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
Page 70
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 70
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
Inpatient Hospital - continued on next page