Alveolar ridge surgery of the jaws if performed primarily to treat diseases
related to the teeth, gums, or periodontal structures, or to support natural or
prosthetic teeth; or
•Fluoride treatments for any reason other than preparation of the oral cavity
for radiation therapy or for Benefits covered under Preventive Health Services.
Mental Health and Substance Use Disorder Benefits
The Claims Administrator administers Mental Health Services and Substance Use
Disorder Services for Members. See the Out-of-area services section for an explanation
of how Benefits are administered for out-of-state services.
A Participating Provider must get prior authorization from the Claims Administrator for all
non-emergency Hospital admissions for Mental Health Services and Substance Use
Disorder Services, and for certain outpatient Mental Health and Substance Use Disorder
Services. See the Medical Management Programs section for more information about
prior authorization.
All covered Mental Health and Substance Use Disorder Services must be received from
a Participating Provider, except:
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•For Emergency or Urgent Services
•Inter-Plan Arrangements, including the BlueCard® and Blue Shield Global®
Core programs described in the Out-of-area services section; and
•When prior authorized by the Claims Administrator.
Office visits
Benefits are available for professional office visits, including Physician office visits, for
the diagnosis and treatment of Mental Health Conditions and Substance Use
Disorder Conditions in an individual, Family, or group setting.
Benefits are also available for telebehavioral health online counseling services,
psychotherapy, and medication management with a mental health or substance
use disorder provider.
Other Outpatient Mental Health and Substance Use Disorder Services
In addition to office visits, Benefits are available for other outpatient services for the
diagnosis and treatment of Mental Health Conditions and Substance Use Disorder
Conditions. You can receive these other outpatient services in a facility, office,
home, or other non-institutional setting.
Other Outpatient Mental Health and Substance Use Disorder Services include, but
are not limited to:
•Behavioral Health Treatment – professional services and treatment programs,
including applied behavior analysis and evidence-based intervention
programs, prescribed by a Physician or licensed psychologist and provided
under a treatment plan to develop or restore, to the maximum extent
practicable, the functioning of an individual with pervasive developmental
disorder or autism;
•Electroconvulsive therapy – the passing of a small electric current through the
brain to induce a seizure, used in the treatment of severe depression;
•Intensive Outpatient Program – outpatient care for Mental Health Conditions
or Substance Use Disorder Conditions when your condition requires structure,
monitoring, and medical/psychological intervention at least three hours per
day, three days per week;
•Office-based opioid treatment – substance use disorder maintenance
therapy, including methadone maintenance treatment;
•Partial Hospitalization Program – an outpatient treatment program that may
be in a free-standing or Hospital-based facility and provides services at least
five hours per day, four days per week when you are admitted directly or
transferred from acute inpatient care following stabilization;
•Psychological Testing – testing to diagnose a Mental Health Condition; and
•Transcranial magnetic stimulation – a non-invasive method of delivering
electrical stimulation to the brain for the treatment of severe depression.
Benefits do not include:
•Treatment for the purposes of providing respite, day care, or educational
services, or to reimburse a parent for participation in the treatment.
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Inpatient Services
Benefits are available for inpatient facility and professional services for the treatment
of Mental Health Conditions and Substance Use Disorder Conditions in:
•A Hospital; or
•A free-standing residential treatment center that provides 24-hour care when
you do not require acute inpatient care.
Medically Necessary inpatient substance use disorder detoxification is covered
under the Hospital services Benefit.
Outpatient Prescription Drug Benefits
No Benefits are provided for Outpatient prescription Drugs under this Plan. Please
contact your Employer for information on the Outpatient prescription Drug Benefits
provided through a separate entity other than the Claims Administrator.
Physician and other professional services
Benefits are available for services performed by a Physician, surgeon, or other Health
Care Provider to diagnose or treat a medical condition.
Benefits include:
•Office visits for examination, diagnosis, counseling, education, consultation,
and treatment;
•Specialist office visits;
•Urgent care center visits;
•Second medical opinions;
•Administration of injectable medications;
•Administration of radiopharmaceutical medications;
•Outpatient services;
•Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment
center, or emergency room;
•Home visits;
•Telehealth consultations, provided remotely via communication
technologies, for examination, diagnosis, counseling, education, and
treatment; and
•Teladoc general medical consultations.
See the Mental Health and Substance Use Disorder Benefits section for information on
Mental Health and Substance Use Disorder office visits and Other Outpatient Mental
Health and Substance Use Disorder services.
Medical nutrition therapy
Benefits are provided for office visits for medical nutrition therapy for conditions other
than diabetes. Treatment must be prescribed by a Physician and provided by a
Registered Dietitian Nutritionist or other appropriately-licensed or certified Health
Care Provider. You can continue to receive medical nutrition therapy as long as your
treatment is Medically Necessary. The Claims Administrator may periodically review
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the provider’s treatment plan and records for Medical Necessity. See the Diabetes
care services section for information about medical nutrition therapy for diabetes.
PKU formulas and special food products
Benefits are available for formulas and special food products if you are diagnosed with
phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a
Physician or appropriately-licensed Health Care Provider.
Benefits include:
•Enteral formulas;
•Parenteral nutrition formulations; and
•Special food products for the dietary treatment of PKU.
Benefits do not include:
•Grocery store foods including shakes, snack bars, used by the general
population;
•Additives such as thickeners, enzyme products, or
•Food that is naturally low in protein, unless specially formulated to have less
than one gram of protein per serving.
Podiatric services
Benefits are available for the diagnosis and treatment of conditions of the foot, ankle,
and related structures. These services, including surgery, are generally provided by a
licensed doctor of podiatric medicine.
Pregnancy and maternity care
Benefits are available for maternity care services.
Benefits include:
•Prenatal care;
•Postnatal care;
•Involuntary complications of pregnancy;
•Inpatient Hospital services including labor, delivery, and postpartum care;
•Elective newborn circumcision within 18 months of birth; and
•Abortion and abortion-related services, including pre-abortion and follow-up
services.
See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive
Health Services sections for information about coverage of genetic testing and
diagnostic procedures related to pregnancy and maternity care.
The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a
minimum Hospital stay for the mother and newborn child of 48 hours after a normal,
vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation
with the mother, may determine that a shorter length of stay is adequate. If your
Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a
Health Care Provider whose scope of practice includes postpartum and newborn care.
This follow-up visit may occur at home or as an outpatient, as necessary. This visit will
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include parent education, assistance and training in breast or bottle feeding, and any
necessary physical assessments for the mother and child. Prior authorization is not
required for this follow-up visit.
Preventive Health Services
Benefits are available for Preventive Health Services such as screenings, checkups, and
counseling to prevent health problems or detect them at an early stage. The Claims
Administrator only covers Preventive Health Services when you receive them from a
Participating Provider.
Benefits include:
•Evidence-based items, drugs, or services that have a rating of A or B in the
current recommendations of the United States Preventive Services Task Force
(USPSTF), such as:
o Screening for cancer, such as colorectal cancer, cervical cancer,
breast cancer, and prostate cancer;
o Screening for HPV;
o Screening for osteoporosis; and
o Health education;
•Immunizations recommended by either the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention, or
the most current version of the Recommended Childhood Immunization
Schedule/United States, jointly adopted by the American Academy of
Pediatrics, the Advisory Committee on Immunization Practices, and the
American Academy of Family Physicians;
•Evidence-informed preventive care and screenings for infants, children, and
adolescents as listed in the comprehensive guidelines supported by the
Health Resources and Services Administration, including screening for risk of
lead exposure and blood lead levels in children at risk for lead poisoning;
•California Prenatal Screening Program; and
•Additional preventive care and screenings for women not described above
as provided for in comprehensive guidelines supported by the Health
Resources and Services Administration. See the Family planning Benefits
section for more information.
If there is a new recommendation or guideline in any of the resources described above,
the Claims Administrator will have at least one year to implement coverage. The new
recommendation will be covered as a Preventive Health Service in the Plan Year that
begins after that year. However, for COVID-19 Preventive Health Services and
Preventive Health Services for a disease for which the Governor of the State of
California has declared a public health emergency, a new recommendation will be
covered within 15 business days.
Visit blueshieldca.com/preventive for more information about
Preventive Health Services.
Your Benefits 61
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Reconstructive Surgery Benefits
Benefits are available for Reconstructive Surgery services.
Benefits include:
•Surgery to correct or repair abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma, infection, tumors,
or disease to:
o Improve function; or
o Create a normal appearance to the extent possible;
•Dental and orthodontic surgery services directly related to cleft palate repair;
and
•Surgery and surgically-implanted prosthetic devices in accordance with the
Women’s Health and Cancer Rights Act of 1998 (WHCRA).
Benefits do not include:
•Cosmetic surgery, which is surgery that is performed to alter or reshape
normal structures of the body to improve appearance;
•Reconstructive Surgery when there is a more appropriate procedure that will
be approved; or
•Reconstructive Surgery to create a normal appearance when it offers only a
minimal improvement in appearance.
In accordance with the WHCRA, Reconstructive Surgery, and surgically implanted and
non-surgically implanted prosthetic devices (including prosthetic bras), are covered for
either breast to restore and achieve symmetry following a mastectomy, and for the
treatment of the physical complications of a mastectomy, including lymphedemas. For
coverage of prosthetic devices following a mastectomy, see the Durable medical
equipment section. Medically Necessary services will be determined by your attending
Physician in consultation with you.
Benefits will be provided in accordance with guidelines established by the Claims
Administrator and developed in conjunction with plastic and reconstructive surgeons,
except as required under the WHCRA.
Rehabilitative and habilitative services
Benefits are available for outpatient rehabilitative and habilitative services.
Rehabilitative services help to restore the skills and functional ability you need to
perform Activities of Daily Living when you are disabled by injury or illness. Habilitative
services are therapies that help you learn, keep, or improve the skills or functioning you
need for Activities of Daily Living.
