Transcript Why Blue is the Solution!

Welcome
Real world practical solutions
designed
with you in mind
2011 Benefits Overview
PPO Plan
Overview of Health Products
Blue Options
PPO Plan 3562
Health Plan Terminology
• Deductible – what member pays before health plan pays
• Copayments (copays) – a set amount member pays for covered services
• Coinsurance – how a member and the company share costs after
deductibles and copays: e.g., 80%/20% or 70%/30%
• Annual out-of-pocket (OOP) maximum (max) – the maximum a member
pays out-of-pocket in any benefit year
– BlueOptions® – max includes all applicable health-related copays
(except Rx), deductibles, and coinsurance
• Allowed amount – maximum amount an in-network provider is allowed to
charge for covered service
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Other Words to Know
• Balance billing – additional amount member may be billed if they seek
care from an out-of-network provider
• Covered services – medical services that are eligible for payment under
health plan
• In-network – refers to provider network made up of independent
hospitals, physicians and ancillary providers (e.g., family physician, urgent
care centers, hospitals) who are participants within health plan network;
members pay less if they receive covered services from in-network
providers. The in-network name is: NetworkBlueSM (BlueOptions®)
• Out-of-network – provider not in network; out-of-pocket costs will
generally be higher
• Provider – person or institution offering health care services (e.g.,
doctors, specialists, hospitals, labs)
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Changes From 2010 Benefits
• Changes to Benefits
– In-Network Family Physician/PCP from $20 to $25
– In-Network Specialist from $35 to $40
– Pharmacy from $15/$40/$60 to $15/$45/$65
– Ambulance Per Day Air/Water from $4,000 to $10,000
• Changes to Benefit Maximums based on Health Care Reform
– Lifetime from $5,000,000 to No Limit
– Hospice from $10,000 to No Limit
– Home Health Care from $5,000 to 20 Visits
– Outpatient Therapy and Spinal Manipulation
(Rehabilitation) from $5,000 to 35 visits
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Office Visits
Family Physician/PCP
$25
Specialist
$40
Lab
In Network – Quest
Out of Network
Out-of-Network
$0
CYD + 30%
CYD + 30%
Any services received at
doctors office will apply to
copay.
Lab is paid at 100% by
using Quest. You can
make appointments
online!!!
www.questdiagnostics.com
Anything other than
NetworkBlue is Out of
Network. Using Traditional
doctors will protect you
from balance billing.
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Preventative Health
Mammogram
$0
Based on doctor’s
recommendation.
$500
Any allowances in
excess of $500 will be
the responsibility of the
member
In addition to the $500 Adult
Wellness Benefit
Adult Wellness
Colonoscopy
Included in the
$500 Adult
Adult Wellness Benefit
One routine colonoscopy (age Wellness
Benefit
50+ paid in full of allowed
amount)
The U.S. Preventive Services
Task Force (USPSTF)
recommends screening for
colorectal cancer (CRC)
using a colonoscopy, in
adults, beginning at age 50
years and continuing until
age 75 years. The risks and
benefits of these screening
methods vary.
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Hospital Services - Inpatient
Inpatient
In-Network
Out of Network
Provider Services while
Inpatient
In Network
Out of Network
$750/$1,500
$2,500
CYD + 20%
CYD + 30%
To determine tier levels
or participation, go to the
Online Provider Directory
www.bcbsfl.com
Any services received by
a Provider while in the
hospital.
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Hospital Services - Outpatient
Outpatient
In-Network Hospital
Out of Network
Provider Services while
Outpatient
In Network
Out of Network
$150/$250
$350
To determine tier levels
or participation, go to the
Online Provider Directory
www.bcbsfl.com
Any services received by
a Provider
CYD + 20%
CYD + 30%
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Mental Health/Substance Abuse
Office Visits
Family Physician/PCP
Specialist
Out of Network
$25
$25
CYD + 30%
See disclaimer below
“The information contained in this document includes benefit changes required as
a result of the Patient Protection And Affordable Care Act (PPACA), otherwise
known as Health Care Reform (HCR). Please note that plan benefits are subject to
change and may be revised based on guidance and regulations issued by the
Secretary of Health and Human Services (HHS) or other applicable federal agency.
