Personal Comp Member Handbook - CareFirst BlueCross BlueShield

Your Member Handbook■ What is covered under my Adultphysical / routine benefit?■ Do I need an authorization forBehavioral Health Services?■ How do I file a Rx Claim?

Please call the Member Services telephone number listedon your member ID card. Our service hours are:If you prefer, you can submit your inquiry to us inwriting at the following address:Please include your name, address, telephone numberand membership number on all correspondence.You may also meet with our Member Servicesrepresentatives in person at our main office or at oneof our regional service centers. Walk-in service isprovided on a first-come, first-served basis at thelocations below.10802 Red Run BoulevardOwings Mills, MD 21117151 West Street, Suite 101Annapolis, MD 21401-2405(410) 268-648881 Baltimore Street, Suite 608Cumberland, MD 21502-2370(301) 722-4585301 Bay Street, Suite 401Easton, MD 21601-2746(410) 763-6454182-184 Eastern BoulevardHagerstown, MD 21740-5843(301) 733-2935110 Baughman’s Lane, Suite 180Frederick, MD 21702(301) 663-3138224 Phillip Morris Drive, Suite 106Salisbury, MD 21804-1962(410) 546-0513The following telephone numbersmay or may not be associated withyour particular plan.(800) 810-BLUEsMagellan Behavioral Health(800) 245-7013Argus Health Systems(888) 850-2405Refer to page 22 for the OptionsProgram DirectoryThe Dental Network *(410) 847-9060(888) 833-8464Davis Vision (800) 783-5602Product Specialists (to inquire aboutOther CareFirst products)(410) 356-8000 or (800) 544-8703* The Dental Network, Inc. is anindependent licensee of the BlueCross and Blue ShieldAssociation.

Thank you for choosing Personal Comp. We are committed to providing our members and theirfamilies with the highest level of service possible and hope that the information included in thishandbook will assist you in understanding your Personal Comp benefits and options. Please take amoment to review this information and keep it in a safe place for future reference. This book, alongwith your Personal Comp Policy and enrollment materials, gives you tips on how to receive thehighest level of health care benefits. This guide is meant to be an overview and describes importantfeatures of Personal Comp. However, it is not a contract. A detailed description of specific terms, aswell as the conditions and limitations of your coverage, is included in your Personal Comp Policy.As always, please contact Member Services at the telephone number listed on the front of yourmember ID card if you have any questions regarding your coverage. We appreciate your business andlook forward to serving you in the future.When you visit My Account on www.carefirst.com, you can find information about your medicalplan including who and what is covered, claims status, and how much has been applied to yourdeductible if you have one. (Note: While claims information is available to all members, somemembers do not yet have access to all features.) In addition, our secure email feature will enableyou to send inquiries to us.To use My Account:1. Go to the Members & Visitors section of www.carefirst.com and click on the My Account buttonon the left.2. Register using the membership number located on your member ID card.You may also view this handbook online at www.carefirst.com in the “Members & Visitors” section.i

ContentsYour Member ID Card ........................................................................................................... 1When You Need Care .............................................................................................................2■ Medical Records ■ Scheduling Appointments ■ Canceling Appointments■ Preventive Care Benefits ■ Well Child Care ■ Adult Physical Exams ■ Medical Emergencies ■ FirstHelp®■ Mental Health, Alcohol Abuse and Drug Abuse Benefits ■ Coverage When Traveling■ Receiving Health Care Outside of the CareFirst BlueCross BlueShield Service Area■ Pre-Existing Conditions ■ ExclusionsCareEssentials ......................................................................................................................... 7■ Prevention ■ Vitality Newsletter ■ Get Healthy with My Care First■ Great Beginnings Program for Expectant Mothers ■ Preventive Services Guidelines■ Utilization Management ■ Hospital Care ■ Disease Management ■ Case ManagementHealth Savings Account Plan ............................................................................................... 11Claims, Enrollment Changes & Payments .......................................................................... 14■ Coordination of Health Care Benefits ■ Subrogation and Workers’ Compensation■ Paying for your Health Care Coverage ■ Personal and Enrollment Changes ■ Filing Claims■ Explanation of Health Care Benefits StatementAdditional CareFirst Benefits ............................................................................................... 20■ Your Dental Benefits ■ Your Vision Benefits ■ Save Money with the Discount Drug ProgramDiscount Program ................................................................................................................ 22■ Discounts on Alternative Therapies and Wellness ServicesAppeals Process .................................................................................................................... 25Member Rights and Responsibilities ................................................................................... 26Portability ............................................................................................................................. 27Confidentiality ...................................................................................................................... 28Frequently Asked Questions ................................................................................................ 29Definition of Terms .............................................................................................................. 30Index ...................................................................................................................................... 31ii

Your member ID card provides you with health care protection nationwide. Be sure to carry it withyou at all times.The diagram below highlights the information that appears on your member ID card.Please take a moment to review your card. If any of the information is incorrect please contact MemberServices immediately.The back of your member ID card includes medical emergency assistance and mental health/substanceabuse telephone numbers, as well as instructions and an address for filing claims and sending correspondence.If your ID card is lost or stolen, please contact Member Services immediately for a replacement.Remember to destroy any old cards and always present your current ID card when receiving services.Below is a sample member ID card. Please review your actual card for your ID number and informationspecific to your coverage.Your Member ID Card 1

2When You Need CareYou should take the time to meet with your physicianand establish a relationship because you cannot predictwhen you may become ill or require hospitalization. Inan emergency, you may find it more comforting to seea doctor whom you already know.Each physician’s office keeps a copy of your medicalrecords. If you are a new member, we encourage you totransfer your previous medical records to your currentphysician’s office. Transferring your records to yourphysician’s office will give your physician easieraccess to your medical history. Your previous physicianmay charge you a fee for this transfer of records. Yourmedical records are kept in confidence and will only bereleased as authorized by law.Always call for an appointment before visiting yourprovider and identify yourself as a CareFirst member.Don’t forget to bring your member ID card to yourappointment and present the card to the receptionist.You should always present your member ID cardwhenever you seek care at your physician’s office or thehospital.CareFirst has set goals for providers in our participatingnetworks regarding appointment availability and officewaiting times. For appointments for non-symptomaticvisits, such as preventive care or routine wellness, weexpect the doctor to schedule the appointment withinfour weeks.If you are unable to keep a scheduled appointment,call the physician’s office as soon as possible. Mostphysicians prefer at least 24-hour notice so they canoffer your appointment time to another patient. Somephysicians may charge you a fee if you miss anappointment and have not called to cancel. Preventive health care services are procedures youshould have to detect any health problems. It is veryimportant that you are aware of the preventive servicesfor which you are eligible.Important: If during a routine/preventive exam,additional services are performed and/or a condition isidentified and treated, these services may be subject todeductibles and coinsurance. Your policy notes certainlimitations on preventive care benefits. American Academy of Pediatrics) shots (diphtheria, whooping cough, tetanus); oralpolio vaccines; measles, mumps and rubella (asrecommended by the Advisory Committee onImmunization Practices of the Center for DiseaseControl) anemia, lead toxicity, vision and hearing Contact your physician to determine whether your childhas received all screenings and tests appropriate forhis or her age. Then set up an appointment for regularpreventive care.Adult Preventive Care Services are listed on thefollowing page. The information on the following pageis for most options. In the Health Savings Account(HSA) Compatible options, these preventive carebenefits are not limited to those indicated on page 3 ofthis handbook. Please refer to your policy for specificinformation about your preventive care benefits.

Benefits Ages Frequency* 18-39 1 every 3 years40-64 1 every yearIncludes:■ Medical history■ Serum Cholesterol■ TB test■ Stool for occult blood■ Hematocrit■ Clinical breast exam■ Urinalysis■ Immunizations fortetanus and flu 35-3940-4918 and up 1 every year*Service should fall on same date ormonth as year (or 3 years) before oranytime thereafter.1 baseline screening1 routine screening per24-month period (morefrequent if recommendedby physician)50 and up 1 routine screening per year 50 and up 3 per lifetimesubject to deductible and coinsuranceYour Member ID CardWhen you have a medical emergency, your health carecoverage is not the first thought that comes to mind.We encourage you to become familiar with this sectionso you’ll know how to get the maximum benefitsavailable under the policy if you should have a medicalemergency. If the situation is a medical emergency: A “Medical Emergency” is the sudden onset of a seriousillness or injury that in the absence of immediatemedical attention could reasonably be expected bya prudent layperson (one who possesses an averageknowledge of health and medicine) to result in: serious dysfunction of any bodily organ or part jeopardy to the health of the fetus.If you believe a situation is a medical emergency,call 911 immediately or go to the nearest emergencyfacility. In an urgent situation, contact your physicianfor advice. If your physician is not available and youhave symptoms and don’t know exactly what theymean or how serious they are, CareFirst BlueChoiceprovides you with an outside vendor, FirstHelp®, a24-Hour Emergency Assistance and Medical Advicehotline. Here’s how it works:1. If you are unable to reach your physician, youcan take advantage of our arrangements withFirstHelp®, a 24-Hour Medical Advice/EmergencyAssistance Service at (800) 535-9700. (Thetelephone number is also listed on the back ofyour member ID card.) Your call will be answeredpromptly by an experienced registered nurse.2. If the nurse determines that your situation is amedical emergency, he or she will advise you toseek immediate medical care. NOTE: If taking thetime to call FirstHelp® would seriously jeopardizeyour health, call 911 directly or go to an emergencyfacility immediately. 3

