The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
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, BCBS of MN 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 option 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 deductibles or out-of-pocket
maximums.
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
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