The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 the opportunity to select the provider. Examples of this situation include diagnostic lab, independent diagnostic X-ray and independent anesthesia providers. To locate in-network/participating providers, you may ask your provider if he or she participates with BCBS, call the BCBS customer service department, or access their Web site*. (See the “Important Resources” section of this SPD.) In addition, you may call 1-800-810-BLUE (1-800- 810-2583). It is your responsibility to confirm that the provider you use is an in-network/participating provider. * Every effort is made to ensure that the list of providers on the BCBS Web site is up-to-date and accurate. However, the network is subject to change throughout the year. It is your responsibility to verify that the provider you or a covered family member uses is in the network associated with your health care option. You should call BCBS’s customer service department or access their Web site before you receive care to find out if a specific provider continues to be part of the network. Example The following example (if you are enrolled in the Comprehensive option) shows how coverage is calculated when you use a non-participating or participating provider, assuming your annual deductible has already been satisfied. In the example, the physician's charges exceed the Program's allowed amount. Out-of-Network In-Network Billed charge for covered service: $100 Billed charge for covered service: $100 Allowed amount: $85 Allowed amount: $85 Non-participating coverage pays 60% $51 Participating coverage pays 80% of $68 of $85: $85: You pay $100 minus $51: $49 You pay $85 minus $68: $17 Eligible Health Care Professionals In order to receive coverage for eligible health care expenses, you need to make sure the practitioner you are using is eligible. To be eligible, practitioners must practice within the scope of their licenses and must not be members of your immediate family. Examples of eligible practitioners include: • Doctors of medicine (MD) and their supervised employees • Doctors of chiropractic (DC) and their supervised employees • Doctors of podiatry (DP or DPM) • Doctors of optometry (OD) • Doctors of osteopathy (DO) • Optometrists • Licensed acupuncture practitioner • Licensed psychologists • Licensed consulting psychologists (LCP) • Doctors of dental surgery (DDS) • Certified nurse midwives • Nurse anesthetists 100
Retiree Health Care SPD Effective January 1, 2012 • Nurse practitioners • Audiologists • Physical therapists (PT) • Certified speech and language pathologists • Occupational therapists (OT) • Master level clinical social workers (MLCSW) • Licensed professional counselors • Mental health professionals • Physician assistants • Registered dieticians Note: Although a practitioner may be considered eligible, services provided by the practitioner may not be eligible under your option. Please see the “What the Options Cover” and the “General Exclusions” sections in this SPD. In addition, there may be other types of practitioners that are eligible, but not listed. If you have any questions regarding eligible practitioners, call the BCBS customer service department at the number listed in the “Important Resources” section in this SPD. Home Health Care Covered home health care services must be provided by an eligible provider, examples of which include: • Nurse • Physical therapist (PT) • Certified speech and language pathologist • Medical technologist • Dietician • Master level clinical social worker (MLCSW) • Occupational therapist (OT) • Home health aide Note: Although a provider may be considered eligible, services provided by the provider may not be eligible under your plan. Please see the “What the Options Cover” and the “General Exclusions” sections in this SPD. In addition, there may be other types of providers that are eligible, but not listed. If you have any questions regarding eligible providers, call the BCBS customer service department at the number listed in the “Important Resources” section in this SPD. Eligible Facilities In order to receive coverage for eligible health care expenses, you need to make sure the facility you are using is eligible. For example, hospitals providing care must generally be licensed, under the direction of physicians, have 24-hour registered nursing services, and be privately owned, or owned or operated by state or local government to be eligible. Examples of eligible facilities are: • Hospitals • Skilled nursing facilities • Residential treatment facilities for substance abuse and mental health • Hospices • Ambulatory surgery centers 101
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The eligibility and enrollment rules for the U

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