When You Need Care3. If your condition is not an emergency situation, thenurse will ask you about your symptoms. The nursewill then make recommendations to help you decidethe safest and most appropriate course of action,whether it’s a participating urgent care center, anappointment at your physician’s office, or self-care.4. If the nurse recommends self-care, he or she willeducate you about your condition, explain what todo for pain or symptom relief and tell you what toexpect or watch for. The nurse may also call you thenext day to check on your condition.As a result of legislation passed in the MarylandGeneral Assembly, effective October 1, 2007, you mayrequest a referral to see a non-participating health careSpecialist (physician or non-physician) provider undercertain circumstances. Here’s how:1. You or your eligible dependent must be diagnosedwith a disease or condition requiring specializedhealth care services or medical care and there isnot a provider in the CareFirst provider panel(participating or network level) with the professionaltraining or expertise to treat or provide health careservices for the condition or disease;OR2. You or your eligible dependent must be diagnosedwith a disease or condition requiring specializedhealth care services or medical care and CareFirstcannot provide reasonable access to a specialistor non-physician specialist with the professionaltraining or expertise to treat or provide healthcare services for the condition or diseases withoutunreasonable delay or travel.If you meet the circumstances above and have the nameof a non-participating health care specialist provideryou’d like to receive care from, please call the MembersServices phone number on the back of your member IDcard. A Customer Services Representative will work withyou to determine the next steps in obtaining a referral.You are responsible for the full charges fromnon-participating health care providers. CareFirstwill pay you directly for covered services renderedby a non-participating health care provider. Thenon-participating health care provider may balance billyou between our allowed benefit (subject to in-networkco-payments, coinsurance and deductibles) and theircharge.CareFirst recognizes that there are times when adeteriorating quality of life can trigger even moreserious consequences. For people struggling to overcomealcoholism or trying to cope with depression, anxiety or astress disorder, CareFirst works with Magellan BehavioralHealth (Magellan), a professional review organization,to ensure the coordinated delivery of inpatient andoutpatient services.Your coverage provides benefits for psychotherapy,family counseling, group therapy and alcohol recoveryprograms.While these services can be obtained through anyqualified provider, your program requires preauthorizationfrom Magellan for all outpatientcare and for inpatient mental health or alcoholrehabilitation. This pre-authorization is requiredeven in emergency cases.If you don’t follow the process of obtaining the requiredcertification of authorized care, you will forfeit benefitsfor which you might otherwise be eligible.To learn more about this comprehensive coordinatedcare program and how it works or to begin the preauthorizationprocess, call Magellan’s professional servicecounselors at (800) 245-7013. In case of emergency, callthe same number for assistance. A Magellan representativeis available 24 hours a day, 7 days a week.4

No matter where you go, your member ID card makesyou feel at home. CareFirst health benefits travel easilyall across the country. Carry your member ID card, theBlueCard® – and you’ll always travel with confidence. Because you are a CareFirst member, your member IDcard is your direct link to care anywhere in the country.Show your member ID card to any hospital or physicianparticipating with a Blue Cross and Blue Shield Plan andreceive the same benefits as you would for a local provider.In the United States, more than 80 percent of hospitalsand nearly 90 percent of physicians contract directlywith Blue Cross and Blue Shield Plans. Your CareFirstBlueCross BlueShield member ID card – the BlueCard®– links these health care providers to an electronic datasystem that quickly delivers your benefit informationanywhere in the country.Your CareFirst BlueCross BlueShield member ID card– the BlueCard® – gives you access to care throughoutthe United States. The three-letter prefix on your cardtells any participating hospital or physician whichindependent Blue Cross and Blue Shield Plan youbelong to. This ensures that you will receive all of thecomforts and conveniences that you’re accustomed tofrom your own Blue Cross and Blue Shield Plan. ■ You are outside of the CareFirst service area andneed health care.■ You visit a participating Blue Cross and BlueShield Plan provider and present yourmembership card.■ Your provider quickly verifies your membershipand coverage.■ After you receive medical attention, your claimis electronically routed to CareFirst, whichprocesses the claim. You are responsible for anydeductible and coinsurance payments.■ CareFirst then sends you a detailedExplanation of Benefits Statement.■ All participating providers are reimbursed,relieving you of any hassle and worry. If youplan to travel outside of the USA and itsterritories, please contact BlueCard® Worldwideat (800) 810-BLUE to find out what to do if youneed medical care during your trip.It’s easy, it’s accurate and it takes care of yourhealth care needs anywhere, anytime.A pre-existing condition is defined as: date; which you sought or received medical treatment bya practitioner prior to your effective date; or effective date that caused you to seek treatment.Services to treat a pre-existing condition (orcomplications related to a pre-existing condition) areeligible for coverage once you have been covered for10 months. Coverage is not provided for pre-existingconditions within the first 10 months of your healthbenefit plan. You are eligible for a waiver of the preexistingperiod if you have a certificate of creditablecoverage demonstrating prior health coverage for 18months with the most recent coverage being with a groupand no more than a 63-day break in coverage.If you disclosed a condition on your medically underwritten application, it will not be considered a pre-existingcondition unless we mailed you a pre-existing conditionwaiver rider that specifically excludes coverage for thecondition listed for a waiting period of 10 months.Services rendered for maternity care are subject tothe pre-existing condition waiting period only if thepregnancy existed before the effective date of the policy.If the pregnancy occurs after the effective date, thenCareFirst will begin covering extended maternity andrelated services immediately.*If you have Personal Comp Qualified Tax Credit Coverage,the pre-existing condition waiting period does not apply.When You Need Care 5

When You Need CareWhile the Personal Comp plan offers coverage forcomprehensive medical care, it does not cover thefollowing: the diagnosis or treatment of an injury or illness asdefined by CareFirst an eligible practitioner considered experimental or investigative charges which you are not legally obligated to pay, orcharges made only to insured persons (This exclusiondoes not apply to Medicaid.) Compensation or Occupational Disease Act or Law scheduled visit, or charges for completion of a claimform or medical statement diagnostic services for screening except for thosecovered under Preventive Benefits diaphragms and IUDs condition that is identified in a pre-existing conditionwaiver rider that specifically excludes coverage for thecondition listed for a waiting period of 10 months as a covered service under the policy Please note, this list is a general listing for your referenceand is not a complete listing of exclusions. Refer to yourPersonal Comp Policy for all exclusions that apply to yourpolicy.6

CareEssentialsCareEssentials is CareFirst’s care management program that integrates Prevention, Utilization Management, DiseaseManagement and Case Management to provide you with the resources to make intelligent health care decisions.CareFirst understands that taking the firststep to get healthier is one of the toughest.That’s why we’re providing you with tools to make iteasier – and fun – to get healthy.MyHealthProfile is a health risk assessment tool thatprovides you with a personalized health report. Once youare enrolled in a CareFirst health plan, you will receive aletter in the mail that gives you a temporary usernameand password to take MyHealthProfile online. You canlog on to www.myhealthiq.com/carefirst and answerquestions about your medical history, what types ofpreventive services you are receiving, your emotionalhealth as well as your current lifestyle choices.Our lifestyle management programs provideyou with online health information basedon your answers from MyHealthProfile.This information is customized just foryou and can help you achieve a healthierlifestyle! We have lifestyle managementprograms to help you:■ Manage stress■ Keep a healthy diet■ Quit smoking■ Lose weightCareEssentialsAfter completing MyHealthProfile, you will receive acustomized health report that will alert you to possiblehealth risks and provide you with recommendationson how to stay healthy. The report also includes asummary page that you can take to your doctor to useas a guide when talking about your health.MyHealthProfile is available online, by phone and bymail. Taking it online provides advantages like linkingyou to helpful tools such as our lifestyle managementprograms, keeping your personal history up-to-dateand tracking your progress using your previous results.■ Develop and maintain an exercise routine■ Prevent depression■ Adhere to your medicationsOnce you enroll, you can participate inhealth-related quizzes, surveys, and exercises– all to help you stay on track.The lifestyle management tools are availableonly if you complete MyHealthProfileonline. If you have any questionsregarding MyHealthProfile or our lifestylemanagement programs, contact a healthsupport representative at (866) 449-9705. 7

