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PPO Plan
Blue Shield Evidence of Coverage
and Disclosure Form
City of Anaheim
Group Number: 977662
80%/70% Plan
Effective Date: January 1, 2004
Visit us at mylifepath.com
Group
Evidence of Coverage
and Disclosure Form
City of Anaheim
Preferred Provider Plan
Effective Date: January 1, 2004
NOTICE
This Evidence of Coverage and Disclosure Form booklet describes the terms and conditions of coverage
of your Blue Shield health plan.
Please read this Evidence of Coverage and Disclosure Form carefully and completely so that you under-
stand which services are covered health care services, and the limitations and exclusions that apply to
your plan. If you or your dependents have special health care needs, you should read carefully those
sections of the booklet that apply to those needs.
If you have questions about the benefits of your plan, or if you would like additional information, please
contact Blue Shield Customer Service at the address or telephone number listed at the back of this
booklet.
PLEASE NOTE
Some hospitals and other providers do not provide one or more of the following services that may be
covered under your plan contract and that you or your family member might need: family planning;
contraceptive services, including emergency contraception; sterilization, including tubal ligation at the
time of labor and delivery; infertility treatments; or abortion. You should obtain more information be-
fore you enroll. Call your prospective doctor, medical group, independent practice association, or clinic,
or call the health plan at Blue Shield’s Customer Service telephone number listed at the back of this
booklet to ensure that you can obtain the health care services that you need.
ppo (7/03)
TABLE OF CONTENTS
SUMMARY OF BENEFITS ................................................................................................................................5
INTRODUCTION TO THE BLUE SHIELD OF CALIFORNIA PREFERRED PLAN ....................................................9
YOUR BLUE SHIELD OF CALIFORNIA PREFERRED PLAN AND HOW TO USE IT .............................................10
The Blue Shield of California Preferred Plan ......................................................................................10
Blue Shield of California's Preferred Providers...................................................................................10
How to Receive Services .....................................................................................................................11
DEFINITIONS ...............................................................................................................................................12
ELIGIBILITY ................................................................................................................................................19
EFFECTIVE DATE OF COVERAGE .................................................................................................................20
RENEWAL OF GROUP HEALTH SERVICE CONTRACT....................................................................................21
PREPAYMENT FEE .......................................................................................................................................22
PLAN CHANGES...........................................................................................................................................22
MEDICAL NECESSITY ..................................................................................................................................22
UTILIZATION REVIEW .................................................................................................................................22
SECOND MEDICAL OPINION POLICY ...........................................................................................................23
HEALTH EDUCATION AND HEALTH PROMOTION SERVICES ........................................................................23
LIFEPATH ADVISERS ...................................................................................................................................23
BLUE SHIELD ONLINE .................................................................................................................................23
BENEFITS MANAGEMENT PROGRAM ...........................................................................................................23
Preservice Review................................................................................................................................24
Prior Authorization ..............................................................................................................................24
Preadmission Review – Hospital Admissions ....................................................................................25
Emergency Admission Notification.....................................................................................................26
Hospital Inpatient Utilization Review .................................................................................................26
Discharge Planning ..............................................................................................................................27
Care Management ................................................................................................................................27
DEDUCTIBLE ...............................................................................................................................................27
ADDITIONAL AND REDUCED PAYMENTS FOR FAILURE TO USE
THE BENEFITS MANAGEMENT PROGRAM ...................................................................................................27
MAXIMUM AGGREGATE PAYMENT AMOUNT ..............................................................................................28
PAYMENT ....................................................................................................................................................28
Maximum Calendar Year Copayment Responsibility .........................................................................33
Continuity of Care by a Terminated Provider......................................................................................34
Preferred Provider Benefit Features.....................................................................................................34
PRINCIPAL BENEFITS AND COVERAGES (COVERED SERVICES) ...................................................................35
Hospital Benefits..................................................................................................................................35
Skilled Nursing Facilities Benefits ......................................................................................................36
Surgical Benefits..................................................................................................................................36
Ambulatory Surgical Benefits..............................................................................................................36
Medical Benefits ..................................................................................................................................37
Preventive Care Benefits......................................................................................................................37
Outpatient or Out-of-Hospital X-ray and Laboratory Benefits............................................................38
Chemotherapy Benefits........................................................................................................................38
Acupuncture Benefits...........................................................................................................................38
Prosthetic Appliances and Home Medical Equipment Benefits ..........................................................38
Orthoses Benefits .................................................................................................................................39
Diabetes Care .......................................................................................................................................39
Pregnancy Benefits ..............................................................................................................................40
Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits.................................40
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TABLE OF CONTENTS
Reconstructive Surgery........................................................................................................................41
