The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
• reports in peer-reviewed medical literature;
• reports and guidelines, including supporting scientific data, published by nationally
recognized health care organizations;
• generally recognized (in the United States) professional standards of safety and
effectiveness for diagnosis, care or treatment; and
• the opinions of health professionals in the generally recognized health specialty involved.
Generally, BCBS of MN makes medical necessity determinations. However, in certain locations,
medical necessity determinations may be made by the local BCBS plan.
Mental Health
As defined in the International Classification of Diseases. It does not include alcohol or drug
dependence, recreational abuse of drugs or mental retardation.
Non-Embedded
Something that is not enclosed within something else. For example, the per person deductible
and out-of-pocket maximum amount is not within the family deductible and out-of-pocket
maximum amount for the Early Retiree Medical option. The entire family amount must be met if
you elect family coverage. It can be met by one covered family member or by a combination of
covered family members.
Non-Participating Provider
For the Comprehensive option, a provider that has not entered into any service agreement with
the Claims Administrator. If you receive services from a non-participating provider, your
expenses are generally covered at a lower level than if you chose a participating provider and
you will be responsible for paying the difference between the billed charge and the allowed
amount. Refer to the “Which Network Providers to Use” section of this SPD for more
information on the provider network.
Non-Preventive Service/Non-Routine Care
A service that is performed on a regular basis to monitor health as a result of medical or family
history or is associated with an injury or illness.
Out-of-Network Provider
For the Early Retiree Medical option, a provider who has a service agreement with BCBS, but
not for the network associated with your location and health care option. If you receive services
from an out-of-network provider, your expenses are generally covered at a lower level than if
you chose an in-network provider and in most cases, you will not be responsible for paying the
difference between the billed charged and the allowed amount. Refer to the “Which Network
Providers to Use” section of this SPD for more information on the provider networks.
Out-of-Pocket Maximum
The per plan year limit you must pay toward eligible expenses before any additional eligible
services you incur are paid by the health care option at 100% of the allowed amount for the
remainder of the year (as long as any applicable annual or lifetime maximums have not been
exceeded). See “Embedded” and “Non-Embedded” in this glossary and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information.
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