These services include physical therapy, occupational therapy, and speech therapy.
Your Physician or Health Care Provider must prepare a treatment plan. Treatment must
be provided by an appropriately-licensed or certified Health Care Provider. You can
continue to receive rehabilitative or habilitative services as long as your treatment is
Medically Necessary.
The Claims Administrator may periodically review the provider’s treatment plan and
records for Medical Necessity.
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See the Hospital services section for information about inpatient rehabilitative Benefits.
See the Home health services and Hospice program services sections for information
about coverage for rehabilitative and habilitative services provided in the home.
Physical therapy
Physical therapy uses physical agents and therapeutic treatment to develop,
improve, and maintain your musculoskeletal, neuromuscular, and respiratory systems.
Physical agents and therapeutic treatments include but are not limited to:
•Ultrasound;
•Heat;
•Range of motion testing;
•Targeted exercise; and
•Massage as a component of a multimodality rehabilitative treatment plan or
physical therapy treatment plan.
Occupational therapy
Occupational therapy is treatment to develop, improve, and maintain the skills you
need for Activities of Daily Living, such as dressing, eating, and drinking.
Speech therapy
Speech therapy is used to develop, improve, and maintain vocal or swallowing skills
that have not developed according to established norms or have been impaired by
a diagnosed illness or injury. Benefits are available for outpatient speech therapy for
the treatment of:
•A communication impairment;
•A swallowing disorder;
•An expressive or receptive language disorder; and
•An abnormal delay in speech development.
Skilled Nursing Facility (SNF) services
Benefits are available for treatment in the Skilled Nursing unit of a Hospital or in a free-
standing Skilled Nursing Facility (SNF) when you are receiving Skilled Nursing or
rehabilitative services. This Benefit also includes care at the Subacute Care level.
Benefits must be prior authorized and are limited to a day maximum per benefit period,
as shown in the Summary of Benefits section. A benefit period begins on the date you
are admitted to the facility. A benefit period ends 60 days after you are discharged
from the facility or you stop receiving Skilled Nursing services. A new benefit period can
only begin after an existing benefit period ends.
Transplant services
Benefits are available for tissue and kidney transplants and special transplants.
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Tissue and kidney transplants
Benefits are available for facility and professional services provided in connection
with human tissue and kidney transplants when you are the transplant recipient.
Benefits include services incident to obtaining the human transplant material from a
living donor or a tissue/organ transplant bank.
Special transplants
Benefits are available for special transplants only if:
•The procedure is performed at a special transplant facility contracting with
the Claims Administrator, or if you access this Benefit outside of California, the
procedure is performed at a transplant facility designated by the Claims
Administrator; and
•You are the recipient of the transplant.
Special transplants are:
•Human heart transplants;
•Human lung transplants;
•Human heart and lung transplants in combination;
•Human liver transplants;
•Human kidney and pancreas transplants in combination;
•Human bone marrow transplants, including autologous bone marrow
transplantation (ABMT) or autologous peripheral stem cell transplantation
used to support high-dose chemotherapy when such treatment is Medically
Necessary and is not Experimental or Investigational;
•Pediatric human small bowel transplants; and
•Pediatric and adult human small bowel and liver transplants in combination.
Donor services
Transplant Benefits include coverage for donation-related services for a living donor,
including a potential donor, or a transplant organ bank. Donor services must be
directly related to a covered transplant for a Member of this plan.
Donor services include:
•Donor evaluation;
•Harvesting of the organ, tissue, or bone marrow; and
•Treatment of medical complications for 90 days after the evaluation or
harvest procedure.
Urgent care services
Benefits are available for urgent care services you receive at an urgent care center or
during an after-hours office visit. You can access urgent care instead of going to the
emergency room if you have a medical condition that is not life-threatening but
prompt care is needed to prevent serious deterioration of your health.
See the Out-of-area services section for information on urgent care services outside
California.
64
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2650.
Exclusions and limitations
This section describes the general exclusions and limitations that apply to all your plan
Benefits.
General exclusions and limitations
1
This plan does not cover services received from Non-Participating Providers,
except:
•For Emergency or Urgent Services;
•Inter-Plan Arrangements, including the BlueCard® and Blue Shield
Global® Core programs described in the Out-of-area services section;
and
•When prior authorized by Claims Administrator.
2
This Plan only covers services that are Medically Necessary. A Physician or other
Health Care Provider’s decision to prescribe, order, recommend, or approve a
service or supply does not, in itself, make it Medically Necessary.
3
Routine physical examinations solely for:
•Immunizations and vaccinations, by any mode of administration, for
the purpose of travel; or
•Licensure, employment, insurance, court order, parole, or probation.
This exclusion does not apply to Medically Necessary services that the Claims
Administrator is required by law to cover for Severe Mental Illnesses or Serious
Emotional Disturbances of a Child.
4 Hospitalization solely for X-ray, laboratory or any other outpatient diagnostic
studies, or for medical observation.
5
Routine foot care items and services that are not Medically Necessary,
including:
•Callus treatment;
•Corn paring or excision;
•Toenail trimming;
•Over-the-counter shoe inserts or arch supports; or
•Any type of massage procedure on the foot.
This exclusion does not apply to items or services provided through a
Participating Hospice Agency or covered under the diabetes care Benefit.
6 Home services, hospitalization, or confinement in a health facility primarily for
rest, custodial care, or domiciliary care.
Exclusions and limitations 65
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General exclusions and limitations
Custodial care is assistance with Activities of Daily Living furnished in the home
primarily for supervisory care or supportive services, or in a facility primarily to
provide room and board.
Domiciliary care is a supervised living arrangement in a home-like environment
for adults who are unable to live alone because of age-related impairments or
physical, mental, or visual disabilities.
7 Continuous Nursing Services, private duty nursing, or nursing shift care, except
as provided through a Participating Hospice Agency.
8
Prescription and non-prescription oral food and nutritional supplements. This
exclusion does not apply to services listed in the Home infusion and injectable
medication services and PKU formulas and special food products sections, or as
provided through a Participating Hospice Agency. This exclusion does not apply
to Medically Necessary services that the Claims Administrator is required by law
to cover for Severe Mental Illnesses or Serious Emotional Disturbances of a Child.
9 For any services relating to the diagnosis or treatment of any mental or
emotional illness or disorder that is not a Mental Health Condition.
10
Unless selected as an optional Benefit by your Employer, hearing aids, hearing
aid examinations for the appropriate type of hearing aid, fitting, and hearing
aid recheck appointments.
11
Eye exams and refractions, lenses and frames for eyeglasses, lens options,
treatments, and contact lenses, except as listed under the Prosthetic
equipment and devices section.
Video-assisted visual aids or video magnification equipment for any purpose, or
surgery to correct refractive error.
12
Any type of communicator, voice enhancer, voice prosthesis, electronic voice
producing machine, or any other language assistive device. This exclusion does
not apply to items or services listed under the Prosthetic equipment and devices
section.
13
Dental services and supplies for treatment of the teeth, gums, and associated
periodontal structures, including but not limited to the treatment, prevention, or
relief of pain or dysfunction of the temporomandibular joint and muscles of
mastication. This exclusion does not apply to items or services provided under
the Medical treatment of the teeth, gums, or jaw joints and jaw bones and
Hospital services sections.
14 Surgery that is performed to alter or reshape normal structures of the body to
improve appearance. This exclusion does not apply to Medically Necessary
Exclusions and limitations 66
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General exclusions and limitations
treatment for complications resulting from cosmetic surgery, such as infections
or hemorrhages.
15 Treatment of sexual dysfunctions and sexual inadequacies. This exclusion does
not apply to the treatment of organically-based conditions.
16
Unless selected as an optional Benefit by your Employer, any services related to
assisted reproductive technology (including associated services such as
radiology, laboratory, medications, and procedures) including but not limited
to the harvesting or stimulation of the human ovum, in vitro fertilization, Gamete
Intrafallopian Transfer (GIFT) procedure, Zygote Intrafallopian Transfer (ZIFT),
Intracytoplasmic sperm Injection (ICSI), pre-implantation genetic screening,
donor services or procurement and storage of donor embryos, oocytes, ovarian
tissue, or sperm, any type of artificial insemination, services or medications to
treat low sperm count, services incident to or resulting from procedures for a
surrogate mother who is otherwise not eligible for covered pregnancy and
maternity care under a Claims Administrator’s health plan, or services incident
to reversal of surgical sterilization, except for Medically Necessary treatment of
medical complications of the reversal procedure.
17
Home testing devices and monitoring equipment. This exclusion does not apply
to COVID-19 at-home testing kits or items specifically described in the Durable
medical equipment or Diabetes care services sections.
18 Preventive Health Services performed by a Non-Participating Provider.
19
Services performed in a Hospital by house officers, residents, interns, or other
professionals in training without the supervision of an attending Physician in
association with an accredited clinical education program.
20 Services performed by your spouse, Domestic Partner, child, brother, sister, or
parent.
21
Services provided by an individual or entity that:
•Is not appropriately licensed or certified by the state to provide
health care services;
•Is not operating within the scope of such license or certification; or
•Does not maintain the Clinical Laboratory Improvement Amendments
certificate required to perform laboratory testing services.
This exclusion does not apply to Behavioral Health Treatment Benefits listed
under the Mental Health and Substance Use Disorder Benefits section or to
Medically Necessary services that the Claims Administrator is required by law to
cover for Severe Mental Illnesses or Serious Emotional Disturbances of a Child
services.
Exclusions and limitations 67
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General exclusions and limitations
22
Select physical and occupational therapies, such as:
•Massage therapy, unless it is a component of a multimodality
rehabilitative treatment plan or physical therapy treatment plan; and
•Vocational, educational, recreational, art, dance, music, or reading
therapy.