Chiropractic Services ...........................................................................................................................41
Outpatient Physical Medicine Benefits................................................................................................41
Speech Therapy Benefits .....................................................................................................................41
Transplant Benefits ..............................................................................................................................42
Home Health Care/ Home Infusion Care Benefits, and PKU Related Formulas and
Special Food Products..........................................................................................................................43
Hospice Program Services ...................................................................................................................44
Ambulance Benefits.............................................................................................................................47
Podiatric Services.................................................................................................................................47
Clinical Trial for Cancer ......................................................................................................................47
Well Baby Care....................................................................................................................................47
Hearing Aid Services ...........................................................................................................................48
Mental Health and Substance Abuse Benefits .....................................................................................48
Substance Abuse Benefits....................................................................................................................48
PRINCIPAL LIMITATIONS, EXCEPTIONS, EXCLUSIONS AND REDUCTIONS ....................................................48
General Exclusions ..............................................................................................................................48
Medical Necessity Exclusion...............................................................................................................51
Pre-Existing Conditions .......................................................................................................................51
Exclusion for Duplicate Coverage .......................................................................................................52
Exception for Other Coverage .............................................................................................................53
Claims Review .....................................................................................................................................53
Reductions............................................................................................................................................53
GENERAL PROVISIONS ................................................................................................................................53
Coordination of Benefits......................................................................................................................53
Continuation of Group Coverage.........................................................................................................55
Continuation of Group Coverage after COBRA and/or Cal-COBRA.................................................59
Individual Conversion Plan..................................................................................................................60
Extension of Benefits...........................................................................................................................60
Termination of Benefits .......................................................................................................................61
Reinstatement, Cancellation and Rescission Provisions......................................................................62
Liability of Subscribers in the Event of Non-Payment by Blue Shield ...............................................62
Non-Assignability................................................................................................................................63
Customer Service .................................................................................................................................63
Grievance Process................................................................................................................................64
Department of Managed Health Care Review .....................................................................................65
Public Policy Participation Procedure .................................................................................................65
Confidentiality of Personal and Health Information............................................................................66
Independent Contractors ......................................................................................................................66
BLUE SHIELD OF CALIFORNIA VISION PLAN ...............................................................................................67
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This booklet constitutes only a summary of the health plan. The health plan contract must be
consulted to determine the exact terms and conditions of coverage.
The group contract is on file with your employer and a copy will be furnished upon request.
This is a Preferred Provider plan. Benefits, particularly the payment provisions, differ from other
Blue Shield of California plans. Be sure you understand the benefits of this plan before Services
are received.
NOTICE
Please read this Evidence of Coverage and Disclosure Form booklet carefully to be sure you
understand the benefits, exclusions and general provisions. It is your responsibility to keep in-
formed about any changes in your health coverage.
Should you have any questions regarding your Blue Shield of California health plan, see your
employer or contact any of the Blue Shield of California offices listed on the last page of this
booklet.
IMPORTANT
No Person has the right to receive the benefits of this plan for Services or supplies furnished
following termination of coverage, except as specifically provided under the Extension of Bene-
fits provision, and when applicable, the Continuation of Group Coverage provision in this
booklet.
Benefits of this plan are available only for Services and supplies furnished during the term it is
in effect and while the individual claiming benefits is actually covered by this group contract.
Benefits may be modified during the term of this plan as specifically provided under the terms
of the group contract or upon renewal. If benefits are modified, the revised benefits (including
any reduction in benefits or the elimination of benefits) apply for Services or supplies furnished
on or after the effective date of modification. There is no vested right to receive the benefits of
this plan.
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SUMMARY OF BENEFITS
Preferred Provider Plan
DEDUCTIBLE
Subscriber’s Calendar Year Deductible For Illness/
Accidental Injury
The Calendar Year deductible does not apply to:
$1,000 per Person
Preventive Care Benefits for the following Services:
Annual Health Appraisal Exam Services including, $3,000 per Family
annual physical examination,
routine laboratory Services,
mammography and Papanicolaou’s test;
Well Baby Care office visits;
the Preventive Care Sigmoidoscopy;
Family Planning counseling and consultation Services;
Preferred Physician office visits including:
Mammography and Papanicolaou’s Test. However, other covered
Services received during or in connection with a Preferred Physician
office visit are subject to the Calendar Year deductible;
Emergency Room Facility Services not resulting in an admission.
ADDITIONAL AND REDUCED PAYMENT(S)
Additional and Reduced Payment(s)
Refer to the Benefits Management Program for any Additional Payments and Re-
duced Payments which may apply.
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SUMMARY OF BENEFITS
Preferred Provider Plan
BLUE SHIELD’S PAYMENT PERCENTAGE
Physicians (except for Hospice Program Services)
Participating Physicians 80%
Non-Participating Physicians 70%
Hospitals (except for Hospice Program Services)
Preferred Hospitals — Emergency and Non-Emergency Services 80%
Non-Preferred Hospitals
Emergency 80%
Non-Emergency 70%*
(*Payment
not to exceed $420
per Person per day.)