CareEssentialsWe also have a Healthy Lifestyle Coaching programthat provides you with support if you are at risk fora disease. While you may not have a disease, yourMyHealthProfile report may determine that you couldbe at risk.For example, the MyHealthProfile report may identifyyou if you are a heavy smoker and also have asthmain your family history. If you were to develop asthma,your condition may be severe because of smoking.You could be invited to participate in health coachingsessions where a health coach helps you set goals tohelp you quit smoking — and not only that, but youcan talk to your coach every step of the way untilyou’ve reached your goal(s). Call (866) 737-5569 if youhave questions about the Healthy Lifestyle Coachingprogram.You will receive Vitality, our quarterly membernewsletter. Each issue is filled with useful and timelyinformation on a variety of health-related topics.You’ll learn about food and nutrition, physical fitness,recreation and preventive health care. You’ll also getto know about our company and how to get the mostfrom your benefits.Looking for ways to get healthy and stay healthy? Gosurfing – on the web, that is. Visit My Care First, thehealth and wellness section of www.carefirst.com.Our award-winning site contains a wealth of healthinformation and interactive features that can help youtake an active role in managing your health.If you are looking for information about a specificcondition, just select a topic from our health library.You can also learn about a variety of health issuesfrom our weekly stories and quizzes. You also canoffer your opinion on a health issue by taking theweekly poll.Visit My Care First, the health and wellness section ofwww.carefirst.com for information that can help youmanage your health.At My Care First you will find:■ Information on over 300 health-related topics■ Personalized health calculators that determineyour body mass index or target heart rateIf you or a loved one has asthma, diabetes or heartdisease, visit our asthma center, diabetes center or hearthealth center for the information, quizzes and tools tohelp manage these conditions.You can also obtain personalized health information,such as your body mass index, your target heart rate andyour ideal weight by using the health calculator. For evenmore detail about your health, you can register with thesite. Registering will enable you to take a personalizedhealth assessment, set health goals, track your progressand have reminders sent via e-mail. You can even gethelp to manage weight, stress or blood pressure and toquit smoking.To visit My Care First, go to www.carefirst.com andclick on “Health and Wellness – My Care First” in theSolution Center.CareFirst also offers Case Management support tomembers during pregnancy. The Great Beginningsprogram is designed to supplement the prenatal careand education you receive from your doctor duringpregnancy. Our Case Managers strive to help you andyour baby stay healthy during pregnancy.When you enroll in Great Beginnings, one of our CaseManagers will contact you to review your medical historyand to identify any other conditions that may affectyour pregnancy. You will receive information related toyour condition and your baby’s development. Your CaseManager will contact you during each trimester to seehow you are feeling and to answer any questions.If you have not chosen a pediatrician, the CaseManager also may assist you in finding a pediatricianclose to your home. If you experience anycomplications during pregnancy, your Case Managerwill work closely with your doctor to coordinatenecessary services and provide additional support andinformation you may need during this time.8

Each year, CareFirst publishes a list of preventive servicesguidelines. Preventive services are procedures you shouldhave, if applicable, to detect any health problems. Yourphysician may recommend additional tests or exams.Adult preventive services include:■ periodic physicals■ blood pressure checks■ height and weight monitoring■ cholesterol screening■ colon and prostate cancer screening■ gynecological exams■ testicular exams■ diabetes screening■ mammograms■ immunizations■ depression screening■ tuberculosis screening■ osteoporosis screening■ aortic abdominal aneurysm screening■ counseling/education/ screening for high risk factors■ HIV screening■ Hepatitis C screening■ preconception counselingIf you would like a list of the specific guidelines,call Member Services at the number listed on yourmember ID card. You may also visit our web site atwww.carefirst.com and click on My Care First.The goal of Utilization Management is toensure that care is provided at the right timeand in the proper setting. Registered nurses and boardcertifiedpractitioners administer CareFirst’s UtilizationManagement Program.The program includes prior authorization requirementsfor certain services, review of authorizations forhospital admissions according to a nationally-acceptedset of criteria and retrospective review of treatment forwhich CareFirst did not give prior authorization.Pre-admission review is for non-emergency hospitalization.If you are going to be admitted to a hospital for elective(non-emergency) surgery, you or your physician mustnotify CareFirst before your admission.This gives one of our nurses or trained medicalprofessionals time to review the appropriateness of anin-hospital setting and to determine whether analternative, such as outpatient treatment, may be moresuitable. Please note that the pre-admission reviewprocedure does not apply when the patient is admittedto the hospital for normal childbirth. If you have anyquestions regarding pre-admission review, please callMember Services.In most instances, the proposed hospital admissiontakes place exactly as planned. However, there have beeninstances in which a more appropriate setting was found.If you do not obtain a pre-admission review for anelective inpatient admission, then the benefits for roomand board and ancillary charges (additional services, suchas drugs and laboratory tests) for a medically necessaryhospitalization will be reduced to 50% of the allowedbenefit.When you need non-emergency surgery, your policywill cover a voluntary second opinion. You canschedule an appointment with another surgeon of yourchoice to:■ confirm the need for surgery■ learn about alternative treatments, if available■ to make the most informed decision possibleCareEssentials 9

CareEssentialsAfter your hospital admission has been authorized, aCareFirst nurse will review your admission to determine ifadditional inpatient hospital days are medically necessary.This type of review is known as Continued Stay Review.Your physician, hospital representative and the CareFirstnurse will coordinate the approval of additional hospitaldays. The CareFirst nurse can also assist with dischargeplanning as needed. If it is determined that extra days arenot medically necessary, your doctor will be notified byphone and in writing.Your policy also includes important benefits for homecare and hospice. This program allows you to receivenecessary medical services on a intermittent basis in thecomfort and privacy of your own home. Some of theservices provided include skilled nursing visits, homehealth aide assistance, physical therapy and social work.Please note that these benefits are not provided for custodialor long-term care. Refer to your policy for specific details.If you need to rent or purchase durable medicalequipment (for example, a wheelchair, a walker or someother device to aid your recovery), you can obtain moredetails on the necessary steps by calling Member Services.CareFirst wants to help you achieve the bestpossible state of health. We know that thereare many things to remember when you are living with achronic condition. That’s why our disease managementprograms can help you manage your condition and helpyou to avoid complications.We have nurses available to provide you withinformation and assist you in managing:■ Asthma■ Diabetes■ Chronic obstructivepulmonary disease(COPD)■ Heart failure■ Coronary obstructiveartery disease■ Low Back Pain■ Osteoporosis■ Hepatitis C■ Urinary Incontinence■ Fibromyalgia■ Decubitus (pressure)ulcers■ Atrial Fibrillation■ Irritable BowelSyndrome■ Acid-related disordersOnce you enroll, you will:■ Be able to call a toll-free number 24 hoursa day, seven days a week, to speak with aregistered nurse■ Receive educational materials and quarterlynewsletters with information about yourcondition■ Receive reminders and tools to help youmanage your conditionThese programs are free, voluntary andconfidential. Call (800) 783-4582 to find out if youare eligible or to enroll in one of the programs.When faced with health care decisions, youand your family may have many questionsand difficult choices to make. The Case ManagementDepartment of CareFirst wants to make sure you get allthe help you need for any health problems or concernsyou may have. The Case Management Program is part ofyour medical benefits. As a member of CareFirst, you willnot be charged any fee for this service. It’s one of the ways wecan help you to remain active and in the best health possible.Case Managers are registered nurses who play an active rolein working with your physician to help develop a plan ofcare that will ensure that you receive the best possible care inan efficient and timely manner. Your relationship with yourCase Manager enables you to receive prompt answers to anyof your questions or concerns.Please keep in mind that since this program is voluntaryyou can withdraw at any time without a penalty.When appropriate, Case Management can helpyou with conditions such as (but not limited to):■ Amputation■ AIDS■ Asthma■ Burns■ Cancer■ Diabetes■ Heart Disease■ High Risk Newborns■ High RiskPregnancies■ Multiple Fractures■ Severe Head Trauma■ Stroke■ Spinal Cord Injury10

