2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Inpatient Hospital
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Inpatient Hospital
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefit Description
Inpatient Hospital
Room and board, such as:
Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a hospital only has private rooms.
Other inpatient hospital services and supplies, such as:
Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described on page 74. See page 132 for more information about these types of services.
Here are some things to keep in mind:
Notes:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Inpatient Hospital
Room and board, such as:
- Semiprivate or intensive care accommodations
- General nursing care
- Meals and special diets
Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a hospital only has private rooms.
Other inpatient hospital services and supplies, such as:
- Operating, recovery, and other treatment rooms
- Prescribed drugs and medications
- Diagnostic studies, radiology services, laboratory tests, and pathology services
- Administration of blood or blood plasma
- Dressings, splints, casts, and sterile tray services
- Internal prosthetic devices
- Other medical supplies and equipment, including oxygen
- Anesthetics and anesthesia services
- Take-home items
- Pre-admission testing recognized as part of the hospital admissions process
- Nutritional counseling
- Acute inpatient rehabilitation
Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described on page 74. See page 132 for more information about these types of services.
Here are some things to keep in mind:
- If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See page 26 for information on requesting additional days.
- We pay inpatient hospital benefits for an admission in connection with the treatment of children up to age 22 with severe dental caries. We cover hospitalization for other types of dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(g).
Notes:
- See pages 76 and 87 for inpatient residential treatment center.
- See pages 71-73 for other covered maternity services.
- For inpatient care received overseas, refer to Section 5(i) page 107.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Inpatient Hospital (cont.)
Not covered:
Note: If we determine that an inpatient admission is one of the types listed above, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting. Benefits are limited to care provided by covered facility providers (see pages 17-18).
You Pay
All charges
Inpatient Hospital (cont.)
Not covered:
- Admission to noncovered facilities, such as nursing homes, extended care/skilled nursing facilities, schools, or residential treatment centers (except as described on pages 76 and 87)
- Personal comfort items, such as guest meals and beds, phone, television, beauty and barber services
- Private duty nursing
- Facility room and board expenses when, in our judgment, an admission or portion of an admission is:
- Custodial or long-term care (see Definitions)
- Convalescent care or a rest cure
- Domiciliary care provided because care in the home is not available or is unsuitable
- Custodial or long-term care (see Definitions)
- Care that is not medically necessary, such as:
- When services did not require the acute hospital inpatient (overnight) setting but could have been provided safely and adequately in a physician’s office, the outpatient department of a hospital, or some other setting, without adversely affecting your condition or the quality of medical care you receive.
- Admissions for, or consisting primarily of, observation and/or evaluation that could have been provided safely and adequately in some other setting (such as a physician’s office)
- Admissions primarily for diagnostic studies, radiology services, laboratory tests, or pathology services that could have been provided safely and adequately in some other setting (such as the outpatient department of a hospital or a physician’s office)
- When services did not require the acute hospital inpatient (overnight) setting but could have been provided safely and adequately in a physician’s office, the outpatient department of a hospital, or some other setting, without adversely affecting your condition or the quality of medical care you receive.
Note: If we determine that an inpatient admission is one of the types listed above, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting. Benefits are limited to care provided by covered facility providers (see pages 17-18).
You Pay
All charges