Alternate Care Services Providers
Includes Home Medical Equipment suppliers, individual certified orthotists,
prosthetists, and prosthetist-orthotists.
Participating Alternate Care Services Providers 80%
Non-Participating Alternate Care Services Providers 70%
Note: for all Services covered under the Orthoses Benefit Subscribers have a
combined $2,000 per Person per Calendar Year benefit maximum. This maxi-
mum does not apply to Services covered under the Prosthetic Appliances and
Home Medical Equipment Benefits or the Diabetes Care benefit.
Ambulatory Surgery Centers
Participating Ambulatory Surgery Centers 80%
Non-Participating Ambulatory Surgery Centers 70%*
(*Payment
NOTE: Outpatient ambulatory surgery Services may also be obtained from a
not to exceed $420
Hospital. Ambulatory surgery Services obtained from a Hospital will be paid at
per Person per day)
the Preferred or Non-Preferred level as specified in the Hospital section of this
Summary of Benefits.
Hearing Aid Services
Audiological Evaluation 80%
Hearing Aid and ancillary Equipment 100% of the Allow-
able Amount up to a
maximum payment of
$1,000 per Person
every 36 months
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SUMMARY OF BENEFITS
Preferred Provider Plan
BLUE SHIELD’S PAYMENT PERCENTAGE (CONT.)
Acupuncture Services
Benefits are limited to a maximum of 20 visits per Person per Calendar Year
Preferred Provider 80%
Non-Preferred Provider Not covered
Chiropractic Services
Benefits are limited to a maximum of 20 visits per Person per Calendar Year
Preferred Provider 80%
Non-Preferred Provider Not covered
Other Providers 80%
Home Health Care and Home Infusion Agencies1
Participating Home Health Care and Home Infusion Agencies 80%
Non-Participating Home Health Care and Home Infusion Agencies Not covered unless
prior authorized by
Blue Shield2.
Hospice Program Services
Participating Hospice Agency
Continuous Home Care provided during a Period of Crisis
General Inpatient care 80%
Inpatient Respite Care 80%
Routine home care 100%
Non-Participating Hospice Agency3 100%
Not covered3
unless prior authorized by
Blue Shield
1
All benefits for home health care, home infusion and home injectable treatment must be prior
authorized by Blue Shield.
2
No benefits are provided for Home Health Care Benefits and Home Infusion Therapy Benefits
by Non-Participating Providers except as may be prior authorized by Blue Shield. If prior
authorized by Blue Shield, Non-Participating Providers will be reimbursed at a rate deter-
mined by the agency and Blue Shield, with the Subscriber Copayment at the Participating
Provider level..
3
Covered Hospice Services received from Non-Participating Hospice Agencies must be prior
authorized by Blue Shield. If Blue Shield prior authorizes Hospice services from a Non-
Participating Hospice Agency, those Hospice Services will be reimbursed at the Participating
Hospice Agency level.
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SUMMARY OF BENEFITS
Preferred Provider Plan
COPAYMENT RESPONSIBILITY
Subscriber’s maximum Calendar Year copayment for covered Services rendered $6,000 per Person
by Preferred Providers (Physician Members, Preferred Hospitals, Participating per Calendar Year
Providers), and Other Providers
$18,000 per Family
per Calendar Year
Subscriber’s maximum Calendar Year copayment for covered Services rendered $9,000 per Person
by any combination of Preferred Providers, Non-Preferred Providers, and Other per Calendar Year
Providers
$27,000 per Family
per Calendar Year
The following are not included in the Subscriber’s maximum Calendar Year copayment amount:
Preventive Care Benefits Services for the Annual routine physical exam (includes eye/ear screenings
and vaccinations);
Well baby care office visits and consultations;
Family Planning counseling and consultation Services;
Physician office visits and consultations, specialist visits and consultations;
Emergency Room Facility Services not resulting in an admission;
The Calendar Year deductible;
Charges by Non-Preferred Providers in excess of covered amounts;
Charges in excess of specified benefit maximums;
Non-Preferred Hospital and Professional Services (except for emergencies);
Non-Participating Ambulatory Surgery Center Services;
Additional and Reduced Payments under the Benefits Management Program.
Note: The Summary of Benefits represents only a brief description of some of the
benefits. Please read this booklet carefully for a complete description of provisions,
benefits and exclusions of the plan.
