The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Allowed Amounts To make sure the fees charged by providers are not excessive, BCBS pays based on “allowed amounts.” The allowed amount is the negotiated amount of payment that a participating provider has agreed to accept as payment in full (less deductibles, coinsurance and copayments) for a covered service at the time a claim is processed. All Program payments are based on the allowed amount. The allowed amount may vary from one provider to another for the same service. Also, BCBS may periodically adjust the allowed amount. If participating providers charge more than the allowed amount, the difference will appear in the provider reduction column on your Explanation of Benefits (the statement sent from BCBS following a claim). Except for certain locations and for non-covered services, you should not be billed for any amounts exceeding allowed amounts when you use participating providers. Refer to the “Which Network Providers to Use” section of this SPD for more information.. If you are so billed, do not pay the invoice. Check with your health care provider or the BCBS customer service department. When you obtain health care services through the BlueCard Program outside the geographic area BCBS of MN serves, the amount you pay for covered services is usually calculated on the lower of: 1. The billed charges for your covered services; or 2. The negotiated price that the on-site Blue Cross and/or Blue Shield Plan (“Host Blue”) passes on to the Claims Administrator. Often, this “negotiated price” consists of a simple discount that reflects the actual price paid by the Host Blue. Sometimes, however, the negotiated price is either 1) an estimated price that factors expected settlements, withholds, any other contingent payment arrangements and nonclaims transactions with your health care provider or with a specified group of providers into the actual price; or 2) billed charges reduced to reflect an average expected savings with your health care provider or with a specified group of providers. The price that reflects average savings may result in greater variation (more or less) from the actual price paid than will the estimated price. The negotiated price will be prospectively adjusted to correct for over- or underestimation of past prices. The amount you pay, however, is considered a final price and will not be affected by the prospective adjustment. Statutes in a small number of states may require the Host Blue either 1) to use a basis for calculating your liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim; or 2) to add a surcharge. If any state statutes mandate liability calculation methods that differ from the usual BlueCard method noted above or require a surcharge, the Claims Administrator will calculate your liability for any covered health care services according to the applicable state statute in effect at the time you received your care. Regardless of the plan you are enrolled in, if you obtain care from a non-participating provider, you are responsible for paying the difference between the billed charge and the allowed amount if your provider charges more than the allowed amount. The additional cost would depend on what your physician charges. For expensive procedures, this amount could be significant. Also, this excess amount will not apply to the deductible or out-ofpocket maximum. 48
Retiree Health Care SPD Effective January 1, 2012 For BCBS participants using a non-participating provider, if the provider is: • a facility in Minnesota, the allowed amount is a designated percentage of the facility’s billed charges. Outside of Minnesota, the allowed amount is determined by the local Blue Cross and/or Blue Shield Plan, unless that amount is greater than the billed charge, or no allowed amount is provided by the local Blue Plan. In that case, the allowed amount is determined from a Medicare-based fee schedule. If such pricing is not available, payment will be based on a percentage of the billed charges. • a physician or clinic in Minnesota, the allowed amount is the lesser of: (1) the Nonparticipating Provider Professional Services in Minnesota Fee Schedule or (2) a designated percentage of the billed charges. Outside of Minnesota, the allowed amount is determined by the local Blue Cross and/or Blue Shield Plan, unless that amount is greater than the billed charge, or no allowed amount is provided by the local Blue Plan. In that case, the allowed amount payment will be based on a percentage of pricing obtained from a nationwide provider reimbursement database that considers various factors, including the zip code of the place of service and the type of service provided. If this database pricing is not available for the service provided, payment will be based on the lesser of: (1) the Nonparticipating Provider Professional Services in Minnesota Fee Schedule or (2) a designated percentage of the billed charges. When you receive care from certain non-participating professionals, the reimbursement to the non-participating professional may include some of the costs that you would otherwise be required to pay (e.g., the difference between the allowed amount and the provider's billed charge) as well as the services may be paid at the highest level of benefits. This applies in limited circumstances when you receive care from non-participating professionals and you did not have 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, call the BCBS customer service department or access their Web site*. (See the “Important Resources” section in this SPD.) 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 of a retiree enrolled in the Early Retiree Medical 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. Non-Participating Participating Billed charge for covered service: $100 Billed charge for covered service: $100 Allowed amount: $85 Allowed amount: $85 Non-participating coverage (plan pays 55% $46.75 Participating coverage (plan pays 75% $63.75 of $85): of $85): You pay $100 minus $46.75: $53.25 You pay $85 minus $63.75: $21.25 49
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The eligibility and enrollment rules for the U

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