This exclusion does not apply to Medically Necessary services that the Claims
Administrator is required by law to cover for Severe Mental Illnesses or Serious
Emotional Disturbances of a Child.
23
Weight control programs and exercise programs. This exclusion does not apply
to nutritional counseling provided under the Diabetes care services section, or
to Medically Necessary services that the Claims Administrator is required by law
to cover for Severe Mental Illnesses, Serious Emotional Disturbances of a Child,
or Preventive Health Services.
24 Services or Drugs that are Experimental or Investigational in nature.
25
Services that cannot be lawfully marketed without approval of the U.S. Food
and Drug Administration (FDA), including, but not limited to:
•Drugs;
•Medicines;
•Supplements;
•Tests;
•Vaccines;
•Devices; and
•Radioactive material.
However, drugs and medicines that have received FDA approval for marketing
for one or more uses will not be denied on the basis that they are being
prescribed for an off-label use if the conditions set forth in California Health &
Safety Code Section 1367.21 have been met.
26
The following non-prescription (over-the-counter) medical equipment or
supplies:
•Oxygen saturation monitors;
•Prophylactic knee braces; and
•Bath chairs.
27 Member convenience items or services, such as internet, phones, televisions,
guest trays, personal hygiene items, and food delivery services.
28
Disposable supplies for home use except as provided under the Durable
medical equipment, Home health services, and Hospice program services
sections.
Exclusions and limitations 68
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General exclusions and limitations
29
Services incident to any injury or disease arising out of, or in the course of,
employment for salary, wage, or profit if such injury or disease is covered by any
workers’ compensation law, occupational disease law, or similar legislation.
However, if the Claims Administrator provides payment for such services, we will
be entitled to establish a lien up to the amount paid by the Claims
Administrator for the treatment of such injury or disease.
30
Transportation by car, taxi, bus, gurney van, wheelchair van, and any other
type of transportation (other than a licensed ambulance or psychiatric
transport van).
31 Hospital care programs or services provided in a home setting (Hospital-at-
home programs).
32
Prescribed Drugs and medicines for outpatient care except as provided
through a Participating Hospice Agency when the Member is receiving Hospice
Services and except as may be provided under the Home Infusion/Home
Injectable Therapy Benefits in the Covered Services section.
33 Outpatient prescription Drugs.
34
Rehabilitative Services, except as specifically provided in the Home health
services, Hospice program services, Hospital services, or Rehabilitative and
habilitative services sections.
35
Speech therapy, speech correction or speech pathology or speech
abnormalities that are not likely the result of a diagnosed, identifiable medical
condition, injury or illness except as specifically listed under the Home health
services, Hospice program services, or Rehabilitative and habilitative services
sections.
69
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2650.
Settlement of Disputes
Internal Appeals
Initial Internal Appeal
If you have received an Adverse Benefit Determination on a claim from the Claims
Administrator, you, a designated representative, a provider or an attorney on your
behalf may submit a request for an appeal to the Claims Administrator. Contact
Customer Service via telephone, mail, or by visiting the Claims Administrator’s
website at blueshieldca.com and include relevant information, such as:
•Your name;
•Member ID number;
•Date of service;
•Claim number;
•Provider name;
•Your explanation of what happened and why you believe the original
determination was incorrect; and
•Any other supporting documents.
Written requests for initial internal appeal may be submitted to the following address:
Blue Shield of California
Attn: Initial Appeals
P.O. Box 5588
El Dorado Hills, CA 95762-0011
Appeals must be submitted within 180 days after you receive notice of an Adverse
Benefit Determination. The Claims Administrator will acknowledge receipt of an
appeal within five calendar days. Appeals are resolved in writing within 30 days from
the date of receipt by the Claims Administrator, unless qualified for an expedited
decision.
Final Internal Appeal
If you are dissatisfied with the initial internal appeal determination by the Claims
Administrator, the determination may be appealed in writing to the Claims
Administrator within 60 days after the date of receipt of the notice of the initial appeal
determination. Such written request shall contain any additional information that you
wish the Claims Administrator to consider. The Claims Administrator shall notify you in
writing of the results of its review and the specific basis therefor. In the event the Claims
Administrator finds all or part of the appeal to be valid, the Claims Administrator, on
behalf of the Employer, shall reimburse either you or your Health Care Provider for those
expenses which the Claims Administrator allowed as a result of its review of the appeal.
Final appeals are resolved in writing within 30 days from the date of receipt to the
Claims Administrator. Written requests for final internal standard appeals may be
submitted to:
Blue Shield of California
Attn: Final Appeals
Settlement of Disputes 70
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599-2650.
P.O. Box 5588
El Dorado Hills, CA 95762-0011
Expedited Appeal (Initial and Final)
You have the right to an expedited decision when the routine decision-making
process might pose an imminent or serious threat to your health, including but not
limited to severe pain or potential loss of life, limb or major bodily function. To initiate
a request for an expedited decision, you, a designated representative, a provider or
an attorney on your behalf may call or write as instructed under the Initial and Final
Appeals sections outlined above. Specifically state that you want an expedited
decision and that waiting for the standard processing might seriously jeopardize your
health. The Claims Administrator will evaluate your request and medical condition to
determine if it qualifies for an expedited decision. If it qualifies, your request will be
processed as soon as possible to accommodate your condition, not to exceed 72
hours.
External Review
Standard External Review
If you are dissatisfied with the final internal appeal determination, and the
determination involves medical judgment, a rescission of coverage, or consideration
of whether the Plan is complying with surprise billing and cost-share protections
under the federal No Surprises Act, you, a designated representative, a provider or
an attorney on your behalf, may request an external review with an Independent
Review Organization.
Requests for external review must be submitted within four months after notice of the
final internal appeal determination. The Independent Review Organization will
provide a determination within 45 days after the Independent Review Organization
receives the request for the external review. Instructions for submitting a request for
external review will be outlined in the final internal appeal response letter.
Expedited External Review
If your situation is eligible for an expedited decision, you, a designated representative,
a provider or an attorney on your behalf may request external review within four
months from the Adverse Benefit Determination without participating in the initial or
final internal appeal process.
To initiate a request for an expedited external review, you, a designated
representative, a provider or an attorney on your behalf may fax a request to (844)
696-6071, or write to the following address. Specifically state that you want an
expedited external review decision and that waiting for the standard processing
might seriously jeopardize your health.
Blue Shield of California
Attn: Expedited External Review
P.O. Box 5588
El Dorado Hills, CA 95762-0011
Settlement of Disputes 71
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599-2650.
Other Resources to Help You
For questions about your appeal rights, or for assistance, you may contact the
Employee Benefits Security Administration at 1-866-444-EBSA (3272).
72
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2650.
Other important information about your Plan
This section provides legal and regulatory details that impact your health care
coverage. This information is a supplement to the information provided in earlier
sections of this document.
Your coverage, continued
Special enrollment period
For more information about special enrollment periods, see
Special enrollment period on page 36 in the Your coverage
section.
A special enrollment period is a timeframe outside of open enrollment when an
eligible Participant or Dependent can enroll in, or change enrollment in, a health
plan. The special enrollment period is 30 days following the date of a Qualifying
Event except as otherwise specified below. The following are examples of Qualifying
Events. For complete details and a determination of eligibility for special enrollment,
please consult your Employer.
•Loss of eligibility for coverage, including the following:
o The eligible Employee or Dependent loses coverage under another
employer health benefit plan or other health insurance and meets all
of the following requirements:
▪The Employee or Dependent was covered under another
employer health benefit plan or had other health insurance
coverage at the time the Employee was initially offered
enrollment under this Plan;
▪If required by the Employer, the Employee certified, at the time
of the initial enrollment, that coverage under another employer
health benefit plan or other health insurance was the reason for
declining enrollment provided that the Employee was given
notice that such certification was required and that failure to
comply could result in later treatment as a Late Enrollee;
o The Employee or Dependent was eligible for coverage under
Medicaid (e.g. Healthy Families Program or Medi-Cal) and such
coverage was terminated due to loss of such eligibility, provided that
enrollment is requested no later than 60 days after the termination of
coverage;
o The eligible Employee or Dependent loses coverage due to legal
separation, divorce, loss of dependent status, death of the Employee,
termination of employment, or reduction in the number of hours of
employment;
o In the case of coverage offered through an HMO, loss of coverage
because the eligible Employee or Dependent no longer resides, lives,
or works in the service area (whether or not within the choice of the
Other important information about your plan 73
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599-2650.
individual), and if the previous HMO coverage was group coverage,
no other benefit package is available to the Employee or Dependent;
o Termination of the employer health plan or contributions to Employee
or Dependent coverage;
o Exhaustion of COBRA group continuation coverage; or
•The Employee or Dependent is eligible for coverage under a Medicaid (e.g.
Healthy Families Program or Medi-Cal) premium assistance program,
provided that enrollment is within 60 days of the notice of eligibility for these
premium assistance programs;
•A court has ordered that coverage be provided for a spouse or Domestic
Partner or minor child under a covered Employee’s health benefit Plan. The
health Plan shall enroll a Dependent child effective the first day of the month
following presentation of a court order by the district attorney, or upon
presentation of a court order or request by a custodial party or the employer,
as described in Section 3751.5 and 3766 of the Family Code; or
•An eligible Employee acquires a Dependent through marriage, establishment
of domestic partnership, birth, or placement for adoption. Applies to both the
Employee and the Dependent.
Out-of-area services
Overview
The Claims Administrator has a variety of relationships with other Blue Cross and/or
Blue Shield Licensees. Generally, these relationships are called Inter-Plan
Arrangements and they work based on rules and procedures issued by the Blue
Cross Blue Shield Association. Whenever you receive Covered Services outside of
California, the claims for those services may be processed through one of these Inter-
Plan Arrangements described below.