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INTRODUCTION TO THE BLUE SHIELD OF Failure to meet these responsibilities may re-
sult in your incurring a substantial financial
CALIFORNIA PREFERRED PLAN liability. Some Services may not be covered
If you have questions about your benefits, unless prior review and other requirements
contact Blue Shield of California before Hos- are met.
pital or medical Services are received. NOTE: Blue Shield will render a decision on
This plan is designed to reduce the cost of all requests for pre-service review, prior
health care to you, the Subscriber. In order to authorization and pre-admission review
reduce your costs, much greater responsibility is within 5 business days from receipt of the re-
placed on you. quest. The treating provider will be notified
of the decision within 24 hours followed by
You are responsible for following the Blue written notice to the provider and Subscriber
Shield of California Benefits Management within 2 business days of the decision. For
Program including: urgent services in situations in which the rou-
tine decision making process might seriously
1. Assuring that the Physician or Hospital you jeopardize the life or health of a Person or
choose is a Preferred Provider. when the Person is experiencing severe pain,
Blue Shield will respond within 72 hours
2. Obtaining, or assuring that your Physician
from receipt of the request.
obtains, Preservice Benefit Determination
and Certification to determine if contem-
plated Services are covered.
Blue Shield of California
Preferred Providers
3. Obtaining, or assuring that your Physician
obtains, Blue Shield of California approval 5 The Blue Shield of California Preferred Plan is
working days before Hospital admission for specifically designed for you to use Blue Shield
all non-emergency Inpatient Hospital Serv- of California Preferred Providers. Preferred
ices. Providers include certain Physicians, Hospitals,
Alternate Care Services Providers, and other
4. Notifying Blue Shield of California within providers. They are listed in the Preferred Pro-
24 hours or by the end of the first business vider directories. It is your obligation to be
day following emergency admissions. sure that the Physician, Hospital, or Alter-
nate Care Services Provider you choose is a
5. Assuring that you obtain Blue Shield of Preferred Provider, in case there have been
California's recommendation regarding sur- any changes since your Preferred Provider
gical procedures to be performed on an Out- directory was published.
patient basis.
Blue Shield of California Preferred Providers
6. Obtaining approval from Blue Shield of agree to accept Blue Shield of California's pay-
California for any proposed treatment plan ment, plus your payment of any applicable de-
for home care, Home Medical Equipment, ductible and copayment, or amounts in excess of
home infusion therapy, Speech Therapy or benefit dollar maximums specified, as payment-
Rehabilitation or Rehabilitative Care. in-full for covered Services. This is not true of
Non-Preferred Providers.
7. Obtaining prior approval for admission into
an approved Hospice Program as specified If you go to a Non-Preferred Provider, Blue
under the Hospice Program Services in the Shield of California's payment for a service
Covered Services section. by that Non-Preferred Provider may be sub-
-9-
stantially less than the amount billed. You BLUE SHIELD OF CALIFORNIA'S
are responsible for the difference between the PREFERRED PROVIDERS
amount Blue Shield of California pays and
the amount billed by Non-Preferred Provid- All Blue Shield of California Physician Mem-
ers. It is therefore to your advantage to ob- bers are Blue Shield of California Preferred
tain medical and Hospital Services from Pre- Providers. So are selected Hospitals in your
ferred Providers. community.
If emergency care is needed in a Non-Preferred Many other healthcare professionals, including
Hospital, payment will be made at the Hospital's dentists, podiatrists, optometrists, audiologists,
Billed Charge for covered Services, less any ap- licensed clinical psychologists and marriage,
plicable deductible or copayment. You are re- family and child counselors are also Preferred
sponsible for notifying Blue Shield of California Providers. They are all listed in your Preferred
within 24 hours, or by the end of the first busi- Provider Directories.
ness day following emergency admission at a
Non-Preferred Hospital. Blue Shield of California Preferred Providers
are working to hold down the costs of health
Directories of Blue Shield of California Pre- care while maintaining quality care. They agree
ferred Providers located in your area have been to accept Blue Shield of California's payment,
provided to you. Extra copies are available plus any deductibles or copayments you may be
from Blue Shield of California. If you do not responsible for under the terms of your plan, as
have the directories, please contact Blue Shield payment-in-full for covered Services.
of California immediately and request them at
the telephone number listed on the last page of USING PREFERRED PROVIDERS SAVES
this booklet. YOU MONEY; USING NON-PREFERRED
PROVIDERS CAN COST YOU MONEY
YOUR BLUE SHIELD OF CALIFORNIA
When you receive covered Services from a Pre-
PREFERRED PLAN AND HOW TO USE ferred Provider, Blue Shield of California pays
IT the provider directly, and except for any de-
ductibles or copayments that may apply, you
THE BLUE SHIELD OF CALIFORNIA have no further financial responsibility.