The information provided in this section is specifically formembers of CareFirst’s Personal Comp HSA Plan. If youare unsure as to whether this information applies to you,please refer to your Certificate of Coverage.Members of CareFirst’s Personal Comp HSA healthplan have the option to participate in a Health SavingsAccount to pay for qualified medical expenses withtax-free dollars. HSA health plans are always highdeductible health plans (HDHPs).A Health Savings Account is a tax-free savings account thatallows you to put aside pre-tax income, earn interest onthe savings, and use the tax-free savings for eligible healthcare expenses. And, unlike other medical savings accounts(such as Flexible Spending Accounts), any money youdon’t spend stays in your account for future use.Each year you, your employer (if applicable) or bothmake a contribution toward your HSA. You then usethe money in your account to pay the full or discountedcost of covered services until you reach your benefit yeardeductible.Once you meet your plan year deductible, your PersonalComp coverage begins. You then pay a copaymentor coinsurance for all covered services, includingprescription drugs.Your HSA is your personal account and is entirelyportable. If you are a member of an employer-basedplan, this means that, should you leave your currentemployer, you can take the money with you.An HSA can be an excellent way to put money asidefor any qualified health care expenses that might notbe covered by your plan today. And if you don’t spendit, it’s also a tax-free way to prepare for future expenses– such as the need to cover retiree health premiums(excluding Medicare Supplement plans) or to pay forfuture non-covered health care expenses.While your HSA was designed to fund your health care,now and in the future, HSA funds can be “cashed out” atany time. The money will be subject to income tax and a10 percent penalty if you close the account before you turn65. Of course, you can always use the money for qualifiedhealth care expenses with no penalty and no taxes.Depending on the amount of qualified health careexpenses you incur in a given year, you may not needto use all of the funds in your HSA. In this event, theremaining balance in your HSA will automatically rollover to the following benefit year.HSAs are available to members of employer-basedhealth plans, as well as members who purchase aqualifying high deductible health plan on their own.With your Personal Comp HSA plan, CareFirst hascombined your medical and prescription drug coverageinto one easily managed benefit year deductible. Thismeans that until you meet your combined deductible,you will be responsible for the covered expensesassociated with your health care services, as well asyour prescription drugs. These expenses can be fundedthrough the money in your Health Savings Account.See your contract, benefit summary or contact MemberServices if you are unsure of the type of deductible inyour plan.Because you have a combined deductible, you alsohave a combined out-of-pocket maximum. This meansyour eligible health care and prescription drug out-ofpocket expenses will be applied towards meeting yourout-of-pocket maximum. Should you reach your outof-pocketmaximum, CareFirst will pay 100% of theapplicable plan allowance for most covered services forthe remainder of the benefit year.The deductible is based on a calendar year and thedeductible starts over each January.There is an old saying that “an ounce of prevention isworth a pound of cure.” That’s why CareFirst coversthe cost of certain preventive care in full, or for apredictable copayment or coinsurance, regardless of thelevel of your deductible.Health Savings Account 11

Health Savings AccountHow do I contribute to my HSA?You can make contributions to your HSA at anytime,up to the allowable amount determined by the IRS.Are there limits to how much I can contributeto my HSA?The IRS stipulates that your plan year HSA fundingcan be no more than $3,000* if you have individualcoverage and $5,950* if you have family coverage. Theseamounts may be adjusted each year by the IRS. Foradditional information, you can visit the IRS web siteat: www.IRS.gov or call (800) 829-3676.How are my medical and prescription drugclaims paid?When visiting your doctor, lab or urgent carefacility, you will likely be charged your normal pervisit copayment or any portion of your benefit yeardeductible that has not yet been satisfied. Your providerwill then submit a claim to CareFirst for benefitsconsideration. If you have not already met your benefityear deductible, the claim will be processed and abenefit determination will be sent to you and to theprovider. The provider will in turn seek any remainingpayments from you. You will be responsible for the costof your medical services until you meet your deductible.These expenses can be paid out of your HSA by usingyour HSA debit card or checks. By seeking services fromPreferred Providers, your responsibility will be limitedto the discounted amount or plan allowance that ourproviders agree to accept as payment in full. Yourpharmacist will charge you CareFirst’s discounted costfor prescription drugs until you reach your benefit yeardeductible. These expenses can also be paid directlyfrom your HSA using your debit card or checks.Since prescription deductible information is automaticallytransmitted to CareFirst so that we may efficiently trackyour deductible balances, it is important for you to pickup your prescription drugs from the pharmacy as soonas possible. Pharmacies have their own guidelines forreturning medications back to their inventory stock. Ifthe pharmacy returns your prescription drugs to theirinventory stock, any applicable deductible will be retracted.Each of these deductible and retracted deductibletransactions will be recorded on your HSA account.What happens when HSA funds have been exhausted?If you use all the money in your HSA before meetingyour annual deductible, you will then be responsiblefor a limited out-of-pocket amount, called the “Bridge.”The Bridge is the difference between the amount inyour HSA and your deductible.The amount of money you and/or your employer havecontributed to your HSA will determine how much of a“bridge” you have before your Personal Comp coveragebecomes available.Who is eligible to participate in an HSA?To be eligible to enroll in a Health Savings Account,you must be covered by a high deductible health plan(HDHP), such as Personal Comp HSA.To enroll in a health savings account,you cannot be:■ covered by any medical plan other than ahigh deductible health plan (dental andvision are not included in this restriction);■ enrolled in Medicare Part A orPart B; or■ claimed as a dependent on anotherindividual’s tax return.How can I track my health benefits?The more you know, the better you can manage yourhealth care needs. With a CareFirst Personal Comp HSAyou can tap into the power of the Internet to help youmanage your benefits.CareFirst online tools, available at www.carefirst.com, allow you to:■ Check the status of a claim■ Compare hospitals■ Compare prescription drug costs■ Request a member ID card■ Confirm or review eligibility■ Find a doctor■ Access health and wellness informationYour HSA funds are available to pay for qualified healthcare expenses covered under your CareFirst BlueCrossBlueShield Personal Comp coverage.*This amount applies to year 2009 only.12

What is the definition of a “Qualified MedicalExpense”?Qualified expenses are those permitted bySection 213(d) of the Internal Revenue Tax Codeand that are otherwise permissible under the IRSregulations. When you use the account to pay forqualified expenses, you pay with tax-free dollars.Qualified expenses include but are not limited to:■ Prescription Drugs■ Non-Prescription Drugs■ Doctor’s visits, lab, x-ray and other diagnosticand treatment services■ Routine health care, including prenatalcare, smoking cessation, obesity weight lossprograms■ Qualified long-term care services and qualifiedlong-term care insurance■ COBRA premiums■ Health insurance for those on unemploymentcompensation■ Medicare Part A and B premiums, MedicareHMO or Medicare Advantage premiums (butnot premiums for Medicare Supplementalpolicies).Health Savings AccountFor a complete list of qualified and unqualifiedHSA expenses, visit the IRS web site at:www.IRS.gov or call (800) 829-3676.Please Note: HSA funds can also be spent on qualifiedexpenses that are not covered by your Personal Compplan. These expenses will not be applied toward yourbenefit year deductible. Only covered expenses will beapplied toward your benefit year deductible. 13

Claims, Enrollment Changes & PaymentsIf a family member is covered by another healthinsurance carrier, please file all claims with the primaryinsurance carrier first. If the primary carrier fails to paythe entire claim and a balance remains, simply submitthe claim to CareFirst along with the other carrier’sExplanation of Benefits. If you are uncertain aboutwhich insurer is primary, call our Coordination ofBenefits Analysts at (410) 308-3258 or (877) 849-9297.■ You are required to notify the Legal Recovery Teamat (410) 308-3247 from the Baltimore MetropolitanArea or call collect from outside the Baltimore area if:■ You have sustained an injury or illness which mayhave been caused by someone else and may becovered under a third party’s insurance; or■ You have sustained an injury which is related toyour occupation and should be covered under yourWorkers’ Compensation insurance.By following the above guidelines, you can ensure thatyour claims are paid promptly and by the properinsurance company.Paying for your CareFirst coverage is simple andconvenient. We offer you three ways to pay your premium.1. Personal check:When billed, you can pay your quarterly premiumby check or money order. It is important to pay thefull amount due by the date shown on the BillingStatement. We are unable to accept partial payments.Please do not include any correspondence with yourpayments as this may delay payment processing.2. Credit card:You can charge your quarterly premium to a majorcredit card when due. Just complete the bottomportion of the Billing Statement with your VISA orMasterCard credit card number and sign your name.3. EasyPay:Our convenient EasyPay service allows you to pay yourinsurance premium automatically on a monthly basis.You simply authorize us to withdraw the amount duefrom your checking account or to charge the amountdue to your VISA or MasterCard credit card eachmonth. To choose this option, just complete the EasyPayauthorization form, which you can obtain by calling acustomer service representative at the Member Servicephone number located on your member ID card.Please note: it will take four to six weeks for your EasyPayauthorization to be processed. Once your application formedical coverage has been processed and approved, youwill receive a bill in the mail. When you receive that bill,you must send in your payment. It is very important thatyou pay this bill on time in order to keep your coverage ineffect. We will notify you in writing when your monthlyEasyPay payments will begin. Until that time, please payany bills you receive.If you change your name, address or phone number,please contact Member Services and we will update ourrecords or advise you of any forms you need to submit.Remember, we need your correct address to keep youinformed about critical program information includingpolicies, procedures and benefit changes.Generally, to add family members to your coverageyou must submit a medically underwritten applicationto CareFirst. Changes are effective on the first of themonth following acceptance of the application byCareFirst. A newborn or adopted child is not subjectto medical underwriting if added to your coveragewithin 31 days from the date of birth or date ofadoption. You must notify CareFirst to continuecoverage beyond the first 31 days if additionalpremium is required.Full-time college students are covered until age 25. Afull-time college student attends at least 12 credit hours,or 9 credit hours of graduate course, per semester atan accredited college or university. Full-time studentsmust be enrolled in continuous academic semesters(excluding summers). In addition to covering full-timestudents, the policy also offers coverage for part-timestudents with disabilities who are maintaining courseloads of at least seven credit hours per semester. AStudent Certification Form must be completed andsubmitted to CareFirst at the beginning of everysemester. You may obtain a Student Certification formby calling Member Services at the telephone numberon your member ID card or by downloading the formfrom www.carefirst.com.14