When you access Covered Services outside of California, but within the United
States, the Commonwealth of Puerto Rico, or the U.S. Virgin Islands (BlueCard®
Service Area), you will receive the care from one of two kinds of providers.
Participating providers contract with the local Blue Cross and/or Blue Shield Licensee
in that other geographic area (Host Blue). Non-participating providers don’t contract
with the Host Blue. The Claims Administrator’s payment practices for both kinds of
providers are described below and in the Introduction section of this Benefit Booklet.
See the Care outside of California section for more
information about receiving care while outside of California.
To find participating providers while outside of California, visit
bcbs.com.
Other important information about your plan 74
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599-2650.
Inter-Plan Arrangements
Emergency Services
Members who experience an Emergency Medical Condition while traveling
outside of California should seek immediate care from the nearest Hospital. The
Benefits of this Plan will be provided anywhere in the world for treatment of an
Emergency Medical Condition.
BlueCard® Program
Under the BlueCard® Program, benefits will be provided for Covered Services
received outside of California, but within the BlueCard® Service Area. When you
receive Covered Services within the geographic area served by a Host Blue, the
Claims Administrator will remain responsible for doing what we agreed to in the
Benefit Booklet. However, the Host Blue is responsible for contracting with and
generally handling all interactions with its participating healthcare providers,
including direct payment to the provider.
The BlueCard® Program enables you to obtain Covered Services outside of
California, from a healthcare provider participating with a Host Blue, where
available. The participating healthcare provider will automatically file a claim for
the Covered Services provided to you, so there are no claim forms for you to fill
out. You will be responsible for the member Copayment, Coinsurance and
Deductible amounts, if any, as stated in this Benefit Booklet.
The Claims Administrator calculates the Member’s share of cost either as a
percentage of the Allowable Amount or a dollar Copayment, as defined in this
Benefit Booklet. Whenever you receive Covered Services outside of California,
within the BlueCard Service Area, and the claim is processed through the
BlueCard® Program, the amount you pay for Covered Services, if not a flat dollar
Copayment, is calculated based on the lower of:
•The billed charges for Covered Services; or
•The negotiated price that the Host Blue makes available to the Claims
Administrator.
Often, this negotiated price will be a simple discount that reflects an actual price
that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated
price that takes into account special arrangements with your healthcare
provider or provider group that may include types of settlements, incentive
payments, and/or other credits or charges. Occasionally, it may be an average
price, based on a discount that results in expected average savings for similar
types of healthcare providers after taking into account the same types of
transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account
adjustments to correct for over- or underestimation of modifications of past
pricing of claims as noted above. However, such adjustments will not affect the
price the Claims Administrator used for your claim because these adjustments
will not be applied retroactively to claims already paid.
Other important information about your plan 75
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599-2650.
Laws in a small number of states may require the Host Blue to add a surcharge to
your calculation. If any state laws mandate other liability calculation methods,
including a surcharge, we would then calculate your liability for any Covered
Services according to applicable law.
To find participating BlueCard® providers you can call BlueCard Access® at 1-
800-810-BLUE (2583) or go online at bcbs.com and select “Find a Doctor.”
Prior authorization may be required for non-emergency services. Please see the
Medical Management Programs section for additional information on prior
authorization and the Emergency Benefits section for information on emergency
admission notification.
Non-participating providers outside of California
Except where prohibited by state law, this Claims Administrator plan does
not provide coverage for health care services provided by non-
participating providers outside of California except for Emergency
Services, Urgent Services, and Out-of-Area Follow-up Care. When
Emergency Services or Urgent Services are provided within the BlueCard®
Service Area by a non-participating provider, the amount you pay is
based on federal or state law, as applicable. When Out-of-Area Follow-up
Care is provided within the BlueCard® Service Area by a non-participating
provider, the amount you pay for such services will normally be based on
either the Host Blue’s non-participating provider local payment, the
Allowable Amount the Claims Administrator pays a Non-Participating
Provider in California if the Host Blue has no non-participating provider
allowance, or the pricing arrangements required by applicable state or
federal law. In these situations, you will be responsible for any difference
between the amount that the non-participating provider bills and the
payment the Claims Administrator will make for Out-of-Area Follow-Up
Care Services as set forth in this paragraph.
If you do not see a participating provider through the BlueCard® Program,
you will have to pay the entire bill for your medical care and submit a
claim to the local Blue Cross and/or Blue Shield plan, or to the Claims
Administrator for reimbursement. The Claims Administrator will review your
claim and notify you of its coverage determination within 30 days after
receipt of the claim; you will be reimbursed as described in the preceding
paragraph. Remember, your share of cost is higher when you see a non-
participating provider.
Prior authorization is not required for Emergency Services. In an
emergency, go directly to the nearest hospital. Please see the Medical
Other important information about your plan 76
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599-2650.
Management Programs section for additional information on emergency
admission notification.
Blue Shield Global® Core
Care for Covered Urgent and Emergency Services outside the BlueCard
Service Area
If you are outside of the BlueCard® Service Area, you may be able to take
advantage of Blue Shield Global® Core when accessing Out-of-Area
Covered Health Care Services. Blue Shield Global® Core is unlike the
BlueCard® Program available within the BlueCard® Service Area in certain
ways. For instance, although Blue Shield Global® Core assists you with
accessing a network of inpatient, outpatient, and professional providers,
the network is not served by a Host Blue. As such, when you receive care
from provider outside the BlueCard® Service Area, you will typically have
to pay the providers and submit the claim yourself to obtain
reimbursement for these services.
If you need assistance locating a doctor or hospital outside the BlueCard®
Service Area you should call the service center at (800) 810-BLUE (2583) or
call collect at (804) 673-1177, 24 hours a day, seven days a week. Provider
information is also available online at www.bcbs.com: select “Find a
Doctor” and then “Blue Shield Global Core.”
Submitting a Blue Shield Global® Core claim
When you pay directly for services outside the BlueCard® Service Area,
you must submit a claim to obtain reimbursement. You should complete a
Blue Shield Global® Core claim form and send the claim form along with
the provider’s itemized bill to the service center at the address provided
on the form to initiate claims processing. Following the instructions on the
claim form will help ensure timely processing of your claim. The claim form
is available from Customer Service, the service center or online at
www.bcbsglobalcore.com. If you need assistance with your claim
submission, you should call the service center at (800) 810-BLUE (2583) or
call collect at (804) 673-1177, 24 hours a day, seven days a week.
Special Cases: Value-Based Programs
Claims Administrator Value-Based Programs
You may have access to Covered Services from providers that participate
in a Claims Administrator Value-Based Program. Claims Administrator
Value-Based Programs include, but are not limited to, Accountable Care
Organizations, Episode Based Payments, Patient Centered Medical
Homes, and Shared Savings arrangements.
From the Find A Doctor search page, click on the hyperlink "Providers
outside of CA" under the Accessing Care Outside CA descriptor. National
Doctor and Hospital Finder at www.bcbs.com/find-a-doctor, Blue
Other important information about your plan 77
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Distinction Center Finder at www.bcbs.com/blue-distinction-center or by
calling (800) 810-BLUE.
BlueCard® Program
If you receive Covered Services under a Value-Based Program inside a
Host Blue’s service area, you will not be responsible for paying any of the
Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a
part of such an arrangement, except when a Host Blue passes these fees
to the Claims Administrator through average pricing or fee schedule
adjustments.
Limitation for duplicate coverage
Medicare
This Plan will provide Benefits before Medicare when:
•The Employee or his/her spouse is eligible for Medicare due to age, if the
Employee is actively working for a group that employs 20 or more employees
(as defined by Medicare Secondary Payer laws);
•The Participant is eligible for Medicare due to disability, if the Employee is
covered by a group that employs 100 or more employees (as defined by
Medicare Secondary Payer laws); or
•The Participant is eligible for Medicare solely due to end-stage renal disease
during the first 30 months he/she is eligible to receive benefits for end-stage
renal disease from Medicare.
This Plan will provide Benefits after Medicare when:
•The Employee or his/her spouse is eligible for Medicare due to age, if the
Employee is actively working for a group that employs less than 20 employees
(as defined by Medicare Secondary Payer laws);
•The Participant is eligible for Medicare due to disability, if the Employee is
covered by a group that employs less than 100 employees (as defined by
Medicare Secondary Payer laws);
•The Participant is eligible for Medicare solely due to end-stage renal disease
after the first 30 months he/she is eligible to receive benefits for end-stage
renal disease from Medicare; or
•The Employee is retired and the Employee or his/her spouse is age 65 or older.
When this Plan provides Benefits after Medicare, your combined Benefits from
Medicare and this Plan may be lower than the Medicare allowed amount but will
not exceed the Medicare allowed amount. You do not have to pay any Plan
Deductibles, Copayments, or Coinsurance.
Medi-Cal
Medi-Cal always pays for Benefits last when you have coverage from more than one
payor.
Other important information about your plan 78
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599-2650.
Qualified veterans
If you are a qualified veteran, the Claims Administrator will pay the reasonable value
or the Allowable Amount for Covered Services you receive at a Veterans
Administration facility for a condition that is not related to military service. If you are a
qualified veteran who is not on active duty, the Claims Administrator will pay the
reasonable value or the Allowable Amount for Benefits you receive at a Department
of Defense facility. This includes Benefits for conditions related to military service.
Coverage by another government agency
If you are entitled to receive Benefits from any federal or state governmental
agency, by any municipality, county, or other political subdivision, your combined
Benefits from that coverage and this Plan will equal but not be more than what the
Claims Administrator would pay if you were not eligible for Benefits under that
coverage. The Claims Administrator will provide Benefits based on the reasonable
value or the Allowable Amount.
Exception for other coverage
A Participating Provider may seek reimbursement from other third-party payors for the
balance of their charges for services you receive under this Plan.