PREFERRED PLAN When you use a Non-Preferred Provider, you
are responsible for any difference between Blue
You are now part of the Blue Shield of Califor-
Shield of California's payment (as described in
nia team along with Physicians, Hospitals, and
this Evidence of Coverage and Disclosure Form
other healthcare professionals working together
booklet) and the billed amount. Non-Preferred
toward a common goal — quality medical care
Providers have not agreed to accept Blue Shield
at reasonable costs.
of California's payment determination as pay-
To take full advantage of your Blue Shield of ment-in-full. In addition, what Blue Shield of
California Preferred Plan, and avoid unneces- California will pay for covered Services per-
sary liability, it is very important for you to formed by a Non-Preferred Provider will usually
know how your plan works, what Blue Shield of be considerably less than the amount billed.
California and its Preferred Providers are doing, The additional cost to you could be substantial.
and what you, the Subscriber, will have to do. It makes sense to select a Preferred Provider.
-10-
How to Make Your Hospital, or other licensed healthcare provider.
Blue Shield of California You should verify that the provider is a Pre-
ferred Provider, in case there have been any
Preferred Plan Work for You
changes since your Preferred Provider directory
First, read your Summary of Benefits and Evi- was published.
dence of Coverage and Disclosure Form booklet
Your I.D. card has your Subscriber and group
carefully.
numbers on it. Be sure to include these numbers
Your booklet tells you which Services are cov- on all claims you submit to Blue Shield of Cali-
ered by your health plan and which are ex- fornia.
cluded. It also spells out your responsibility for
any copayments and deductibles. These are im- YOU MAY NEVER HAVE TO FILL OUT A
portant facts for your health care budget. CLAIM FORM...
Hospitals and Blue Shield of California Pre-
HOW TO RECEIVE SERVICES ferred Providers usually bill Blue Shield of Cali-
Remember, it is to your advantage to use Blue fornia directly.
Shield of California Preferred Providers for ...But If You Do Need to Fill Out a Claim —
Services covered by your plan. When you use a It's Easy.
Non-Preferred Provider, the Blue Shield of Cali-
fornia payment may be substantially less than Send a copy of your itemized bill, along with a
the Billed Charge. (The exception to this is the completed Blue Shield of California Sub-
use of Non-Preferred Hospitals for Emergency scriber's Statement of Claim form to the Blue
Services. Further details are contained else- Shield of California service center listed on the
where in the Evidence of Coverage and Disclo- last page of this booklet.
sure Form booklet.) You will be responsible for
that portion of the Non-Preferred Provider's bill You may call Blue Shield of California Cus-
over and above the amount Blue Shield of Cali- tomer Service at the number listed on the last
fornia pays. Directories of the Preferred Pro- page of this booklet to ask for forms. If neces-
viders in your immediate area have been pro- sary, you may use a photocopy of the Blue
vided to you. Extra copies are available from Shield of California claim form.
Blue Shield of California. If you do not have
Be sure to send in a claim for all covered Serv-
the copies you need, you should call Blue Shield
ices even if you have not yet met your Calendar
of California at the number listed on the last
Year deductible. Blue Shield of California will
page of this booklet.
keep track of the deductible for you. Blue
Members who reasonably believe that they have Shield of California uses an Explanation of
an emergency medical condition which requires Benefits to describe how your claim was proc-
an emergency response are encouraged to ap- essed and to inform you of your financial re-
propriately use the “911” emergency response sponsibility.
system where available.
Requests for payment from any source must be
submitted to Blue Shield within 1 year after the
YOUR BLUE SHIELD OF CALIFORNIA I.D. month Services were provided. Blue Shield will
CARD IS YOUR PASSPORT TO SERVICE notify you of its determination within 30 days
When you need health care, present your Blue after receipt of the claim.
Shield of California I.D. card to your Physician,
-11-
DEFINITIONS fied orthotists, prosthetists and prosthetist-
orthotists.
Whenever any of the following terms are capi-
talized in this booklet, they will have the mean- Billed Charges — the amount actually charged
ing stated below. for covered Services except the amount which
exceeds that normally charged other patients for
Accidental Injury — definite trauma resulting the same Service.
from a sudden, unexpected and unplanned
event, occurring by chance, caused by an inde- Calendar Year — a period beginning on Janu-
pendent, external source. ary 1 of any year and terminating on January 1
of the following year.
Activities of Daily Living (ADL) — the self-
care and mobility skills required for independ- Chronic Care — care (different from Acute
ence in normal everyday living. This does not Care) furnished to treat an illness, injury or con-
include recreational or sports activities. dition, which does not require hospitalization
(although confinement in a lesser facility may
Acute Care — care rendered in the course of be appropriate), which may be expected to be of
treating an illness, injury or condition marked long duration without any reasonably predict-
by a sudden onset or change of status requiring able date of termination, and which may be
prompt attention, which may include hospitali- marked by recurrences requiring continuous or
zation, but which is of limited duration and periodic care as necessary.
which is not expected to last indefinitely.