As a result of legislation passed in the MarylandGeneral Assembly, effective January 1, 2008, a childdependent may remain on your current health carepolicy until the child reaches the age of 25 withoutbeing a student as long as the following criteria are met: is used in the IRS code-U.S.C. 104, 105 and 106 andregulations adopted under those sections, issued in the State of Maryland.A qualifying child has the following relationship to thesubscriber: legal adoption, guardianship appointment of more than 12 months asa result of a will decree.At the request of an insured under an individual policy,CareFirst must offer health insurance benefits to adomestic partner or the child of the domestic partner.Additionally, a grandchild is allowed to remain on thegrandparent’s coverage until the age of 25 withoutbeing in the court ordered custody of the grandparent.For domestic partner relationships, if coverage isrequested by the insured, a child dependent of thedomestic partner means an individual who is: partner of an insured for legal adoption, guardianship appointment of more than 12 months asthe result of a will decree, or If a child dependent will no longer be covered underyour policy, it is important that you contact CareFirstimmediately. This will help us prevent a lapse incoverage or the imposition of a pre-existing waitingperiod. Additionally, we will be able to ensure thatthere are no requirements for medical underwriting.If your child gets married or enters the military,coverage will expire at the end of the period for whichCareFirst has accepted premiums. A disabled child,who was covered under your policy before age 19 (or 25if a full-time student) remains covered as long as you paypremiums for the child.To end coverage for family members, you must notifyCareFirst.Claims can be filed in two ways:1. Your claims are filed automatically on your behalf ifyour doctor or hospital is a participating provider.2. You file your own claims with us if your doctor orhospital is a non-participating provider.One of the primary advantages of CareFirst coverage isthat we have established relationships with most physiciansand hospitals in the state. These relationships allow ourmembers to enjoy the convenience of automatic claimsfiling.A participating provider automatically files your claimsfor you – leaving you with little or no paperworkSimply call your doctor or hospital to find out if theyparticipate with us.Another important advantage to using a CareFirstparticipating provider is that our allowed benefits areaccepted as payment in full. Your plan pays a certainpercentage of these allowed benefits based on theprovisions within your policy. You are only responsiblefor any copayments, coinsurance and deductiblerequirements. In most cases where care has beenrendered by a CareFirst participating provider, you willnot have to reimburse the health care providers’ charges.Your participating health care provider can only billyou for an applicable preventive care copayment, thedeductible and coinsurance fees at the time of service.When care is provided by a non-participating physicianor hospital, you must pay the provider at the time ofservice and then request reimbursement from CareFirst.Whenever you are required to make payment, be certainto obtain itemized receipts in order to file a claim. Wedo not provide benefits for any amount charged thatexceeds the allowed benefit.Claims, Enrollment Changes & Payments 15

Claims, Enrollment Changes & PaymentsIn most cases where care has been rendered by an eligiblenon-participating provider, you will have to reimburse thehealth care provider the difference between the allowedbenefit minus copayments, coinsurance, or penalties andthe provider’s service charge.To obtain claim forms, call Member Services or downloada form from www.carefirst.com. In the “Members &Visitors” section click on “Forms,” then choose “PersonalComp.” (an example appears on page 17)REMEMBER: All bills must be submitted within the yearfollowing the date of service to ensure payment. For thefastest service, we suggest that you submit your claims assoon as possible, rather than accumulating them until theend of the year.Mail completed claim forms to:Please refer to the form on the next page.Section 1 requires subscriber and/patientinformation.Section 2 requires information about the injuries,conditions, diseases or ailments that required theservices and supplies shown on the bills you aresubmitting with this claim form.Section 3 requires information about the injury if it isaccidental.Section 4 asks if the injury is work related.Section 5 asks for Medicare information.Section 6 requires additional information about otherinsurance coverage the patient may have.Section 7 requires the subscriber’s signature.It is important that you complete every section andevery box within each section. If any questions donot apply to your personal situation, write “N/A”(not applicable) in the box as the response to thatquestion. Any missing information will likely delaythe processing of your claim. All questions must beanswered or the claim will be returned.16

1.2.3.4.5.6.Subscriber’s Legal Name (Last, First, Middle Initial)Membership Number Patient’s Sex Patient’s Relationship to Subscriber1 2 3List those illnesses for which you are submitting bills and date of first symptom.______________________________________________________Date______________________________________________________Date______________________________________________________Date______________________________________________________DateWas the treatment the result of an accidental injury? ■ Yes ■ NoDescription of Accident _____________________________________________________________________________________________________Date of Accident __________________________________ Where Accident Occurred _______________________________________________Was illness(es) or injury(ies) in any way work related? ■ YesDoes patient have Medicare?a. Medicare Part A (Hospital Insurance)? ■ Yes ■ Nob. Medicare Part B (Physician’s Coverage)? ■ Yes ■ No■ NoEffective Date of CoverageMonth Day YearMonth Day YearIn addition to coverage under this program, is patient covered under any other insurance providing health care benefits or services?■ Yes ■ No If “YES”, please complete:Patient’s Legal Name (Last, First, Middle Initial)■ Male ■ Female ■ Self ■ Spouse ■ ChildSubscriber’s Address (Street) ■ Check box if NEW address Patient’s MO. DAY YR.Date of BirthCity State Zip CodeTelephone NumberGroup Number and NameMAJOR MEDICAL CLAIMIMPORTANT: ALL QUESTIONS MUST BE ANSWEREDHEALTH INSURANCECLAIM NUMBERa. Name of Policy Holder ______________________________________ Relationship to Patient _______________________________________b. Name of Insuring Co. ___________________________________________________________________________________________________c. Policy or Certificate No. ______________________________________ d. Effective Date of CoverageMonth Day Yeare. Check type of coverage: ■ Hospital ■ Surgical-Medical ■ Major Medical ■ Other (specify) _________________________________f. Check One: I have ■ Family ■ Husband and Wife ■ Individual ■ Parent and Child coverage with this carrier.g. Name and Address of Policy Holder’s Employer ______________________________________________________________________________Claims, Enrollment Changes & Payments7.I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.XSIGNATURE OF SUBSCRIBERDATE 17

18Claims, Enrollment Changes & PaymentsMedical review is a process that ensures claims areprocessed according to the terms of your policy.Medical review is an important process. It makes certainthat benefits are properly administered, which helpskeep premium rates as low as possible. Claims may bereviewed for a number of reasons. In most cases, claimsare reviewed for medical necessity, contract limitations,or pre-existing medical conditions.If your insurance policy was medically underwritten,certain individuals may have been excluded fromcoverage.The medical review process sometimes requires usto request additional medical information from yourprovider. This may result in a delay in processing yourclaim. If we find that a condition not listed on yourapplication existed prior to the effective date of yourpolicy, we may deny payment on your claim or cancelyour policy.Please be assured that the medical review process isdesigned to provide you with the maximum allowedbenefits from your policy. By following medical reviewguidelines, we can provide a high quality policy at thelowest premium possible.Here are some reasons why a claim may be denied:■ If the claim is for an over-aged dependent who is nolonger covered on your policy■ If a Student Certification was not submitted in atimely manner■ If the wrong diagnosis code is listed■ If pre-existing conditions that are not covered underyour policy are listed on the claimIf you feel a claim was denied as a result of error or ouwould like to appeal the denial, call Member Servicesat the number on your member ID card. For moreinformation on the appeal process, see page 24.You will receive a detailed Explanation of Health CareBenefits Statement (EOHB) whenever we process aclaim (shown on page 19). The EOHB outlines theservices that were paid; the amount that was appliedto your deductible; and your share, if any, of theremaining cost. The name of the patient is listed on eachseparate page.Your membership number and the nameof your Program.The customer service telephone number listed onyour statement is the one you call when you havea question or problem.Each claim number, the name of eachprovider (doctor, hospital, laboratory, etc.) andeach service you had are listed togetherin this column.The date of service is the date you received service.If multiple dates are shown, they are “from” and“to” dates.The billed charge is the amount billed bythe provider.The reduction of billed charges can be oneof two things:a. The difference between the amount yourprovider charged and, if applicable, processingthe amount Medicare approved for the service.b. The portion of the amount you willhave to pay, if you received anon-covered service.If applicable, the amount paid by Medicare. Thisamount will be deducted from your billed charge.The amount eligible for benefits is the portionof the billed charge that will be consideredfor benefits.