If you recover from a third party the reasonable value of Covered Services received
from a Participating Provider, the Participating Provider is not required to accept the
fees paid by the Claims Administrator as payment in full. You may be liable to the
Participating Provider for the difference, if any, between the fees paid by the Claims
Administrator and the reasonable value recovered for those services.
Reductions – third-party liability
If a Participant is injured or becomes ill due to the act or omission of another person (a
“third party”), the Claims Administrator shall, with respect to Services required as a result
of that injury, provide the Benefits of the Plan and the Plan Administrator have an
equitable right to restitution, reimbursement or other available remedy to recover
amounts the Plan Administrator paid for the Services provided to the Participant on a
fee-for-service basis from any recovery (defined below) obtained by or on behalf of the
Participant, from or on behalf of the third party responsible for the injury or illness or from
uninsured/underinsured motorist coverage.
The Plan Administrator’s right to restitution, reimbursement or other available remedy is
against any recovery the Participant receives as a result of the injury or illness, including
any amount awarded to or received by way of court judgment, arbitration award,
settlement or any other arrangement, from any third party or third party insurer, or from
uninsured or underinsured motorist coverage, related to the illness or injury (the
“Recovery”), without regard to whether the Participant has been “made whole” by the
Recovery. The Plan Administrator’s right to restitution, reimbursement or other available
remedy is with respect to that portion of the total Recovery that is due the Claims
Administrator for the Benefits it paid in connection with such injury or illness.
Other important information about your plan 79
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The Participant is required to:
•Notify the Plan Administrator in writing of any actual or potential claim or
legal action which such Participant expects to bring or has brought against
the third party arising from the alleged acts or omissions causing the injury or
illness, not later than 30 days after submitting or filing a claim or legal action
against the third party; and
•Agree to fully cooperate and execute any forms or documents needed to
enforce this right to restitution, reimbursement or other available remedies;
and
•Agree in writing to reimburse the Plan Administrator for Benefits paid by the
Claims Administrator from any Recovery when the Recovery is obtained from
or on behalf of the third party or the insurer of the third party, or from
uninsured or underinsured motorist coverage; and
•Provide the Plan Administrator with a lien in the amount of Benefits actually
paid. The lien may be filed with the third party, the third party's agent or
attorney, or the court, unless otherwise prohibited by law; and,
•Periodically respond to information requests regarding the claim against the
third party, and notify the Plan Administrator, in writing, within 10 days after
any Recovery has been obtained.
A Participant’s failure to comply with these requirements shall not in any way act as a
waiver, release, or relinquishment of the rights of the Plan Administrator.
If your injury or illness was, in any way, caused by a third party who may be legally liable
or responsible for the injury or illness, no Benefits will be payable or paid under the Plan
unless you agree in writing, in a form satisfactory to the plan, to do all of the following:
•Provide the Plan with a written notice of any claim made against the third
party for damages as a result of the injury or illness;
•Agree in writing to reimburse the Plan for Benefits paid by the Plan from any
Recovery (defined below) when the Recovery is obtained from or on behalf
of the third party or the insurer of the third party, or from your own uninsured
or underinsured motorist coverage;
•Execute a lien in favor of the Plan for the full amount of Benefits paid by the
plan;
•Ensure that any Recovery is kept separate from and not comingled with any
other funds and agree in writing that the portion of any Recovery required to
satisfy the lien of the Plan is held in trust for the sole benefit of the Plan until
such time it is conveyed to the plan;
•Periodically respond to information requests regarding the claim against the
third party, and notify the plan, in writing, within 10 days after any Recovery
has been obtained;
•Direct any legal counsel retained by you or any other person acting on your
behalf to hold that portion of the Recovery to which the Plan is entitled in trust
for the sole benefit of the Plan and to comply with and facilitate the
reimbursement to the Plan of the monies owed it.
If you fail to comply with the above requirements, no benefits will be paid with respect
to the injury or illness. If Benefits have been paid, they may be recouped by the plan,
through deductions from future benefit payments to you or others enrolled through you
in the plan.
Other important information about your plan 80
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599-2650.
“Recovery” includes any amount awarded to or received by way of court judgment,
arbitration award, settlement or any other arrangement, from any third party or third
party insurer, or from your uninsured or underinsured motorist coverage, related to the
illness or injury, without reduction for any attorneys’ fees paid or owed by the you or on
your behalf, and without regard to whether you have been “made whole” by the
Recovery. Recovery does not include monies received from any insurance policy or
certificate issued in your name, except for uninsured or underinsured motorist coverage.
The Recovery includes all monies received, regardless of how held, and includes
monies directly received as well as any monies held in any account or trust on your
behalf, such as an attorney-client trust account.
You shall pay to the Plan from the Recovery an amount equal to the Benefits actually
paid by the Plan in connection with the illness or injury. If the Benefits paid by the Plan in
connection with the illness or injury exceed the amount of the Recovery, you shall not
be responsible to reimburse the Plan for the Benefits paid in connection with the illness
or injury in excess of the Recovery.
Your acceptance of Benefits from the Plan for illness or injury caused by a third party
shall act as a waiver of any defense to full reimbursement of the Plan from the
Recovery, including any defense that the injured individual has not been “made
whole” by the Recovery or that the individual’s attorneys’ fees and costs, in whole or in
part, are required to be paid or are payable from the Recovery, or that the Plan should
pay a portion of the attorneys’ fees and costs incurred in connection with the claims
against the third party.
THE FOLLOWING LANGUAGE APPLIES UNLESS THE PLAN IS PART OF AN EMPLOYEE
WELFARE BENEFIT PLAN SUBJECT TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT
OF 1974 (“ERISA”); IF THE PLAN IS SUBJECT TO ERISA, THE FOLLOWING LANGUAGE DOES
NOT APPLY.
If you receive services from a Participating Hospital for injuries or illness, the Hospital has
the right to collect from you the difference between the amount paid by the Plan and
the Hospital’s reasonable and necessary charges for such services when you receive
payment or reimbursement for medical expenses.
Coordination of benefits, continued
When you are covered by more than one group health plan, payments for allowable
expenses will be coordinated between the two plans. Coordination of benefits ensures
that benefits paid by multiple group health plans do not exceed 100% of allowable
expenses. The coordination of benefits rules also determine which group health plan is
primary and prevent delays in benefit payments. The Claims Administrator determines
the order of benefit payments between two group health plans, as follows:
•When a plan does not have a coordination of benefits provision, that plan will
always provide its benefits first. Otherwise, the plan covering you as an
Employee will provide its benefits before the plan covering you as a
Dependent.
•Coverage for Dependent children:
o When the parents are not divorced or separated, the plan of the parent
whose date of birth (month and day) occurs earlier in the year is primary.
Other important information about your plan 81
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599-2650.
o When the parents are divorced and the specific terms of the court
decree state that one of the parents is responsible for the health care
expenses of the child, the plan of the responsible parent is primary.
o When the parents are divorced or separated, there is no court decree,
and the parent with custody has not remarried, the plan of the custodial
parent is primary.
o When the parents are divorced or separated, there is no court decree,
and the parent with custody has remarried, the order of payment is as
follows:
▪The plan of the custodial parent;
▪The plan of the stepparent; then
▪The plan of the non-custodial parent.
•If the above rules do not apply, the plan which has covered you for the
longer period of time is the primary plan. There may be exceptions for laid-off
or retired Employees.
•When the Claims Administrator is the primary plan, Benefits will be provided
without considering the other group health plan. When the Claims
Administrator is the secondary plan and there is a dispute as to which plan is
primary, or the primary plan has not paid within a reasonable period of time,
the Claims Administrator will provide Benefits as if it were the primary plan.
•Anytime the Claims Administrator makes payments over the amount they
should have paid as the primary or secondary plan, the Claims Administrator
reserves the right to recover the excess payments from the other plan or any
person to whom such payments were made.
These coordination of benefits rules do not apply to the programs included in the
Limitation for Duplicate Coverage section.
General provisions
Independent contractors
Providers are neither agents nor employees of the Claims Administrator but are
independent contractors. In no instance shall the Claims Administrator be liable for
the negligence, wrongful acts, or omissions of any person providing services,
including any Physician, Hospital, or other Health Care Provider or their employees.
Assignment
The Benefits of this plan, including payment of claims, may not be assigned without
the written consent of the Claims Administrator. Participating Providers are paid
directly by the Claims Administrator. When you are authorized to receive Covered
Services from a Non-Participating Provider, the Claims Administrator, at its sole
discretion, may make payment to the Participant or directly to the Non-Participating
Provider. If the Claims Administrator pays the Non-Participating Provider directly, such
payment does not create a third-party beneficiary or other legal relationship
between the Claims Administrator and the Non-Participating Provider. The
Participant must make sure the Non-Participating Provider receives the full billed
amount, whether or not the Claims Administrator makes payment to the Non-
Participating Provider.
Other important information about your plan 82
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599-2650.
Plan interpretation
The Claims Administrator shall have the power and authority to construe and
interpret the provisions of this plan, to determine the Benefits of this plan, and to
determine eligibility to receive Benefits under the Contract. The Claims Administrator
shall exercise this authority for the benefit of all Members entitled to receive Benefits
under this plan.
Access to information
The Claims Administrator may need information from medical providers, from other
carriers or other entities, or from the Member, in order to administer the Benefits and
eligibility provisions of this plan and the Contract. By enrolling in this health plan, each
Member agrees that any provider or entity can disclose to the Claims Administrator
that information that is reasonably needed by the Claims Administrator. Members
also agree to assist the Claims Administrator in obtaining this information, if needed,
(including signing any necessary authorizations) and to cooperate by providing the
Claims Administrator with information in the Member’s possession. Failure to assist the
Claims Administrator in obtaining necessary information or refusal to provide
information reasonably needed may result in the delay or denial of Benefits until the
necessary information is received. Any information received for this purpose by the
Claims Administrator will be maintained as confidential and will not be disclosed
without the Member’s consent, except as otherwise permitted or required by law.