Close Relative — the spouse, children, broth-
Allowable Amount — the Blue Shield of Cali- ers, sisters or parents of a covered Person.
fornia Allowance (as defined below) for the
Service (or Services) rendered, or the provider's Cosmetic Surgery — surgery that is performed
Billed Charge, whichever is less. The Blue to alter or reshape normal structures of the body
Shield of California Allowance is: to improve appearance.
1. the amount Blue Shield of California has Creditable Coverage —
determined is an appropriate payment for the 1. Any individual or group policy, contract or
Service(s) rendered in the provider's geo- program, that is written or administered by a
graphic area, based upon such factors as disability insurer, health care service plan,
Blue Shield's evaluation of the value of the fraternal benefits society, self-insured em-
Service(s) relative to the value of other ployer plan, or any other entity, in this state
Services, market considerations, and pro- or elsewhere, and that arranges or provides
vider charge patterns; or medical, hospital, and surgical coverage not
2. such other amount as the provider and Blue designed to supplement other private or
Shield of California have agreed will be ac- governmental plans. The term includes
cepted as payment for the Service(s) ren- continuation or conversion coverage but
dered; or does not include accident only, credit, cov-
erage for onsite medical clinics, disability
3. if an amount is not determined as described income, Medicare supplement, long-term
in either 1. or 2. above, the amount Blue care, dental, vision, coverage issued as a
Shield of California determines is appropri- supplement to liability insurance, insurance
ate considering the particular circumstances arising out of a workers' compensation or
and the Services rendered. similar law, automobile medical payment in-
surance, or insurance under which benefits
Alternate Care Services Providers — Home are payable with or without regard to fault
Medical Equipment suppliers, individual certi- and that is statutorily required to be con-
-12-
tained in any liability insurance policy or upon the Subscriber for support and mainte-
equivalent self-insurance. nance, or is dependent upon the Subscriber
for medical support by reason of a court or-
2. Title XVIII of the Social Security Act, e.g., der;
Medicare.
and who has been enrolled and accepted by Blue
3. The Medicaid/Medi-Cal program pursuant Shield of California as a Dependent and has
to Title XIX of the Social Security Act. maintained membership under the terms of the
contract.
4. Any other publicly sponsored or funded
program of medical care. 3. If coverage for a Dependent child would be
terminated because of the attainment of age
Custodial or Maintenance Care — care fur-
19 (or age 25, if Dependent has been a full-
nished in the home primarily for supervisory
time student), and the Dependent child is
care or supportive services, or in a facility pri-
Totally Disabled (Physically Handicapped
marily to provide room and board (which may
or Mentally Retarded), benefits for such De-
or may not include nursing care, training in per-
pendent will be continued upon the follow-
sonal hygiene and other forms of self care
ing conditions:
and/or supervisory care by a Physician) or care
furnished to a Person who is mentally or physi- a. the child must be chiefly dependent upon
cally disabled, and the Subscriber for support and mainte-
nance;
1. who is not under specific medical, surgical
or psychiatric treatment to reduce the dis- b. the Subscriber submits to Blue Shield a
ability to the extent necessary to enable the Physician's written certification of Total
patient to live outside an institution provid- Disability within 31 days from the date
ing care; or of the Employer's or Blue Shield's re-
quest; and
2. when, despite medical, surgical or psychiat-
ric treatment, there is no reasonable likeli- c. thereafter, certification of continuing
hood that the disability will be so reduced. disability and dependency from a Physi-
cian is submitted to Blue Shield on the
Dependent —
following schedule:
1. a Subscriber's legally married spouse who is
(1) within 6 months after the month
not covered for benefits as a Subscriber, and
when the Dependent would other-
is not legally separated from the Subscriber;
wise have been terminated; and
or
(2) annually thereafter on the same
2. a Subscriber's unmarried child (including
month when certification was
any stepchild or child placed for adoption)
made in accordance with item (1)
who is: (a) less than 19 years of age; or (b)
above. In no event will coverage
less than 25 years of age, if a full-time stu-
be continued beyond the date when
dent and proof of student status is submitted
the Dependent child becomes in-
to and received by Blue Shield. Full-time
eligible for coverage under this
student means a Dependent must be en-
plan for any reason other than at-
rolled in a college, university, vocational or
tained age.
technical school for a minimum of 8 units as
an undergraduate, or 6 units as a graduate Doctor of Medicine — a licensed Medical
student; and (c) not covered for benefits as a Doctor (M.D.) or Doctor of Osteopathic Medi-
Subscriber; and (d) primarily dependent cine (D.O.).
