The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Comprehensive Option, continued Service 1 Hospital Inpatient Services 1. Hospital Services 2. Acute Rehabilitation (not nursing home) 3. Skilled Nursing Facility (not nursing home) Hospital Outpatient Services 1. Hospital Services 2. Ambulatory Surgery Centers Infertility Treatment Participating Provider After Deductible Coinsurance 2 You pay 20% You pay 20% You pay 20% You pay 20% You pay 20% Non- Participating Provider After Deductible Coinsurance 2 Special Notes You pay 40% You pay 40% You pay 40% You pay 40% You pay 40% For Mental Health and Substance Abuse coverage, refer to that section in this SPD. See the “Knee and Hip Replacements” and “Spine Surgery” sections in this SPD for more information. Coverage is provided for up to 365 hospital days per plan year, including a semiprivate room, meals, general nursing care, intensive and other special care units, ancillary services and supplies such as operating, recovery, and treatment rooms, supplies, and in-hospital and take-home drugs. Private room is covered only when medically necessary or at the allowable charges for an average semiprivate room. Patient convenience items and private duty nursing are not covered. Acute Rehabilitation services covered when services are expected to make measurable or sustainable improvement within a reasonable amount of time. Skilled nursing must be ordered by a physician and be medically necessary. Skilled nursing facility limited to 100 days paid by the Program per plan year. Semiprivate room, meals, general nursing care, ancillary services and supplies, and in-facility drugs are covered. Private room is covered only when medically necessary or at the allowable charges for an average semiprivate room. Patient convenience items, custodial care and private duty nursing are not covered. Coverage for scheduled surgery, radiation, chemotherapy, kidney dialysis, respiratory therapy, diabetes outpatient self-management training and education which includes medical nutrition therapy, and all other eligible outpatient hospital care. See the “Knee and Hip Replacements” and “Spine Surgery” sections in this SPD for more information. You pay 20% You pay 40% A $2,500 lifetime maximum paid by the Program per family (not per person) will apply to all infertility services, including medical and surgical treatment. A separate $7,500 lifetime maximum paid by the Program per family (not per person) will apply to all infertility prescription drugs. See the “Pharmacy” section in this SPD. Coverage is provided for infertility testing and treatment due to the absence of fallopian tubes, a diagnosis of irreparably damaged fallopian tubes due to disease or natural blockage, and low sperm count. Continued on next page ¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if any action is recommended or required on your part before receiving the service. ² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible information related to your health care option. 42
Retiree Health Care SPD Effective January 1, 2012 Comprehensive Option, continued Service 1 Infertility Treatment, continued Lab, X-ray, CT Scans, MRI and Nuclear Imaging 1. Illness-Related 2. Preventive Care Mastectomy and Reconstructive Surgery Maternity 1. Hospital Services (Inpatient or Outpatient) and Postpartum Visits 2. Prenatal Office Visits Participating Provider After Deductible Coinsurance 2 You pay 20% The Program pays 100% (no deductible) Non- Participating Provider After Deductible Coinsurance 2 Special Notes You pay 40% Not covered by the Program Not covered: Sperm banking, donor ova or sperm, post tubal ligation or post sterilization reversal, charges for procedures which facilitate a pregnancy but do not treat the cause of infertility, such as in-vitro fertilization (IF, IVF), artificial insemination (AI), intrauterine insemination (IUI), embryo transfer, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer and tubal ovum transfer, services for or related to assisted reproductive technology (ART) procedures, and surrogate pregnancy and related charges. Contact BCBS of MN for more information. See the “Maternity” section in this chart for prenatal lab and x-ray services. Services are paid based on the billing codes used by your provider on the claim submitted to the medical Claims Administrator for payment. If a non-participating provider performs the procedure and then sends it out to be read, the charges for the reading only will be paid at the participating level. When submitted with an illness diagnosis code. See the “Preventive Care” section in this SPD for more information. You pay 20% You pay 40% See special notice in the section “The Woman’s Health and Cancer Rights Act of 1998” in this SPD.. You pay 20% The Program pays 100% (no deductible) You pay 40% You pay 40% Coverage is the same as for illness. Pregnancy coverage ends when your coverage under your option otherwise ends for any reason. New dependents must be added within 60 days of birth to be covered. (See the applicable “Eligibility and Enrollment section” in this SPD.) Inpatient benefits will not be restricted to less than 48 hours from the time of vaginal delivery or 96 hours from the time of Caesarean section delivery. Refer to the “Inpatient Maternity Care” section in this SPD for further details. You are allowed one home health visit upon discharge. (See “Home Health Care” section in this chart for additional information.) Prenatal lab and x-ray services are paid based on where the services are performed. If in a facility, they will pay under the Hospital Services benefit. If in an office, they will pay under the Prenatal Office Visits benefit. No coverage for adoption or adoption-related expenses, surrogate pregnancy or related expenses, childbirth classes, or delivery at home. Mental Health See the “Mental Health and Substance Abuse Coverage” section in this SPD for more details. ¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if any action is recommended or required on your part before receiving the service. ² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible information related to your health care option. 43
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The eligibility and enrollment rules for the U

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