2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 4. Your Costs for Covered Services
Page 30
Section 4. Your Costs for Covered Services
Page 30
For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.fepblue.org/NSA or contact the customer service phone number on the back of your ID card.
Your costs for other care
Overseas care: Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands are considered overseas care. We pay overseas claims at Preferred benefit levels, so the requirement to use Preferred providers in order to receive benefits does not apply. See Section 5(i) for specific information about our overseas benefits.
Inpatient facility care: You must use Preferred facilities in order to receive benefits. See page 18 for the exceptions to this requirement.
Overseas care: Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands are considered overseas care. We pay overseas claims at Preferred benefit levels, so the requirement to use Preferred providers in order to receive benefits does not apply. See Section 5(i) for specific information about our overseas benefits.
Inpatient facility care: You must use Preferred facilities in order to receive benefits. See page 18 for the exceptions to this requirement.
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
We limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year. For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
Note: Certain types of expenses do not accumulate to the maximum.
Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for your deductible, and for eligible coinsurance and copayment amounts, is $8,500 when you use Preferred providers. For a Self Plus One or a Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $17,000 for Preferred provider services. Only eligible expenses for Preferred provider services count toward these limits.
The following expenses are not included under this feature. These expenses do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay them even after your expenses exceed the limits described above.
We limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year. For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
Note: Certain types of expenses do not accumulate to the maximum.
Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for your deductible, and for eligible coinsurance and copayment amounts, is $8,500 when you use Preferred providers. For a Self Plus One or a Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $17,000 for Preferred provider services. Only eligible expenses for Preferred provider services count toward these limits.
The following expenses are not included under this feature. These expenses do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay them even after your expenses exceed the limits described above.
- The difference between the Plan allowance and the billed amount. See page 29;
- Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;
- The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with our cost containment requirements;
- The $100 penalty for failing to obtain prior approval, and any other amounts you pay because we reduce benefits for not complying with our cost containment requirements;
- If there is a generic substitution available and you or your provider requests a brand-name drug, your expenses for the difference between the cost of the generic medication and the brand-name medication do not count toward your catastrophic protection out-of-pocket maximum (see page 91 for additional information); and
- Expenses for care received from Non-preferred providers (Participating/Non-participating professional providers or Member/Non-member facilities), except for your deductible, coinsurance and/or copayments you pay in those situations where we do pay for care provided by Non-preferred providers. Please see page 18 for the exceptions to the requirement to use Preferred providers.
Carryover
If you change to another plan during Open Season, we will continue to provide benefits between January 1 and the effective date of your new plan.
If you change to another plan during Open Season, we will continue to provide benefits between January 1 and the effective date of your new plan.
- If you had already paid the out-of-pocket maximum, we will continue to provide benefits as described above until the effective date of your new plan.
- If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in January (before the effective date of your new plan) to our prior year’s out-of-pocket maximum. Once you reach the maximum, you do not need to pay our deductibles, copayments, or coinsurance amounts (except as shown above) from that point until the effective date of your new plan.