Right of recovery
Whenever payment on a claim is made in error, the Claims Administrator has the
right to recover such payment from the Participant or, if applicable, the provider or
another health benefit plan, in accordance with applicable laws and regulations.
With notice, the Claims Administrator reserves the right to deduct or offset any
amounts paid in error from any pending or future claim to the extent permitted by
law. Circumstances that might result in payment of a claim in error include, but are
not limited to, payment of benefits in excess of the benefits provided by the health
plan, payment of amounts that are the responsibility of the Participant (Cost Share or
similar charges), payment of amounts that are the responsibility of another payor,
payments made after termination of the Participant’s coverage, or payments made
on fraudulent claims.
83
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Definitions
Activities of Daily
Living
Activities related to independence in normal everyday living.
Recreational, leisure, or sports activities are not considered
Activities of Daily Living.
Adverse Benefit
Determination
A denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for Benefits that is:
•based on a determination of a Participant's or
Dependent's eligibility to participate in the Plan;
•resulting from the application of any utilization review;
or
•a failure to cover an item or service for which Benefits
are otherwise provided because it is determined to be
Experimental or Investigational or not Medically
Necessary or appropriate.
Allowable Amount Unless otherwise stated in this booklet, the lower of either the
Claims Administrator’s Agreed Amount, or the Claims
Administrator’s Reasonable Amount.
Ambulatory Surgery
Center
An outpatient surgery facility that meets both of the following
requirements:
•Is a licensed facility accredited by an ambulatory
surgery center accrediting body; and
•Provides services as a free-standing ambulatory
surgery center, which is not otherwise affiliated with
a Hospital.
Behavioral Health
Treatment (BHT)
Professional services and treatment programs that develop or
restore, to the maximum extent practicable, the functioning
of an individual with pervasive developmental disorder or
autism. BHT includes applied behavior analysis and evidence-
based intervention programs.
Benefits (Covered
Services)Medically Necessary services and supplies you are entitled to
receive pursuant to the Contract.
BlueCard® Service
Area The United States, Commonwealth of Puerto Rico, and U.S.
Virgin Islands.
Calendar Year The 12-month consecutive period beginning on January 1
and ending on December 31 of the same year.
Definitions 84
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Care Coordination Organized, information-driven patient care activities intended
to facilitate the appropriate responses to a Member’s
healthcare needs across the continuum of care.
Care Coordinator An individual within a provider organization who facilitates
Care Coordination for patients.
Care Coordinator
Fee
A fixed amount paid by a Blue Cross and/or Blue Shield
Licensee to providers periodically for Care Coordination
under a Value-Based Program.
Claims Administrator
The claims payor designated by the Employer to adjudicate
claims and provide other services as mutually agreed. Blue
Shield of California has been designated the Claims
Administrator.
Claims
Administrator’s
Agreed Amount
The amount agreed upon by the Claims Administrator and
the provider or, if there is no agreement, the provider’s billed
charges.
Claims
Administrator’s
Reasonable Amount
The amount determined by the Claims Administrator to be the
fair value of the Services. In its discretion, the Claims
Administrator may determine fair value based upon a variety
of data or methods that the Claims Administrator determines
to be appropriate based on the type of Service and the
particular circumstances. The Claims Administrator’s
determination of fair value typically may include use of one or
more of the following factors: (1) the amounts paid by the
Claims Administrator to providers who have agreements with
the Claims Administrator; (2) studies, surveys or third-party
compilations of amounts charged by providers for the
Services; (3) amounts paid by governmental or private payors
for the Services; or (4) amounts dictated by federal law. In
addition, if the Services were rendered outside of California,
the Claims Administrator may determine fair value based
upon the amounts paid by the local Blue Cross and/or Blue
Shield plan for the Services. If the Claims Administrator has not
made a determination of the fair value of the Services, then
the Claims Administrator’s Reasonable Amount will be the
provider’s billed charges.
Coinsurance The percentage amount that a Member is required to pay for
Covered Services after meeting any applicable Deductible.
Continuous Nursing
Services
Nursing care provided on a continuous hourly basis, rather
than intermittent home visits for Members enrolled in a
Hospice Program. Continuous home care can be provided by
a registered or licensed vocational nurse, but is only available
Definitions 85
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599-2650.
for brief periods of crisis and only as necessary to maintain the
terminally ill patient at home.
Copayment The specific dollar amount that a Member is required to pay
for Covered Services after meeting any applicable
Deductible.
Cost Share Any applicable Deductibles, Copayment, and Coinsurance.
Covered Services
(Benefits)Medically Necessary services and supplies you are entitled to
receive pursuant to the Contract.
Deductible The Calendar Year amount you must pay for specific
Covered Services before the Claims Administrator pays for
Covered Services pursuant to the Contract.
Dependent
The spouse, Domestic Partner, or child of an eligible
Employee, who is determined to be eligible.
•A spouse who is legally married to the Participant
and who is not legally separated from the
Participant.
•A Domestic Partner to the Participant who meets
the definition of Domestic Partner as defined in this
Benefit Booklet.
•A child who is the child of, adopted by, or in legal
guardianship of the Participant, spouse, or
Domestic Partner, and who is not covered as a
Participant. A child includes any stepchild, child
placed for adoption, or any other child for whom
the Participant, spouse, or Domestic Partner has
been appointed as a non-temporary legal
guardian by a court of appropriate legal
jurisdiction. A child is an individual less than 26 years
of age. A child does not include any children of a
Dependent child (grandchildren of the Participant,
spouse, or Domestic Partner), unless the Participant,
spouse, or Domestic Partner has adopted or is the
legal guardian of the grandchild.
Domestic Partner
An individual who is personally related to the Participant by a
domestic partnership that meets all the following
requirements:
•Both partners are 18 years of age or older, except
as provided in Section 297.1 of the California Family
Code;
•The partners have chosen to share one another’s
lives in an intimate and committed relationship of
mutual caring;
Definitions 86
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•The partners are:
o not currently married to someone else or a
member of another domestic partnership,
and
o not so closely related by blood that legal
marriage or registered domestic partnership
would otherwise be prohibited;
•Both partners are capable of consenting to the
domestic partnership; and
•If required under your Plan Sponsor’s eligibility
requirements, provide a declaration of domestic
partnership.
The domestic partnership is deemed created on the date
when both partners meet the above requirements.
Emergency Medical
Condition
A medical condition, including a psychiatric emergency,
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that you reasonably believe the
absence of immediate medical attention could result in any
of the following:
•Placing your health in serious jeopardy (including
the health of a pregnant woman or her unborn
child);
•Serious impairment to bodily functions;
•Serious dysfunction of any bodily organ or part;
•Danger to yourself or to others; or
•Inability to provide for, or utilize, food, shelter, or
clothing, due to a mental disorder.
Emergency Services
The following services provided for an Emergency Medical
Condition:
•Medical screening, examination, and evaluation by
a Physician and surgeon, or other appropriately
licensed persons under the supervision of a
Physician and surgeon, to determine if an
Emergency Medical Condition or active labor exists
and, if it does, the care, treatment, and surgery
necessary to relieve or eliminate the Emergency
Medical Condition, within the capability of the
facility;
•Additional screening, examination, and evaluation
by a Physician, or other personnel within the scope
of their licensure and clinical privileges, to
determine if a psychiatric Emergency Medical
Condition exists, and the care and treatment
necessary to relieve or eliminate the psychiatric
Emergency Medical Condition, within the capability
of the facility;
Definitions 87
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•Care and treatment necessary to relieve or
eliminate a psychiatric Emergency Medical
Condition may include admission or transfer to a
psychiatric unit within a general acute care
Hospital or to an acute psychiatric Hospital; and
•Solely to the extent required under federal law,
Emergency Services also include any additional
items or services that are covered under the Plan
and furnished by a Non-Participating Provider or
emergency facility, regardless of the department
where furnished, after stabilization and as part of
outpatient observation or an inpatient or outpatient
stay.
Employee The person who, by meeting the Plan’s eligibility requirements
for Employees, is allowed to choose membership under this
Plan for himself or herself and his or her Dependents.
Employer
(Contractholder)
A public agency that has at least 2 employees and that is
actively engaged in business or service, in which a bona fide
employer-employee relationship exists, in which the majority
of employees were employed within this state, and which was
not formed primarily for purposes of buying health care
coverage or insurance.
Experimental or
Investigational
Any treatment, therapy, procedure, drug or drug usage,
facility or facility usage, equipment or equipment usage,
device or device usage, or supplies that are not recognized in
accordance with generally accepted professional medical
standards as being safe and effective for use in the treatment
of the illness, injury, or condition at issue.
Services that require approval by the Federal government or
any agency thereof, or by any State government agency,
prior to use and where such approval has not been granted
at the time the services or supplies were rendered, shall be
considered experimental or investigational in nature.
Services or supplies that themselves are not approved or
recognized in accordance with accepted professional
medical standards, but nevertheless are authorized by law or
by a government agency for use in testing, trials, or other
studies on human patients, shall be considered experimental
or investigational in nature.
Family The Employee and all enrolled Dependents.
Former Participating
Provider A Former Participating Provider is a provider of services to the
Member under any of the following conditions:
Definitions 88
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•A provider who is no longer available to you as a
Participating Provider, but at the time of the provider's
contract termination with the Claims Administrator, you
were receiving Covered Services from that provider for
one of the conditions listed in the Continuity of care
with a Former Participating Provider table in the
Continuity of care section.
•A Non-Participating Provider to a newly-covered
Member whose health plan was withdrawn from the
market, and at the time your coverage with the Claims
Administrator became effective, you were receiving
Covered Services from that provider for one of the
conditions listed in the Continuity of care with a Former
Participating Provider table in the Continuity of care
section.