-13-
Domiciliary Care — care provided in a Hospi- by any State government agency, prior to use
tal or other licensed facility because care in the and where such approval has not been granted at
patient's home is not available or is unsuitable. the time the services or supplies were rendered,
shall be considered experimental or investiga-
Emergency Services — Services provided for tional in nature. Services or supplies which
an unexpected medical condition, including a themselves are not approved or recognized in
psychiatric emergency medical condition, mani- accordance with accepted professional medical
festing itself by acute symptoms of sufficient standards, but nevertheless are authorized by
severity (including severe pain) such that the law or by a government agency for use in test-
absence of immediate medical attention could ing, trials, or other studies on human patients,
reasonably be expected to result in any of the shall be considered experimental or investiga-
following: tional in nature.
1. placing the patient's health in serious jeop- Family — the Subscriber and all enrolled De-
ardy; pendents.
2. serious impairment to bodily functions; Group Health Service Contract (Contract) —
the contract issued by the Plan to the contrac-
3. serious dysfunction of any bodily organ or
tholder that establishes the services that Sub-
part.
scribers and Dependents are entitled to receive
Employee — an individual who meets the eli- from the Plan.
gibility requirements set forth in the Group
Home Medical Equipment — equipment de-
Health Service Contract between Blue Shield of
signed for repeated use which is medically nec-
California and your employer.
essary to treat an illness or injury, to improve
Employer — any person, firm, proprietary or the functioning of a malformed body member,
non-profit corporation, partnership, public or to prevent further deterioration of the pa-
agency or association that has at least 2 employ- tient's medical condition. Home Medical
ees and that is actively engaged in business or Equipment includes items such as wheelchairs,
service, in which a bona fide employer- hospital beds, respirators, and other items that
employee relationship exists, in which the ma- Blue Shield of California determines are Home
jority of employees were employed within this Medical Equipment.
state, and which was not formed primarily for
Hospice or Hospice Agency — an entity which
purposes of buying health care coverage or in-
provides Hospice Services to Terminally Ill Per-
surance.
sons and holds a license, currently in effect as a
Enrollment Date — the first day of coverage, Hospice pursuant to Health and Safety Code
or if there is a waiting period, the first day of the Section 1747, or a home health agency licensed
waiting period (typically, date of hire). pursuant to Health and Safety Code Sections
1726 and 1747.1 which has Medicare certifica-
Experimental or Investigational in Nature — tion.
any treatment, therapy, procedure, drug or drug
usage, facility or facility usage, equipment or Hospital —
equipment usage, device or device usage, or
1. a licensed institution primarily engaged in
supplies which are not recognized in accordance
providing, for compensation from patients,
with generally accepted professional medical
medical, diagnostic and surgical facilities for
standards as being safe and effective for use in
care and treatment of sick and injured per-
the treatment of the illness, injury, or condition
sons on an Inpatient basis, under the super-
at issue. Services which require approval by the
vision of an organized medical staff, and
Federal government or any agency thereof, or
which provides 24 hour a day nursing serv-
-14-
ice by registered nurses. A facility which is a. The Employee or Dependent was cov-
principally a rest home or nursing home or ered under another employer health
home for the aged is not included. benefit plan at the time he or she was of-
fered enrollment under this plan; and
2. a psychiatric Hospital accredited by the Joint
Commission on Accreditation of Healthcare b. The Employee or Dependent certified, at
Organizations. the time of the initial enrollment, that
coverage under another employer health
3. a psychiatric healthcare facility as defined in benefit plan was the reason for declining
Section 1250.2 of the Health and Safety enrollment, provided that, if he or she
Code; or was covered under another employer
health plan, he or she was given the op-
4. a facility operated primarily for the treat-
portunity to make the certification re-
ment of alcoholism and accredited by the
quired and was notified that failure to do
Joint Commission on Accreditation of
so could result in later treatment as a
Healthcare Organizations.
Late Enrollee; and
Incurred — a charge will be considered to be
c. The Employee or Dependent has lost or
“Incurred” on the date the particular service or
will lose coverage under another em-
supply which gives rise to it is provided or ob-
ployer health benefit plan as a result of
tained.
termination of his or her employment or
Infertility — either (1) the presence of a dem- of the individual through whom he or
onstrated bodily malfunction recognized by a she was covered as a dependent, change
licensed Doctor of Medicine as a cause of infer- in his or her employment status or of the
tility, or (2) because of a demonstrated bodily individual through whom he or she was
malfunction, the inability to conceive a preg- covered as a dependent, termination of
nancy or to carry a pregnancy to a live birth af- the other plan's coverage, exhaustion of
ter a year or more of regular sexual relations COBRA continuation coverage, cessa-
without contraception. tion of an employer's contribution to-
ward his or her coverage, death of the
Inpatient — an individual who has been ad- individual through whom he or she was
mitted to a Hospital as a registered bed patient covered as a dependent, or legal separa-
and is receiving Services under the direction of tion or divorce; and
a Physician.