PAGE 1 PLEASE DIRECT INQUIRIES TO:DATE 04/01/06 CAREFIRST BLUECROSS BLUESHIELDINDIVIDUAL MARKET DIVISION 10455 MILL RUN CIRCLESMITH JOHN OWINGS MILLS, MARYLAND 21117-5559123 GREEN STREET FOR INQUIRIES CALL: (410) 581-3411ANYTOWN MD OUT OF AREA CALL: 1-800-843-4280PATIENT: SMITH , J MEMBERSHIP #: 999-99-9999 RELATIONSHIP TO SUBSCRIBER: SELF SUBSCRIBER: SMITH JOHNPROGRAM: MEDIGAPAMOUNT YOUR * NCLAIM DATE REDUCTION PRIMARY BILLED SHARE OPROVIDER OF BILLED OF BILLED PROVIDER HOSPITAL YOUR % AMOUNT OF THE TSERVICE SERVICE CHARGES CHARGES COVERAGE DIFF/DISC DEDUCTIBLE COV COVERED COST E1109121999999 04/20/06 65.00 13.43 41.26 10.31 100 10.31 0.00WILLIAM PRATT MDMEDICAL CARE16211 05/02/06 3065.00 2408.00 657.00 100 657.00 0.00SINAI HOSPITAL 05/04/96035999 05/02/06 1923.00 593.00 1330.00 100 1065.60 0.00 AJOHN JONES MDSURGERYNOTESA –BENEFITS PAID TO HEALTH CARE PROVIDER:WILLIAM PRATT $10.31SINAI HOSPITAL $657.00JOHN JONES $1065.60TOTALS 1732.90 0.00Patients covered under your contract are not responsible for the difference between the charges and the usual andcustomary allowance for covered services rendered by participating providers of care.SUMMARY OF BENEFITSFOR YOUR INFORMATION* THIS NEW EXPLANATION OF HEALTH CARE BENEFITS (EOHB) HAS BEEN DESIGNED BY CAREFIRST BLUECROSS BLUESHIELDTO BETTER EXPLAIN HOW YOUR CLAIMS HAVE BEEN PROCESSEDYour deductible (if applicable) will besubtracted from the eligible amount.The % covered is the percentage at whicheligible services have been paid after thedeductible was applied.The amount covered is the dollar amountof the billed charge that we will pay.The codes listed in the notes column areexplained on the bottom half of the form.Your summary of benefits will show the amountspaid to providers and the amounts paid to you.For your information, we may include specialremarks that pertain to your contract.Claims, Enrollment Changes & PaymentsYour share of the cost may include yourdeductible, copayment and/or amounts over theMedicare allowed benefits, if applicable. 19

Additional CareFirst BenefitsDental and vision benefits are optional. You may havepurchased these benefits in addition to your healthinsurance policy. These benefits are not administeredthrough CareFirst. If you have questions about thesebenefits, call The Dental Network, Inc.* or Davis Visiondirectly.The Dental HMO plan offers you dental care withpredictable costs. All dental services are provided for thecost of a copay and orthodontia is covered for adults andchildren. There are no deductibles to meet and no claimforms to file.Dental HMO benefits are administered through TheDental Network, Inc. (TDN), an experienced dentalHMO plan administrator. If you added dental benefitsto your Personal Comp plan, you must select a primarydental site for your care. Each family member can selecta different dentist.To select a dentist, call TDN Customer Service Line at(410) 847-9060 or toll-free (888) 833-84648:30 am – 5:00 pm, Monday through Friday.If you do not select a dental site, TDN will select one foryou and send you information about the site. Of course,you can always change your site by calling TDN at theabove number.*The Dental Network, Inc. is an independent licensee ofthe Blue Cross and Blue Shield Association.CareFirst is pleased to offer BlueVision to meet yourvision needs. This vision plan is administered by DavisVision, Inc., a national provider of vision care services.BlueVision provides a routine vision examination(including dilation) once per benefit period for a $10copay when you visit a participating Davis Visionprovider. Through Davis Vision, you can also receivediscounts on eyeglass lenses and frames or contactlenses, as well as laser vision correction surgery. Referto your policy to find out what benefits you have underyour plan.As part of your BlueVision benefit, you areentitled to a $20 allowance if visiting anoptometrist and a $30 allowance if visiting anophthalmologist for an out-of-network exam.Discounts for lenses and frames are not availableout-of-network.If you choose an out-of-network provider, youwill be required to pay the provider directlyfor all charges and then submit a claim forreimbursement to:Vision Care Processing UnitP.O. Box 1525Latham, NY 12110Only one claim per service may be submittedfor reimbursement each benefit cycle. To requestclaim forms, visit the “Members & Visitors”Section of www.carefirst.com and click on“Forms” or call (800) 783-5602.If you don’t have dental and/or vision coverageand would like to learn more about theseprograms, call our Product Specialists at (410)356-8000 or (800) 544-8703.20

Receive valuable discounts on prescription drugs atover 50,000 pharmacies nationwide – for free! Thesediscounts are offered through Argus Health Systems,a pharmacy claims processor that provides pharmacymanagement services to CareFirst. There is no costto you to take advantage of this program. You will bemailed a Discount Drug ID card and other valuableinformation about the program within a few weeks ofenrolling in your Personal Comp plan. Simply show yourprescription card at a participating pharmacy and save.You will receive the lowest price available in thatpharmacy, at the time you purchase your prescription.In addition to the discounts received at the pharmacy,you can also submit your claim form for additionalreimbursement just as you would normally do as part ofyour medical plan.Discounts are not available for most over-the-countermedications. (Diabetic supplies are the only exception.)If you have any questions regarding this program, loseyour ID card or need to order extra cards, call ArgusHealth Systems at (888) 850-2405.Additional CareFirst Benefits 21

22Discount ProgramsOptions is a discount program provided to members ofCareFirst BlueCross BlueShield (CareFirst). Because thisis a discount program and not a covered benefit, there areno claim forms, referrals or paperwork. To receive thesediscounts, simply show your CareFirst ID card or visit thespecial website for members if it’s an online program. Inorder to be responsive to your needs, Options continuallyadds new services. Visit www.carefirst.com/options forthe latest Options programs.Weight Watchers, one of the nation’s most recognizedweight loss programs is online, and CareFirst memberscan save $10 on a 3-month subscription to WeightWatchers Online®. Weight Watchers Online® providesa set of personalized weight loss tools, such as OnlineJournal, Meal Planner, Weight Tracker, and ProgressCharts. Search a database of more than 800 WeightWatchers recipes and calculate POINTS® for your ownfoods and meals.Join Jenny Craig and receive a FREE 30-day program*.Jenny Craig will design a personalized comprehensiveprogram with one-on-one support, that fits your lifestyle.You can also enjoy up to 50% off the 6-month program*or 20% off the 1-year Premium Success Program*.* Plus the cost of food and shipping when applicable.Discounts apply to membership fee only. Offer good atparticipating Centres and Jenny Direct® in the UnitedStates, Canada and Puerto Rico.Through 3 different networks, Options offersflexibility in choosing a gym that is right for you.With GlobalFit’s lowest price guarantee, you’ll receivethe best available rates at more than 10,000 fitnessclubs nationwide, including Bally Total Fitness clubsand Curves, all with month-to-month membershipsand no long-term contracts.NOTE: Discounts in GlobalFit clubs are for newmembers only. If you are already a club member (orwere a member in the last 90 days**) you are noteligible for the discounted rate. The only exceptionis Bally Total Fitness. After you have completedyour current Bally contract, you are eligible for thediscounted rate.** There are a limited number of clubs that require alonger “run-out” period than 90 days. Please contactGlobalFit for more information.Healthways WholeHealth Networks offers anationwide network of approximately 2,900 fitnesscenters and spas. With your CareFirst BlueChoiceplan, you can receive discounts on the following: 10-50% off fitness center initiation fees and/ormembership dues Spa memberships or services ranging from 10-30%NOTE: Membership obligations for fitness centersand discounted spa services are based on individuallocation policies.National Fitness Network consists of approximately100 independent regional health clubs*** and is theonly health club network that offers the convenienceof unlimited access to its entire network of clubs witha single membership. There is no need to select aprimary club or transfer your membership. NationalFitness Network offers the following discounts: and $29 for each additional family member.NOTE: To receive a discount, you must enroll directlythrough the National Fitness Network. If you arealready a member of a National Fitness Network club,you must complete your current contract before youcan get the discounted rate.***Available in MD, DC, VA, NJ, and FL only.