•A provider who is a Participating Provider with the
Claims Administrator but no longer available to you as a
Participating Provider because:
o The Employer has terminated its contract with the
Claims Administrator; and
o The Employer currently contracts with a new
health plan (insurer) that does not include the
Claims Administrator Participating Provider in its
network; and
o At the time of the Employer’s contract
termination you were receiving Covered Services
from that provider for one of the conditions listed
in the Continuity of care with a Former
Participating Provider table in the Continuity of
care section.
Health Care
Provider
An appropriately licensed or certified professional who
provides health care services within the scope of that license,
including, but not limited to:
•Acupuncturist;
•Audiologist;
•Board certified behavior analyst (BCBA);
•Certified nurse midwife;
•Chiropractor;
•Clinical nurse specialist;
•Dentist;
•Hearing aid supplier;
•Licensed clinical social worker;
•Licensed midwife;
•Licensed professional clinical counselor (LPCC);
•Licensed vocational nurse;
•Marriage and family therapist;
•Massage therapist;
Definitions 89
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•Naturopath;
•Nurse anesthetist (CRNA);
•Nurse practitioner;
•Occupational therapist;
•Optician;
•Optometrist;
•Pharmacist;
•Physical therapist;
•Physician;
•Physician assistant;
•Podiatrist;
•Psychiatric/mental health registered nurse;
•Psychologist;
•Registered dietician;
•Registered nurse;
•Registered respiratory therapist;
•Speech and language pathologist.
Hemophilia Home
Infusion Provider
A provider that furnishes blood factor replacement products
and services for in-home treatment of blood disorders such as
hemophilia.
A Participating home infusion agency may not be a
Participating Hemophilia Infusion Provider if it does not have
an agreement with the Claims Administrator to furnish blood
factor replacement products and services.
Home Health Aide
An individual who has successfully completed a state-
approved training program, is employed by a home health
agency or Hospice program, and provides personal care
services in the home.
Hospital
An entity that meets one of the following criteria:
•A licensed and accredited facility primarily
engaged in providing medical, diagnostic, surgical,
or psychiatric services for the care and treatment of
sick and injured persons on an inpatient basis,
under the supervision of an organized medical staff,
and that provides 24-hour a day nursing service by
registered nurses;
•A psychiatric health care facility as defined in
Section 1250.2 of the California Health and Safety
Code.
A facility that is principally a rest home, nursing home, or
home for the aged, is not included in this definition.
Definitions 90
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Host Blue The local Blue Cross and/or Blue Shield licensee in a
geographic area outside of California, within the BlueCard®
Service Area.
Independent Review
Organization An entity that conducts independent external reviews of
Adverse Benefit Determinations.
Infertility
May be either of the following:
•A demonstrated condition recognized by a
licensed Physician or surgeon as a cause for
Infertility; or
•The inability to conceive a pregnancy or to carry a
pregnancy to a live birth after a year of regular
sexual relations without contraception.
Intensive Outpatient
Program
An outpatient treatment program for Mental Health
Conditions or Substance Use Disorder Conditions that provides
structure, monitoring, and medical/psychological intervention
at least three hours per day, three times per week.
Inter-Plan
Arrangements
The Claims Administrator’s relationships with other Blue Cross
and/or Blue Shield licensees, governed by the Blue Cross Blue
Shield Association.
Late Enrollee
An eligible Employee or Dependent who declined enrollment
in this coverage at the time of the initial enrollment period,
and who subsequently requests enrollment for coverage,
provided that the initial enrollment period was a period of at
least 30 days. Coverage is effective for a Late Enrollee the
earlier of 12 months from the date a written request for
coverage is made or at the Employer’s next open enrollment
period.
Medical Necessity
(Medically
Necessary)
Benefits are provided only for services that are Medically
Necessary.
Services that are Medically Necessary include only those
which have been established as safe and effective, are
furnished under generally accepted professional standards to
treat illness, injury, or medical condition, and which, as
determined by the Claims Administrator, are:
•Consistent with the Claims Administrator’s medical
policy;
•Consistent with the symptoms or diagnosis;
•Not furnished primarily for the convenience of the
patient, the attending Physician or other provider;
•Furnished at the most appropriate level that can be
provided safely and effectively to the patient; and
Definitions 91
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•Not more costly than an alternative service or
sequence of services at least as likely to produce
equivalent therapeutic or diagnostic results as to the
diagnosis or treatment of the Member’s illness, injury, or
disease.
Hospital inpatient services that are Medically Necessary
include only those services that satisfy the above
requirements, require the acute bed-patient (overnight)
setting, and could not have been provided in a Physician’s
office, the Outpatient Department of a Hospital, or in another
lesser facility without adversely affecting the patient’s
condition or the quality of medical care rendered.
Inpatient admission is not Medically Necessary for certain
services, including, but not limited to, the following:
•Diagnostic studies that can be provided on an
outpatient basis;
•Medical observation or evaluation;
•Personal comfort;
•Pain management that can be provided on an
outpatient basis; and
•Inpatient rehabilitation that can be provided on an
outpatient basis.
The Claims Administrator reserves the right to review all
services to determine whether they are Medically Necessary,
and may use the services of Physician consultants, peer
review committees of professional societies or Hospitals, and
other consultants.
Member
An individual who is enrolled and maintains coverage in the
plan pursuant to the Plan Document as either a Participant or
a Dependent. Use of “you” in this document refers to the
Member.
Mental Health
Condition
Mental disorders listed in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV), including Severe
Mental Illnesses and Serious Emotional Disturbances of a Child.
Mental Health
Services Services provided to treat a Mental Health Condition.
Non-Participating
(Non-Participating
Provider)
Any provider who does not participate in this plan’s network
and does not contract with the Claims Administrator to
accept the Claims Administrator’s payment, plus any
applicable Member Cost Share, or amounts in excess of
specified Benefit maximums, as payment in full for Covered
Services. Also referred to as an out-of-network provider.
Definitions 92
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Certain services of this plan are not covered if the service is
provided by a Non-Participating Provider.
Non-Participating
Pharmacy
A pharmacy that does not participate in the Claims
Administrator Pharmacy Network. These pharmacies are not
contracted to provide services to the Claims Administrator
Members.
Other Outpatient
Mental Health and
Substance Use
Disorder Services
Outpatient Facility and professional services for the diagnosis
and treatment of Mental Health and Substance Use Disorder
Conditions, including but not limited to the following:
•Partial Hospitalization;
•Intensive Outpatient Program;
•Electroconvulsive therapy;
•Office-based opioid treatment;
•Transcranial magnetic stimulation;
•Psychological Testing; and
•Behavioral Health Treatment.
These services may also be provided in the office, home, or
other non-institutional setting.
Out-of-Area
Covered Health
Care Services
Medically Necessary Emergency Services, Urgent Services or
Out-of-Area Follow-up Care provided outside the Plan Service
Area.
Out-of-Area Follow-
up Care
Non-emergent Medically Necessary services to evaluate your
progress after Emergency or Urgent Services are provided
outside the Plan Service Area.
Out-of-Pocket
Maximum
The highest Deductible, Copayment, and Coinsurance
amount an individual or Family is required to pay for
designated Covered Services each year as indicated in the
Summary of Benefits section. Charges for services that are not
covered, charges in excess of the Allowable Amount or
contracted rate do not accrue to the Calendar Year Out-of-
Pocket Maximum.
Outpatient
Department of a
Hospital
Any department or facility integrated with the Hospital that
provides outpatient services under the Hospital’s license,
which may or may not be physically separate from the
Hospital.
Outpatient Facility A licensed facility that provides medical and/or surgical
services on an outpatient basis but is not a Physician’s office
or a Hospital.
Partial
Hospitalization
An outpatient treatment program that may be free-standing
or Hospital-based and provides services at least five hours per
day, four days per week. You may be admitted directly to this
Definitions 93
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Program (Day
Treatment)
level of care or transferred from inpatient care following
stabilization.
Participant An Employee who has been accepted by the Employer and
enrolled by the Claims Administrator and who has maintained
enrollment in accordance with this plan.
Participant
Contribution (Dues)Amounts the Plan Sponsor may require Participants to
contribute toward the cost of coverage under the Plan.
Participating
Employer
A California city or county government. Specific
qualifications of a Participating Employer are stipulated in the
participation agreement.
Participating
Hospice or
Participating
Hospice Agency
An entity that has either contracted with the Claims
Administrator or has received prior approval from the Claims
Administrator to provide Hospice service Benefits.
Participating
(Participating
Provider)
A provider who participates in this Plan’s network and
contracts with the Claims Administrator to accept the Claims
Administrator’s payment, plus any applicable Member Cost
Share, as payment in full for Covered Services. Also referred to
as an in-network provider.
Physician An individual licensed and authorized to engage in the
practice of medicine.
Plan the ASO EPO Plan Benefit Plan for eligible Employees of the
Employer.
Plan Administrator The designated party that sets up a healthcare plan for the
benefit of the Employer’s Employees. The responsibilities of
the Plan Administrator include determining membership
parameters, investment choices and providing contribution
payments.
Plan Document The document adopted by the Plan Sponsor that establishes
the services that Participants and Dependents are entitled to
receive under the Plan.
Plan Service Area A geographical area designated by the Plan within which a
plan shall provide health care services.
Plan Sponsor
The designated party that sets up a healthcare plan for the
benefit of the Employer’s Employees. The responsibilities of
the Plan Sponsor include determining membership
parameters, investment choices and providing contribution
payments.
Definitions 94
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Plan Year The 12-month consecutive period established by the
Employer.
Preventive Health
Services
Preventive medical services for early detection of disease,
including related laboratory services, as specifically described
in the Preventive Health Services section.
Primary Care
Physician (PCP)A general or family practitioner, internist,
obstetrician/gynecologist, or pediatrician.
Program
Administrator Public Risk Innovation, Solutions and Management (PRISM).
