The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Spine Surgery In order to receive the highest level of benefits, use of a Blue Distinction Centers for Spine Surgery SM is required for members age 18 and older for health care plans administered by BCBS. This national network includes facilities that have demonstrated their commitment to quality care, resulting in better overall outcomes for spine surgery patients. Blue Distinction Centers for Spine Surgery SM provide comprehensive inpatient spine surgery services, including discectomy, fusion and decompression procedures. You may view a listing of designated centers at www.bluecrossmn.com/usb. Once you locate a designated center, you need to confirm the designated center is participating in your applicable network. To do this, choose your applicable network from the drop down menu under “Network” and search for the designated center to make sure it displays. You may also get information by calling BCBS customer service (see the “Important Resources” section in this SPD). Expenses for Travel and Lodging Expenses for travel and lodging for the patient and a companion are available as follows: • Transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of the surgery for the purposes of an evaluation, the surgical procedure or necessary post-discharge follow-up. • Reasonable and necessary expenses for lodging for the patient (while not hospitalized) and lodging only for one companion. Expenses are reimbursed at a per diem rate of up to $50 for one person or up to $100 for two people. • Travel and lodging expenses are available only if the patient resides more than 50 miles from the designated facility. There is a combined overall lifetime maximum of $1,500 paid by the Program per covered person for all transportation and lodging expenses incurred by the patient and companion(s) and reimbursed under this Program in connection with the surgery. Note: The deductible must be met by members enrolled in the Early Retiree Medical option before these expenses can be reimbursed by the Program. The Women’s Health and Cancer Rights Act of 1998 The Women’s Health and Cancer Rights Act requires that group health plans providing coverage for mastectomies also provide certain mastectomy-related benefits or services. Under federal law, because this Program provides medical and surgical benefits for mastectomies, it must also provide coverage for: • reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction on the other breast to produce a symmetrical appearance; and • coverage for prostheses and physical complications at all stages of the mastectomy, including lymphedemas. The same deductibles and coinsurance limitations apply to these procedures as apply to any other illness. 96
Retiree Health Care SPD Effective January 1, 2012 Transplants Coverage for transplants is limited to human organ or tissue transplants that are not experimental, investigative or unproven, including bone marrow, kidney, cornea, heart, lung(s), or heart and lung(s), liver, and pancreas if in conjunction with a kidney transplant. There is no coverage for artificial organs, transplantation of animal organs and/or tissue, and all services and supplies related to artificial or non-human organ implants. Contact BCBS for information about living donor transplant coverage. All transplants must be performed at a participating transplant center associated with BCBS. Services performed at non-participating transplant centers are not covered even if the services are medically necessary and/or referred. Other benefit limits and restrictions apply. All transplants, except cornea and kidney transplants, must be received at a Blue Distinction Centers for Transplants ® . A BCBS Transplant Coordinator will authorize and coordinate your care and assist you with travel and lodging reimbursement. Contact a BCBS Transplant Coordinator at 651-662-9936 or 866-309-6564. You may view a listing of designated transplant centers at www.bluecrossmn.com/usb. Expenses for Travel and Lodging Except for cornea and kidney transplants, expenses for travel and lodging for the transplant recipient and a companion are available as follows: • Transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of the transplant for the purposes of an evaluation, the transplant procedure or necessary post-discharge follow-up. • Reasonable and necessary expenses for lodging for the patient (while not hospitalized) and lodging only for one companion. Expenses are reimbursed at a per diem rate of up to $50 for one person or up to $100 for two people. • Travel and lodging expenses are available only if the transplant recipient resides more than 50 miles from the designated transplant facility. • If the patient is a covered dependent minor child, the transportation expenses of two companions will be covered and lodging expenses will be reimbursed up to the $100 per diem rate. There is a combined overall lifetime maximum of $10,000 paid by the plan per covered person for all transportation and lodging expenses incurred by the transplant recipient and companion(s) and reimbursed under this plan in connection with the transplant. Note: The deductible must be met by members enrolled in the Early Retiree Medical option before these expenses can be reimbursed by the Program. Non-Custodial and Full-Time Student Dependents Under the Early Retiree Medical Option If you are required by law to maintain health care coverage for a dependent (under age 18) who lives outside your state or network service area or if you have an eligible dependent attending school full-time outside your state or network service area, your dependent may choose an eligible BCBS BlueCard PPO network provider in the location where your dependent resides. 97
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