Better hearing enriches your quality of life. Takeadvantage of the many discounted services offered byboth Beltone Hearing Care Centers and TruHearing.With Beltone, parents, children, spouses andgrandparents receive free hearing screenings and a 25%discount off the cost of Beltone hearing aids. All Beltonehearing aids include free batteries for one year, a twoyearwarranty, free cleaning and minor repairs andadjustments for the life of the hearing aid. TruHearingoffers free hearing screenings and discounts of up to 60%off quality digital instruments for CareFirst members,their children, parents, and grandparents. TruHearingalso offers an extended two-year warranty and a 45-daymoney back guarantee. All hearing tests are performedusing the latest diagnostic equipment.Through TruVision, CareFirst members canreceive 10% off of LASIK or PRK procedures. Allpricing includes a pre-operative exam, the LaserVision Correction procedure, post-operative careand a one-year enhancement warranty. Discountsare also available on Custom LASIK, IntraLaseBladeless procedures, and some centers offer lifetimere-treatment plans. Members can also receivediscounts of up to 50% off most brands of contactlenses ordered through the Mail and receive freeshipping and handling.ElderCarelink is a free, internet-based service thatspecializes in providing referrals for services for eldersand their families. Services include home health care,home support, assisted living, adult day care, longtermcare, nursing home options and more. Membersfill out a needs assessment online survey and thenElderCarelink will e-mail a list of participatingnetwork providers that match your needs. Membersare also eligible to receive a free 90-day subscriptionto The Caregiver’s Home Companion newsletter.The following services are offered through HealthwaysWholeHealth Networks, Inc. Through the Optionsprogram, members can receive up to a 30% discounton these alternative health and wellness services. Acupuncture Chiropractic Care Guided Imagery Magazine DiscountProgram Massage Therapy Meditation Instruction Mind-BodyInstruction Nutrition Counseling Personal Training/Pilates Qi Gong/Tai Chi YogaDiscount ProgramsQualSight provides affordable access to quality laservision correction services at 600 locations nationwide.QualSight partners with leading ophthalmologistsand credentials each doctor in order to verify theirexperience and work history. Included in the $895 priceper eye are the pre-operative exam, LASIK or PRKprocedure, post-operative exams, and a retreatmentwarranty. Discounts are also available on CustomLASIK, Conductive Keratoplasty, and IntraLase.American Medical ID offers a 22% discount oncustomized medical identification bracelets andnecklaces. Medical IDs allow medics or other medicalprofessionals to give prompt, precise treatment in amedical emergency. They help ensure a patient willreceive proper care, eliminate unnecessary testingand reduce the chance of costly medical errors. Thosewho have chronic medical conditions, drug or foodallergies, or are taking multiple medicines, are advisedto wear a medical ID.In addition to the Options program, the BlueCross and Blue Shield Association gives you accessto even more discounts through Blue365.Blue365 provides tools and guides to help youlearn more about wellness services that go beyondyour covered services. There are four keyareas of Blue365: Health and Wellness Family Care Health-Focused Financial Services Travel InformationWant to know more about what Blue365 hasto offer? Look for the list of Blue365 vendorsand resources on a special Web site designedjust for BlueChoice members. It’s all availableat www.carefirst.com/options. You can alsocall Member Services for more informationon Blue365. 23

Discount ProgramsVisit www.carefirst.com/options for more information on these services or see the followingcontact information below.Healthways WholeHealth Networks, Inc. (800) 514-6502http://options.wholehealthmd.comElderCarelink (866) 451-5577www.eldercarelink.com/carefirstGlobalFit (800) 294-1500www.globalfit.comHealthways WholeHealth Netowrk (800) 514-6502http://options.wholehealthmd.comNational Fitness Network (800) 811-5454www.nationalfitnessnetwork.comBeltone (800) 235-8663www.beltone.comTruHearing (877) 587-3937www.truhearing.comQualSight LASIK (877) 285-2010www.qualsight.com/-carefirstTruVision LASIK* (800) 398-7075www.truvision.com/carefirst/LASIK.htm*Also offers discounts on mail-order contact lensesAmerican Medical ID (800) 363-5985www.americanmedical-id.com/extras/carefirst.phpWeight Watchers Online®www.weightwatchers.com/cs/cfbcbsJenny Craig® (800) 96-JENNYwww.jennycraig.com/corporatechannel/carefirst.aspx24

CareFirst’s appeals procedure is designed to enable youto have your concerns regarding a denial of benefitsor authorization for services heard and resolved. Byfollowing the steps outlined below, you can ensure thatyour appeal is quickly and responsively addressed. Pleasenote that state mandates may alter the steps below.Refer to your Certificate of Coverage for more specificinformation regarding your appeal process.An expedited appeals process has been established in theevent that a delay in a decision would be detrimental toyour health or the health of a covered family member.In an expedited appeal, a decision by CareFirst shallbe made within 24 hours from the time we receive theappeal. Review will be done by a physician in the same orsimilar specialty as the treatment under review, not partof the original denial decision, as appropriate. Expeditedappeals involve care that has not yet occurred or iscurrently occurring (pre-service or concurrent care).Your concerns can often be handled and resolvedthrough informal discussions and informationgathering. If your question relates to our handlingof a claim or other administrative action, call anddiscuss the matter with a CareFirst Member Servicesrepresentative. In many instances, the matter can bequickly resolved.If your concern is not resolved through a discussionwith a CareFirst representative, you or someoneauthorized on your behalf may make a formal requestfor appeal. CareFirst must receive the request within180 days of the date of receipt of notification of denialof benefits or services. If the request for appeal is relatedto a medical or clinical issue, a physician in the sameor similar specialty as the treatment under review,who was not part of the original denial decision, willreview the request. This request should be in writingand addressed to the Member Services Department.A Member Services representative will be available toassist you in submitting your appeal in the event youare unable to put the request in writing.All appeal decisions will be rendered in writing to themember. If the decision remains as a denial of theoriginal request, a detailed explanation that referencesthe rule, policy or guideline used to make the decisionwill be included. Also provided will be an explanationof the appropriate next steps a member may take ifhe/she is not satisfied with the appeal process. Membershave a right to an independent external review of anyfinal appeal or grievance determination.The procedure for filing an appeal is also located onour web site at www.carefirst.com. In the Members &Visitors section, click on “Frequently Asked Questions”in the Solution Center. If you would like a paper copy ofthe appeals process, you may also contact the MemberServices telephone number located on your memberID card. If you wish, you may contact the insuranceregulatory department in your area to file a complaintor an appeal regarding a denial or reduction of benefits.Maryland Insurance AdministrationInquiry and Investigation, Life and Health525 St. Paul PlaceBaltimore, MD 21202-2272(410) 468-2000 or (800) 492-6116Fax: (410) 468-2270www.mdinsurance.state.md.usHealth Education and Advocacy UnitConsumer Protection DivisionOffice of the Attorney General200 St. Paul PlaceBaltimore, MD 21202(410) 528-1840 or (887) 261-8807Fax: (410) 576-6571www.oag.state.md.usOffice of Health Care QualitySpring Grove CenterBland-Bryant Building55 Wade AvenueCatonsville, MD 21228(877) 402-8218Fax: (410) 402-8215www.dhmh.state.md.us/ohcqAppeals Process 25

Members Rights and ResponsibilitiesThe Plan promotes members’ rights by providingmechanisms to ensure:■ Protection of confidential information.■ Accurate and understandable informationabout benefit plans, customer service andaccessing health care services.■ Continuity and coordination ofmedical and/or behavioral health orsubstance abuse care by participatingproviders.■ Professional and responsivecustomer service.■ Timely and complete resolutionof customer complaints and appeals.■ Be treated with respect and recognitionof their dignity and right to privacy.■ Receive information about the Health Plan,its services, its practitioners and providers,and members’ rights and responsibilities.■ Participate with practitioners in decisionmaking regarding their health care.■ Participate in a candid discussion ofappropriate or medically necessarytreatment options for their conditions,regardless of cost or benefit coverage.■ Make recommendations regarding theorganization’s members’ rights andresponsibilities.■ Voice complaints or appeals about theHealth Plan or the care provided.■ Provide, to the extent possible, informationthat the Health Plan and its practitionersand providers need in order to carefor them.■ Understand their health problemsand participate in developing mutuallyagreed upon treatment goals to thedegree possible.■ Follow the plans and instructions forcare that they have agreed on with theirpractitioners.■ Pay copayments or coinsurance at thetime of service.■ Be on time for appointments and tonotify practitioners/providers when anappointment must be canceled.26

The Health Insurance Portability and AccountabilityAct of 1996 (HIPAA) ensures that individuals who havehealth insurance do not experience a gap in coverage dueto termination or departure from their current job. Amember terminating coverage with an insurance carrierwill receive a certificate of creditable coverage indicatingthe length of time they have had health insurancecoverage. This certificate of creditable coverage is used toreduce any waiting time for pre-existing conditions thatmay be part of subsequent health insurance coverage, aslong as there has not been a break in coverage for morethan 63 days.When a member terminates with CareFirst, they receivea Certificate of Health Plan Coverage that indicates howlong the member was covered. The member should thenpresent the certificate to the new insurance carrier. Thiswill reduce or eliminate waiting periods for pre-existingconditions under the member’s new policy.If a policyholder is eligible to receive credit forprevious coverage, he or she must provide tohis/her employer:■ a certificate of the prior (creditable)coverage, or■ other evidence of coverage, such as apay stub or statement from the previousemployer or insurer.If you were covered through a CareFirst health insuranceentity, call the Member Services telephone number onyour member ID card. Please be prepared to provideinformation regarding your prior health care coverage,including your membership number and your mostrecent dates of coverage with CareFirst. A certificate ofcreditable coverage will be requested for you and mailedto your address within 14 days.For other health insurers, you should call the customerservice telephone number for your previous healthinsurer. This phone number is usually located onyour member ID card. Please be prepared to provideinformation regarding your prior health care coverage,including your membership number with that insurerand your most recent dates of coverage.If you are unable to obtain a certificate of creditablecoverage from your prior health insurance carrier,CareFirst will accept a letter from the employer withwhom you had prior health coverage. You should contactthe Human Resources Department of your previousemployer to request this type of letter. Please be sure thisletter indicates your most recent coverage dates.If you are unable to obtain a letter or a certificate,CareFirst will accept copies of your member ID cardsshowing your effective coverage dates and CareFirstwill assist you in obtaining a certificate of creditablecoverage.Portability (HIPPAA) 27

