HMO POS PPO - Arkansas Blue Cross and Blue Shield

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Deductible (Annual)IndividualFamilyIn-Network$500At least two family members mustmeet the $500 deductible.Arkansas State EmployeesIndemnity PPO Benefit Summary 2006Out-of-Network$1,000At least two family members must meet the$1,500 deductible.Coinsurance (what you pay) 20% 30%Annual Out-of-Pocket LimitsIndividual $2,000 $2,500FamilyAt least two family members must At least two family members must meet themeet the individual out-of pocket limit. individual out-of-pocket limitLifetime Maximum None $1,000,000Preventive Care Services – for a complete list of services covered at 100%, please refer to your Summary PlanDescription which can be accessed at www.arbenefits.org.Immunizations, Mammograms,Physical Exams-Adults,Gynecological VisitsWell Baby CareWell Child CareNo deductible, 0% coinsurance30% coinsurance after deductiblePhysician Services 20% coinsurance after deductible 30% coinsurance after deductibleOutpatient Services 20% coinsurance after deductible 30% coinsurance after deductibleInpatient Hospital 20% coinsurance after deductible 30% coinsurance after deductibleEmergency Room Services 20% coinsurance after deductible 30% coinsurance after deductibleMaternity ServicesPhysician and Hospital Services20% coinsurance after deductible 30% coinsurance after deductibleTransplantsMost transplants require20% coinsurance after deductible 30% coinsurance after deductibleprior approvalDurable Medical Equipment$10,000 maximum per year20% coinsurance after deductible 30% coinsurance after deductibleProsthetics20% coinsurance after deductible$15,000 maximum per year30% coinsurance after deductibleTMJ $500 lifetime maximum 20% coinsurance after deductible 30% coinsurance after deductiblePhysical, Occupational, Speech Therapy, Cardiac Rehab, and Chiropractic Services60 visits per member per yearcombined20% coinsurance after deductible 30% coinsurance after deductibleAmbulance (Land or Air)$1,000 maximum per year for 20% coinsurance after deductible 30% coinsurance after deductibletransport servicesHome Nurse Visits 120 visits peryear20% coinsurance after deductible 30% coinsurance after deductibleHome Infusion IV Drugs &Solutions20% coinsurance after deductible 30% coinsurance after deductibleImportant Notice: If you use a hospital/physician who is a preferred provider, such hospital/physician has agreed to accept Arkansas Blue Cross andBlue Shield's payment for covered services as payment in full - except for your deductible and coinsurance, if applicable.If you use a hospital/physician who is a non-preferred provider, such hospital/physician is free to bill you charges for covered services in excess ofArkansas Blue Cross and Blue Shield's payment. Before receiving services from any hospital/physician, please check your directory of participatingproviders. Member may be responsible for charges in excess of any dollar maximum.This benefit summary provides a brief description of your state employee benefits for the Arkansas Blue Cross and Blue Shield Indemnity PPO Plan.Arkansas Blue Cross and Blue Shield is a Claims Administrator under the direction of the Employee Benefits Division. For a complete descriptionof your benefits please refer to the Summary Plan Description (SPD) published by Employee Benefits, your Group Administrator.
PPO QUESTIONS AND ANSWERSQ: What is a PPO plan?A: A PPO (Preferred Provider Organization) isan Indemnity Plan. The Arkansas Blue Cross andBlue Shield PPO Plan offers the largest networkof hospitals, physicians and other health-careproviders, which can be accessed without having toobtain a referral from a Primary Care Physician.Q: What if I receive care outside of the Blue Crossnetwork?A: If you choose a hospital or physician who is aparticipating provider with any Blue Cross and BlueShield nationwide, that provider has agreed toaccept Blue Cross’ payment in full except for yourdeductible and appropriate coinsurance. If you usea hospital or physician who is not a participatingprovider with Blue Cross, that provider is free tobill you charges for covered services in excess ofthe company’s payment.Q: What is BlueCard® and how does it work?A: BlueCard links participating health-careproviders and the independent Blue Cross and BlueShield Plans across the country through a singleelectronic network for professional, outpatient, andinpatient claims processing reimbursement. Theprogram allows participating Blue Cross and BlueShield providers in every state to submit claims forpatients any Blue Cross Blue Shield member. Whenyou need medical assistance out of the service area,you can call 1-800-810-2583 (BLUE) located on theback of the Identification Card to locate a BlueCross and Blue Shield provider. You should ask forthe PPO Network. The call center is open 24 hoursa day, seven days a week. You may also accessBlueCard providers online at www.bcbs.com. Theclaim is filed with the local Blue Plan and the alphaprefix lets the local Plan know where to route theclaim. Members using the BlueCard Access havein-network benefits for care outside the service area.Q: What do I need to do if I have a need formedical assistance and I’m outside the UnitedStates?A: Members traveling abroad should contact theBlueCard helpline at 1-800-810-2583 (BLUE) andask for BlueCard Worldwide. This is a providerlocator service open 24 hours a day, 365 days ayear. We also recommend that you visit the Website at www.bcbs.com to locate providers in advanceand take advantage of the valuable health and travelinformation listed there.Q: Are preventive care services covered by thisPPO plan?A: Yes. For a complete list of preventive careservices, please refer to your Summary PlanDescription (SPD). You may access the SPD onlineat www.arbenefits.org and look in the BenefitsLibrary, or you may call Employee BenefitsDivision at 1-877-815-1017 and request a copy.Q: Are pre-existing conditions covered?A: Yes. All of the health plans offered cover preexistingconditions.Q: How will the Any Willing Provider (AWP) lawaffect my coverage?A: AWP is an Arkansas law, so providers outsideArkansas will not be affected. In Arkansas, if aprovider applies to be a participating provider, andcompletes our credentialing process, then thatprovider will be part of the Blue Cross PPOnetwork, and normal in-network benefits will apply.Providers will still have the choice whether or not toparticipate, so there may still be some providerswho will not be in-network. For the most accurateand up-to-date provider directory, please visitwww.ArkansasBlueCross.com.Q: I am about to retire. What do I need to do tocontinue my insurance, and what are my coverageoptions?A: If you are a non-Medicare primary retiree, youhave the option to remain on the Blue Cross PPOPlan or change to the new ARHealth Benefit Planadministered by Health Advantage.If you are age 65 or older, or Medicare is yourprimary insurer, you will be automatically changedto the ARHealth benefit plan administered byHealth Advantage. For specifics of this plan pleaseaccess the Health Advantage Web site at:www.HealthAdvantage-hmo.com.
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HMO POS PPO - Arkansas Blue Cross and Blue Shield

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