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Mental Health/Substance Abuse
Inpatient
In-Network
Out of Network
$750/$750
$2,500
Disclaimer applies
Outpatient Therapy
In-Network
Out of Network
$45/$45
$150/$250
Disclaimer applies
Provider Services while
Inpatient
In Network
Out of Network
CYD + 20%
CYD + 20%
Disclaimer applies
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Deductible & Coinsurance
Calendar Year Deductible
$500/$1,500
Coinsurance
In Network
Out of Network
20%
30%
Applies to services such
as Provider Services in
Hospital, Independent
Diagnostic Testing
Facility, Durable Medical
Equipment, Prosthetics &
Orthotics and Ambulance
Services
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Out of Pocket Maximum
In Network and Out of
Network (Combined)
Per Person/Family
$ 5,000/$10,000
The maximum a
members pays out of
pocket in a benefit year.
All of the following is
applied to Max Out of
Pocket: Copays except
RX, Calendar Year
Deductible and
Coinsurance
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Pharmacy
Mandatory Generic
$15/$45/$65
30 Day Supply
Mail Order
60 Day Supply
$30/$90/$130
If a Brand Name RX is
purchased when a Generic
RX is available and the
Physician has not indicated
that a Brand Name RX is
medically necessary,
member will be required to
pay the difference between
the cost of the Brand Name
and Generic RX in addition
to the RX copay
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Want to get the most out of your next
doctor's visit?
The more you tell your doctor about your health concerns, the better he or she can prevent, diagnose, or treat any problems.
Follow these tips to get the most from each doctor visit.
Preparing for your doctor's visit
A little preparation can go a long way, saving you time and money.
•Be sure to check our online provider directory to see if your doctor participates in our network. Your cost will be
lowest when you use a participating health care provider.
•Write down your concerns and questions before your visit, and bring them with you.
•Bring paper and pen to take notes.
•Ask a family member or friend to come along. They can help you ask questions and understand the answers.
What Your Doctor Needs to Know
Be sure you cover these topics:
•Let your doctor know of any health concerns you have–even sensitive subjects
•Your symptoms, including when they began, how often they occur, how long they last, and whether they're getting
worse
•Services or tests other doctors have performed for you
•All medications and supplements you take; bring a list or the actual products
•Your family's medical history or know before your visit what language you prefer to speak or if you need an interpreter.
What You Need to Know Before you leave the doctor's office, you may want to ask
these questions:
•What is my condition, and what caused it?
•Which medications or other treatments do you recommend? How will they help?
•Will there be any side effects?
•Can lifestyle measures help my condition?
•Should I avoid certain medicines, activities, or foods?
•What kind of tests do I need–and why?
•How soon will test results be available, and how will I get them?
If you don't understand an answer or feel concerned about it, speak up!
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When you need to see a doctor
right away…
For non-emergency assistance—when you can’t get in to see your family doctor or don’t want to wait hours in
the emergency room—urgent care centers are designed to provide prompt, quality service and help you save
up to 50% on your out-of-pocket costs.
•
Urgent care centers are staffed with qualified doctors and nurses that can handle medical problems like
cuts and colds, flu symptoms, minor fractures, sprains and burns, ear infections, allergic reactions, animal
bites, sprains and even immunizations.
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Most urgent care centers offer: Quality care and prompt service
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Shorter wait times—compared to an emergency room
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Weekend and after-hours care
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Service without an appointment
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Convenient locations
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Check our online provider directory to find participating urgent care centers located near you. Keep the
names and addresses in a convenient place should you need them in a hurry.
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Serious injuries and emergencies
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If you have a serious injury or require immediate attention due to shortness of breath, severe abdominal
or chest pains, uncontrolled bleeding, loss of consciousness, changes in vision, severe vomiting or other
emergency conditions, call 911 or visit the nearest hospital.
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Be sure to contact your family doctor so that follow-up care can be scheduled, if necessary.
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Help is a phone call away
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If you have questions about a health condition or when to visit an urgent care center, you can speak to a
Health coach by calling 1-877-789-2583.
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Know about generics and how to
get them…
One of the easiest ways to save money is to use the generic version of a prescribed brand-name drug when
one is available. Your cost will be lower without sacrificing quality. So if you are starting a new medicine or refilling one, you may want to talk to your doctor, or have your pharmacist talk with your doctor, about whether
a generic is available and right for you.
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Check out this comparison chart and find generics using our online pharmacy tool.
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Over-the-Counter options can lower your costs
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Looking for ways to save money on medicine? There are other ways of filling the medicine cabinet without
depleting your pocketbook. The key? Look for nonprescription, over-the-counter (OTC) medication.