Provider Incentive
An additional amount of compensation paid to a Health
Care Provider by a Blue Cross and/or Blue Shield Plan, based
on the provider's compliance with agreed-upon procedural
and/or outcome measures for a particular group of covered
persons.
Psychological
Testing Testing to diagnose a Mental Health Condition when referred
by a Participating Provider.
Reasonable and
Customary
In California: The lower of (1) the provider’s billed charge, (2)
the amount determined by the Claims Administrator to be the
reasonable and customary value for the services rendered by
a Non-Participating Provider based on statistical information
that is updated at least annually and considers many factors
including, but not limited to, the provider’s training and
experience, and the geographic area where the services are
rendered, or (3) if applicable, the amount determined under
federal law.
Outside of California: The lower of (1) the provider’s billed
charge, or, (2) if applicable, the amount determined under
federal law.
Where required under federal law, the Reasonable and
Customary Amount used for purposes of determining your
Cost Share may be based on the Plan’s “qualifying payment
amount,” which may differ from the amount the Claims
Administrator pays the Non-Participating Provider or facility for
Covered Services.
Reconstructive
Surgery
Surgery to correct or repair abnormal structures of the body
caused by congenital defects, developmental abnormalities,
trauma, infection, tumors, or disease to do either of the
following:
•Improve function; or
•Create a normal appearance to the extent
possible, including dental and orthodontic services
Definitions 95
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that are an integral part of surgery for cleft palate
procedures.
Serious Emotional
Disturbances of a
Child
A minor under the age of 18 years who has one or more
mental disorders in the most recent edition of the Diagnostic
and Statistical Manual of Mental Disorders (other than a
primary substance use disorder or developmental disorder),
that results in behavior inappropriate for the child’s age
according to expected developmental norms.
The child must meet the criteria in paragraph (2) of subdivision
(a) of Section 5600.3 of the Welfare and Institutions Code. This
section states that members of this population shall meet one
or more of the following criteria:
•As a result of the mental disorder, the child has
substantial impairment in at least two of the
following areas:
o Self-care;
o School functioning;
o Family relationships;
o Ability to function in the community; and
o Either the child is at risk of removal from home or
has already been removed from the home or
the mental disorder and impairments have been
present for more than 6 months or are likely to
continue for more than one year without
treatment;
•The child displays one of the following:
o Psychotic features;
o Risk of suicide; or
o Risk of violence due to a mental disorder;
•The child meets special education eligibility
requirements under Chapter 26.5 (starting with
Section 7570) of Division 7 of Title 1 of the
Government Code.
Severe Mental
Illnesses
Conditions with the following diagnoses:
•Schizophrenia
•Schizoaffective disorder
•Bipolar disorder (manic depressive illness)
•Major depressive disorders
•Panic disorder
•Obsessive-compulsive disorder
•Pervasive developmental disorder or autism
•Anorexia nervosa
•Bulimia nervosa
Definitions 96
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Skilled Nursing Services performed by a licensed nurse who is either a
registered nurse or a licensed vocational nurse.
Skilled Nursing
Facility (SNF)
A health facility or a distinct part of a Hospital with a valid
license issued by the California Department of Public Health
that provides continuous Skilled Nursing care to patients
whose primary need is for availability of Skilled Nursing care
on a 24-hour basis.
Specialist
Specialists include Physicians with a specialty as follows:
•Allergy;
•Anesthesiology;
•Dermatology;
•Cardiology and other internal medicine specialists;
•Neonatology;
•Neurology;
•Oncology;
•Ophthalmology;
•Orthopedics;
•Pathology;
•Psychiatry;
•Radiology;
•Any surgical specialty;
•Otolaryngology;
•Urology; and
•Other designated as appropriate.
Subacute Care
Skilled Nursing or skilled rehabilitation provided in a hospital or
Skilled Nursing Facility to patients who require skilled care such
as nursing services, physical, occupational or speech therapy,
a coordinated program of multiple therapies or who have
medical needs that require daily registered nurse monitoring.
A facility that is primarily a rest-home, convalescent facility, or
home for the aged is not included.
Substance Use
Disorder Condition Drug or alcohol abuse or dependence.
Substance Use
Disorder Services Services provided to treat a Substance Use Disorder
Condition.
Total Disability
(Totally Disabled)
In the case of an Employee, or Member otherwise eligible for
coverage as an Employee, a disability which prevents the
individual from working with reasonable continuity in the
individual’s customary employment or in any other
employment in which the individual reasonably might be
expected to engage, in view of the individual’s station in life
and physical and mental capacity.
Definitions 97
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In the case of a Dependent, a disability which prevents the
individual from engaging with normal or reasonable
continuity in the individual’s customary activities or in those in
which the individual otherwise reasonably might be expected
to engage, in view of the individual’s station in life and
physical and mental capacity.
Value-Based
Program
An outcomes-based payment arrangement and/or a
coordinated care model facilitated with one or more local
providers that is evaluated against cost and quality
metrics/factors and is reflected in Provider payment.
Urgent Services
Those Covered Services rendered outside of the Plan Service
Area (other than Emergency Services) which are Medically
Necessary to prevent serious deterioration of your health
resulting from unforeseen illness, injury or complications of an
existing medical condition, for which treatment cannot
reasonably be delayed until you return to the Plan Service
Area.
98
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Notices about your plan
Notice about this Administrative Services Only plan: The Plan Document is on file with
your Employer and a copy will be furnished upon request.
Plan Administrator and Plan Sponsor
The Employer is the Plan Administrator and Plan Sponsor.
The Plan Administrator shall retain the authority to delegate its officers and
Employees such responsibilities that are imposed by the terms of the Plan s
together with authority to control and manage the operation of the Benefit Plan.
The designated party, that sets up a healthcare plan for the benefit of the
Employer’s Employees. The responsibilities of the Plan Sponsor include
determining membership parameters, investment choices and, providing
contribution payment.
Program Administrator
Public Risk Innovation, Solutions and Management (PRISM) is the Program
Administrator. PRISM shall have the duty to interpret and construe the
Memorandum of Understanding with regard to overall administration of the
Program.
Claims Administrator
Blue Shield of California processes and reviews the claims submitted under this
Plan.
Blue Shield of California provides administrative claims payment services only
and does not assume any financial risk or obligation with respect to claims.
Notice about plan Benefits: Benefits are only available for services and supplies you
receive while covered by this Plan. You do not have the right to receive the Benefits of
this Plan after coverage ends, except as specifically provided under the Continuity of
care and Continuation of group coverage sections. The Claims Administrator may
change Benefits during the term of coverage as specifically stated in this Benefit
Booklet. Benefit changes, including any reduction in Benefits or elimination of Benefits,
apply to services or supplies you receive on or after the effective date of the change.
Notice about Medical Necessity: Benefits are only available for services and supplies
that are Medically Necessary. The Claims Administrator reserves the right to review all
claims to determine if a service or supply is Medically Necessary. A Physician or other
Health Care Provider’s decision to prescribe, order, recommend, or approve a service
or supply does not, in itself, make it Medically Necessary.
Notice about reproductive health services: Some Hospitals and providers do not
provide one or more of the following services that may be covered under your Plan
and that you or your family member might need:
•Family planning;
•Contraceptive services, including emergency contraception;
Notices about your plan 99
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
•Sterilization, including tubal ligation at the time of labor and delivery;
•Infertility treatments; or
•Abortion.
You should obtain more information before you enroll. Call your prospective doctor,
medical group, independent practice association, or clinic, or contact Customer
Service to ensure that you can obtain the health care services you need.
Notice about Participating Providers: The Claims Administrator contracts with Hospitals
and Physicians to provide services to Members for specified rates. This contractual
agreement may include incentives to manage all services for Members in an
appropriate manner consistent with the Plan. To learn more about this payment system,
contact Customer Service.
Notice about confidentiality of personal and health information: The Claims
Administrator protects the confidentiality/privacy of individually-identifiable personal
information, including protected health information. Individually-identifiable personal
information includes health, financial, and/or demographic information - such as name,
address, and Social Security number. The Claims Administrator will not disclose this
information without authorization, except as permitted by law.
A STATEMENT DESCRIBING THE CLAIMS ADMINISTRATOR’S POLICIES AND PROCEDURES
FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL
BE FURNISHED TO YOU UPON REQUEST.
The Claims Administrator’s policies and procedures regarding our
confidentiality/privacy practices are contained in the “Notice of Privacy Practices”,
which you may obtain either by calling Customer Service or by visiting
blueshieldca.com.
Members who are concerned that the Claims Administrator may have violated their
privacy rights, or who disagree with a decision the Claims Administrator made about
access to their individually-identifiable personal information, may contact the Claims
Administrator at:
Blue Shield of California Privacy Office
P.O. Box 272540
Chico, CA 95927-2540
Toll-Free Telephone:
1-888-266-8080
Email Address:
blueshieldca_privacy@blueshieldca.com
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.
Notice informing individuals about nondiscrimination and
accessibility requirements
Discrimination is against the law
Blue Shield of California complies with applicable federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Shield
of California does not exclude people or treat them differently because of race, color,
national origin, age, disability, or sex.
Blue Shield of California:
•Provides aids and services at no cost to people with disabilities to communicate
effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (including large print, audio, accessible
electronic formats and other formats)
•Provides language services at no cost to people whose primary language is not English,
such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Blue Shield of California Civil Rights Coordinator.
If you believe that Blue Shield of California has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability,
or sex, you can file a grievance with:
Blue Shield of California Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007
Phone: (844) 831-4133 (TTY: 711)
Fax: (844) 696-6070
Email: BlueShieldCivilRightsCoordinator@blueshieldca.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a
grievance, our Civil Rights Coordinator is available to help you. You can also file a civil
rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
(800) 368-1019; TTY: (800) 537-7697
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Language access services
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Language access services 103
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-
599-2650.