The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Transition of Care If you or a covered family member is currently being treated by a provider who is not in the network applicable to your location and health care option, and treatment is expected to continue after you enroll in the Early Retiree Medical or Comprehensive option, you or your covered family member may qualify for Transition of Care (TOC). TOC is only available for the treatment of acute conditions and not for the convenience of the member being treated. Examples of acute conditions are end-stage renal disease and dialysis, non-surgical cancer therapies (including chemotherapy and radiation), transplants (solid organ and bone marrow), and conditions where transition of care is required by federal law. Mental heath and substance abuse treatment are reviewed on a case-by-case basis. TOC allows you to be treated by your current provider for a specified period of time and receive the higher level of benefits. The length of time depends on the individual's situation. To apply for TOC, you and your physician will be required to complete a form and possibly submit supporting medical information related to your request. Upon receipt of the information, BCBS will review your request and notify you of its approval or denial. If approved, the notification will tell you for how long the approval is in effect. During this time, you are responsible for notifying BCBS of MN prior to receiving certain services or being admitted to the hospital. (See the section “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” in this SPD for more information.) In addition, you may need to file your own claim. See “Filing Health Care Claims – BCBS” in this SPD for more information. For additional information on TOC, call the BCBS of MN customer service department at the number listed in the “Important Resources” section of this SPD, or access the BCBS of MN Web site for forms. If you or a covered family member is pregnant and expects to be in the second or third trimester as of the effective date of coverage, you/she will automatically be eligible for TOC through the first postpartum visit. But you or your family member must still contact BCBS of MN to request the coverage. Kaiser expects that all members who join their plan do so with the knowledge they will receive care from their participating providers only. 50
Retiree Health Care SPD Effective January 1, 2012 Preadmission Notification and Prior Authorization for BCBS of MN- Administered Benefits Preadmission Notification* BCBS needs to be notified of planned (non-emergency) admissions before you or a covered dependent is admitted. This process is known as “preadmission notification.” Verify with your provider if this is a service they will perform for you or if you will need to complete the preadmission notification. Ultimately, you are responsible for ensuring preadmission notification has been made to BCBS. Preadmission notification applies for the following facilities** 1. All hospital admissions; 2. Rehabilitation facility admissions; 3. Long-term acute care (LTAC) admissions; 4. Residential mental health and substance abuse treatment facilities; and 5. Outpatient mental health and substance abuse treatment facilities providing partial hospitalization. This list may not be exhaustive and is subject to change. * Final payment of benefits is based on the coverage you have on the day services are received, whether lifetime benefit maximums have been exceeded, and whether the service authorized is the service billed. Any decision to undergo treatment rests with the patient, subscriber, and the provider. If you want to verify whether a service is covered, you must call BCBS. ** If Medicare is the primary payer for you or a covered dependent, “preadmission notification” does not apply, except for admissions for Transplants and Bariatric Surgery. Preadmission Notification Process In order to avoid liability for charges that are not considered medically necessary, notification is recommended for admissions to a participating facility. However, notification is required for admissions to a non-participating facility for the Comprehensive option or for admissions to an out-of-network facility for the Early Retiree Medical option. If BCBS is not notified before you or a covered dependent is admitted, any benefit payment payable under the plan is reduced. This reduction is called a Non-Notification Penalty. A Non-Notification Penalty of $300 per admission (or the amount of the covered expense, if less than $300), will apply. The Non- Notification Penalty does not apply to your deductible or out-of-pocket limits. If notification is not provided (whether recommended or required), and it’s determined at the point the claim is processed that services were not medically necessary, you are liable for all of the charges. To provide preadmission notification, call BCBS at least five working days before a planned admission. The number to call is on the back of your BCBS ID card. After you call, a patient care coordinator will determine if the admission is medically necessary and consult with your admitting physician regarding your care. In addition to preadmission notification, you should also obtain prior authorization for any services related to the admission for which prior authorization is recommended. See “Prior Authorization” later in this section. 51
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