•
Check with your doctor. An OTC may work for you.
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OTC medication is medicine that can be sold without a prescription and is found on the shelves of stores
like other packaged products. Many OTC medications are just as effective as prescription drugs. In fact,
many OTC drugs were once available only with a prescription. These include popular pain relievers and
allergy medications as well as drugs that fight ulcers, help you quit smoking, and more. Your doctor can
tell you if an OTC medication can replace one of your prescriptions.
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How to save on your next scan
How to save on your next scan
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Not all imaging providers charge the same for their services. For example, an independent imaging center
may charge less than a hospital. To help you reduce your out-of-pocket costs, it pays to do a little legwork.
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Here are some ways to make the most of your benefits and lower your costs:
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Discuss your imaging options with your doctor. Are there other ways to diagnose your condition that are
just as effective?
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If your doctor recommends a CAT scan, PET scan, MRI, MRA or nuclear cardiology, ask where it will be
performed. You’ll have lower out-of-pocket costs if you use providers and facilities that participate in your
plan’s network.
•
To save even more money, ask your doctor if your test can be done at an in-network Independent
Diagnostic Testing Facility (IDTF). Services at an IDTF generally cost less than the same services done in an
outpatient hospital setting.
•
Use our online provider directory or call the number on your ID card to verify whether or not the
providers and facilities participate in your plan’s network.
•
Ask your doctor to request a pre-service review for these procedures. That way, you’ll always know up
front whether the service is a covered benefit. Please be aware that you may be responsible for the cost
of procedures you receive that are not considered medically necessary.
•
Go to http://www.bcbsfl.com/HealthySavings/surgery/doctorSaysSurgery.html for
additional information on healthy savings.
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FAQ’s
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Where can I go to get information about a claim?
–
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When I receive services outside the State of Florida, who submits the claim to BCBSF?
–
•
These are located on your Claims Details pages. Select Claims under the My Benefits menu and locate the specific claim you are
looking for.
What is an Explanation of Benefits statement?
–
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Select Claims Statements under the My Benefits menu.
Where can I find my Explanation of Benefits statements?
–
•
Not if you choose a provider from within your plan provider network. Your provider should process all claim submission
paperwork on your behalf. If you choose a provider outside the network, you may have to file claims for reimbursement.
Where can I find my Member Health statement?
–
•
You can email us a question concerning your claim by selecting Ask a Question about this Claim at the bottom of the Claim Status
Detail page. You will receive a reply in the Message Center or you may call us at 800-255-4908.
Do I have to submit claims?
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Member Responsibility is the out-of-pocket portion of a claim that a member is expected to pay. For example, deductibles,
copayments, and non-covered services are Member Responsibility.
What if I have a question about a claim?
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Under the BlueCard Program, if the physician or provider is participating in the Blue Cross and Blue Shield network in that state,
they will reimburse the physician or provider for the services you receive and them submit claim to BCBSF for reimbursement. If
you should receive a bill from the physician or provider, please contact Customer Service at 800-255-4908 for assistance.
What makes up Member Responsibility?
–
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Visit Claims under the My Benefits menu section to view and print details of your claims.
An Explanation of Benefits (EOB) is a detailed statement that explains how we processed a medical claim based on your benefits
plan. It shows how much was paid by your insurance plan, any out-of-pocket expenses that are your responsibility, and
accumulation of deductibles. Depending on your plan, you may or may not receive Explanation of Benefits statements.
What is a Member Health statement?
–
A Member Health Statement is a detailed reference of finalized health and pharmacy claims activities for the preceding 28days. This statement allows members to track claims and reconcile provider balances and can be used as documentation for
FSA, HRA and HSA accounts.
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Things To Remember
Save Money
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Use NetworkBlue doctors
Use Quest Laboratories
Stay in network using Online Provider Directory
Provide doctor and pharmacy your ID card
Log on to MyBlueService to view claims, benefit
information, order new ID Cards and Member
Handbooks
• Call Customer Service when you have questions 800255-4908
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Creating Value for FCSRMC Members
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BlueCard Outside State of Florida
Discount Programs Through Blue365
MyBlueService
Member Health Statement
Health Dialog – 24x7 Nurse Advice
Care Coordinator – Nancy Nicholas
Prevention and Wellness – Better You From
Blue
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Conclusion
BCBSF appreciates the opportunity to
continue our partnership with
FCSRMC and participating colleges.
Thank you for your continued
support.
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