ConfidentialityEffective April 14, 2003, all health plans and providersmust provide information to members and patientsregarding how their information is protected. You willreceive a Notice of Privacy Practices from CareFirst oryour Health Plan, and from your providers as well, whenyou visit their office.CareFirst has policies and procedures in place to protectthe confidentiality of member information. Yourconfidential information includes Protected HealthInformation (PHI) and other nonpublic financialinformation. Because we are responsible for yourinsurance coverage, making sure your claims are paid,and that you can obtain any important services relatedto your health care, we are permitted to use and discloseyour information. Sometimes we are required by lawto disclose your information in certain situations. Youalso have certain rights to your own protected healthinformation, and there are some requirements you willfollow to allow other people to obtain your informationon your behalf.We are required by law to maintain the privacy of yourPHI, and to have appropriate procedures in place todo so. In accordance with the federal and state Privacylaws, we have the right to use and disclose your PHIfor payment activities and health care operations asexplained in the Notice of Privacy Practices. This Noticeis sent to all policyholders upon enrollment.You have the following rights regarding your ownProtected Health Information. You have the right to:■ request that we restrict the PHI we use ordisclose about you for payment or healthcare operations;■ request that we communicate with youregarding your information in an alternativemanner or at an alternative location if youbelieve that a disclosure of all or part ofyour PHI may endanger you;■ inspect and copy your PHI that is containedin a “designated record set”; including yourmedical records;■ request that we amend your informationif you believe that your PHI is incorrect orincomplete; and■ request and receive an accounting of certaindisclosures of your PHI that are for reasonsother than treatment, payment, or healthcare operations.If you have a privacy-related inquiry, please contactMember Services at the phone number on yourmember ID card.28

What should I do when I have questions about myhealth care coverage?When you have questions, call the Member ServicesDepartment at the number on your member ID card.To help you remember the call and avoid having to callMember Services again, write down:■ The date and time you called,■ The Member Services representative’s name,■ What course of action the Member Servicesrepresentative will take, and■ When you can expect resolution.How do I find out if I have a particular Benefit?Your benefits are detailed in your Personal Comp Policy.You may also contact Member Services at the numberon your member ID card to obtain specific informationon your benefits such as medical care, vision care, and/ordental care.Do I have coverage for pre-existing conditions?Generally, services to treat a pre-existing condition (orcomplications related to a pre-existing condition) areeligible for coverage once you have been covered for10 months. Coverage is not provided for pre-existingconditions within the first 10 months of your healthbenefit plan. If you can prove 18 months of prior healthcoverage with the most recent coverage being with agroup and no more than a 63-day break in coverage, youare eligible for a waiver of the pre-existing waiting period.Please note, a pre-existing condition may be subject toa pre-existing condition waiver rider signed by thepolicyholder. The pre-existing condition named in therider will have a 10 month waiting period.For more information on pre-existing conditions, seepage 5 or call Member Services at the number onyour member ID card.What kind of information can I find on www.carefirst.com?At www.carefirst.com you can:■ Find out the latest member news and updates■ Download claim forms and privacy forms■ Learn how to get discounts on alternative therapies,vision and hearing services, fitness centers and morethrough the Options discount program.■ Find a doctor who participates in your plan usingour searchable provider directory■ Look up health and wellness information at My CareFirst■ Get Member Services phone numbers■ Read answers to more of your frequently askedquestions■ Find benefit and eligibility information onMy Account.■ Order a new member ID card on My Account.I will be traveling out of town. What coverage do I have?If you look at your member ID card, you will see a suitcaseon it. That suitcase tells Blue Cross and Blue Shieldparticipating physicians and hospitals throughout theworld that your benefits include the BlueCard® program.When you travel outside of the service area, show yourmembership card to any hospital or physician whoparticipates with a Blue Cross and Blue Shield Planand you will receive the same benefits as you wouldfor a local provider.For more information about the BlueCard® programsee page 5.I have a dependent who will be going away to college.What coverage does he/she have?Full-time college students are covered until age 25. Youshould contact the local Blue Cross and Blue Shield planthat services the area where the college is located to findout where local doctors and hospitals are located.However, if your child gets married or enters themilitary, coverage will expire at the end of the period forwhich CareFirst has accepted premiums.How can I save money when I buy prescription drugs?You can use the Discount Prescription Drug Program. Thisprogram, brought to you by Argus, provides discounts at50,000 participating pharmacies nationwide.For more information about the Discount PrescriptionDrug Program see page 21.What happens to my coverage if I turn 65?You will not lose coverage as a result of reaching the ageof 65 or becoming eligible for Medicare. Benefits forcovered services that are not covered by Medicare willcontinue to be paid as usual. However, benefits forcovered services that are covered by Medicare will bepaid based on whether the provider accepts Medicareassignment or not.CareFirst also offers MediGap-65 plans that will helpyou with the medical bills that Medicare does not pay.MediGap-65 policies are designed to work hand-in-handwith the Medicare program anywhere in the country.For more information on the MediGap-65 plans,call (800) 275-3802.Frequently Asked Questions 29

Definition of TermsAppeal: A protest filed by a member or a health careprovider under CareFirst’s internal appeal processregarding a coverage decision.Claim Form: A form obtained from Member Servicesfor reimbursement of covered services paid by themember.Certificate of Creditable Coverage: A documentnecessary to waive any waiting periods, exclusionaryamendments or medical underwriting for a personwith a pre-existing condition.Coinsurance: A percentage of the plan allowance thatthe member pays for a covered service (e.g., 20 percentfor lab services or X-rays).Coordination of Benefits (COB): A provision whichdefines the order of benefit reimbursement when amember has health care coverage under more than oneplan.Copayment: A specified amount that the memberpays for a covered benefit (e.g., $10 per office visit to aphysician).Deductible: The dollar amount of incurred coveredexpenses that the member must pay before the Planmakes payment.Dependent: A member who is covered under thePlan as the spouse or eligible child of a Subscriber.Exclusions: Treatments, services, supplies orcircumstances listed in the contract for which CareFirstwill not provide benefits and specific conditions thatare subject to a 10-month waiting period.Health Care Practitioner: An individual, institution ororganization that provides medical services. Examplesof providers include physicians, therapists, hospitalsand home health agencies.HIPAA: Health Insurance Portability andAccountability Act. This Act addresses many tenetsof health insurance coverage including the handlingof Personal Health Information (PHI) and theMember’s ability to receive credit towards his orher waiting period.Member: An individual who is enrolled for coverage,and for whom we receive the premiums and otherrequired payments. A member can be either asubscriber or a dependent.Network: A group of multi-specialty medical groupsand individual practice doctors who are contractedto provide services to members of a health plan.Participating Provider: A covered provider thatcontracts with CareFirst to be paid directly forrendering covered services to eligible membersof this plan.Policyholder: The individual to whom the policyis issued.Preventive Health Care: Care provided to preventdisease or its consequences. It includes programsaimed at warding off illnesses (e.g., immunizations),early detection of disease and inhibiting furtherdeterioration of the body.30

Adult Physical Exams 2-3Adult Preventive Care Services 3Alternative therapies (Options) 22Appeals 25Appointments, canceling 2Appointments, scheduling guidelines 2Argus Health Systems 21BlueCard® Program 5, 29BlueVision 21CareEssentials 7-10Case Management Program 10Changes, personal and enrollment 14Claims filing process 15-16College students 29Confidentiality 28Contact lenses 20Coordination of benefits 14Corrective lenses 20Coverage, continuing 14Coverage, ending 14Covered dependents 14-15Definitions 30Denial of benefits, appeals 25Dental care 20Discount Drug Program 21Disease Management Programs 10Durable Medical Equipment 10Emergency, definition 3Enrollment changes 14Exclusions 6Explanation of Health Care Benefits Statements 18-19Filing a claim for reimbursement 15FirstHelp® 3Frequently Asked Questions 29Great Beginnings Program for Expectant Mothers 8Home Health Care 10Hospital care, authorization for 9Hospital care, continued stay review 10Medical emergency, definition 3Medical records 2Medical records, confidentiality 2Member ID card 1Mental health care 4My Care First 8My Account iOptions Discount Program 22-24Other insurance 14Paying for your health care coverage 14Portability, HIPAA 27Pre-existing conditions 5, 29Prescription drugs 21Preventive Care Benefits 9Prior authorization 10Reimbursement, how to file a claim for 15-16Responsibilities, member 24Rights, member 25Subrogation and Workers’ Compensation 14Substance abuse 4Traveling, care while 5Utilization Management 9-10Vision benefits 20Vitality member newsletter 8Voluntary Second Surgical Opinion Program 9Well child care 2Index 31

Policy Form No.: 365 (1/97) and all amendments.BOK5070-9S (1/09) web onlyCareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. andGroup Hospitalization and Medical Services, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association.® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.