d. The Employee or Dependent requests
Late Enrollee — an eligible Employee or De- enrollment within 31 days after termina-
pendent who has declined enrollment in this tion of coverage or employer contribu-
plan at the time of the initial enrollment period, tion toward coverage provided under an-
and who subsequently requests enrollment in other employer health benefit plan; or
this plan; provided that the initial enrollment pe-
riod shall be a period of at least 30 days. How- 2. The employer offers multiple health benefit
ever, an eligible Employee or Dependent shall plans and the eligible Employee elects this
not be considered a Late Enrollee if any of the plan during an open enrollment period; or
following paragraphs (1.), (2.), (3.), (4.), (5.) or
3. A court has ordered that coverage be pro-
(6.) is applicable:
vided for a spouse or minor child under a
1. The eligible Employee or Dependent meets covered Employee’s health benefit plan.
all of the following requirements of (a.), The health plan shall enroll a Dependent
(b.), (c.) and (d.): child within 31 days of presentation of a
-15-
court order by the district attorney, or upon control and care for their own welfare, or for the
presentation of a court order or request by a welfare of others, or for the welfare of the
custodial party, as described in Section community.
3751.5 of the Family Code; or
Non-Participating Home Health Care and
4. For eligible Employees or Dependents who Home Infusion agency — an agency which has
fail to elect coverage in this plan during their not contracted with Blue Shield and whose
initial enrollment period, the plan cannot services are not covered unless prior authorized
produce a written statement from the em- by Blue Shield.
ployer stating that prior to declining cover-
age, the Employee or Dependent, or the in- Non-Participating/Non-Preferred Providers
dividual through whom he or she was — any provider who has not contracted with
eligible to be covered as a dependent, was Blue Shield to accept Blue Shield's payment,
provided with and signed acknowledgment plus any applicable deductible, copayment or
of a Refusal of Personal Coverage form amounts in excess of specified benefit maxi-
specifying that failure to elect coverage mums, as payment-in-full for covered Services.
during the initial enrollment period permits Certain services of this Plan are not covered or
the plan to impose, at the time of his or her benefits are reduced if the service is provided by
later decision to elect coverage, an exclusion a Non-Participating/Non-Preferred Provider.
from coverage for a period of 12 months, as
Open Enrollment Period — that period of time
well as a 6 month Pre-existing Condition
set forth in the contract during which eligible
exclusion, unless he or she meets the criteria
employees and their dependents may transfer
specified in paragraphs (1.), (2.) or (3.)
from another health benefit plan sponsored by
above; or
the employer to the Preferred Plan.
5. For eligible Dependents who have lost or
Orthosis — an orthopedic appliance or appara-
will lose their no share-of-cost Medi-Cal
tus used to support, align, prevent or correct de-
coverage and who request enrollment within
formities or to improve the function of movable
31 days after notification of this loss of cov-
body parts.
erage.
Other Providers —
6. For eligible Employees who decline cover-
age during the initial enrollment period and 1. Independent Practitioners — licensed voca-
subsequently acquire Dependents through tional nurses; licensed practical nurses; reg-
marriage, birth, or placement for adoption, istered nurses; licensed psychiatric nurses;
and who enroll for coverage for themselves certified nurse anesthetists; certified nurse
and their Dependents within 31 days from midwives; licensed occupational therapists;
the date of marriage, birth, or placement for certificated acupuncturists; inhalation and
adoption. enterostomal therapists; licensed speech
therapists or pathologists; dental technicians;
Mental Health Services — see definition of and lab technicians.
Psychiatric Care.
2. Healthcare Organizations — nurses registry;
Mentally Retarded (or Mental Retardation) licensed mental health, freestanding public
— only those Persons, not psychotic, who are so
health, rehabilitation, hemodialysis and Out-
Mentally Retarded from infancy or before
patient clinics not MD owned; portable X-
reaching maturity that they are incapable of
ray companies; lay-owned independent labo-
managing themselves and their affairs inde-
ratories; blood banks; speech and hearing
pendently, with ordinary prudence, or of being
centers; dental laboratories; dental supply
taught to do so, and who require supervision,
companies; nursing homes; ambulance com-
-16-
panies; Easter Seal Society; American Can- Participating Provider — a Physician, a Hos-
cer Society and Catholic Charities. pital, an Ambulatory Surgery Center, an Alter-
nate Care Services Provider, or a Home Health
Outpatient — an individual receiving Services Care and Home Infusion Agency that has con-
but not as an Inpatient. tracted with Blue Shield of California to furnish
Services and to accept Blue Shield of Califor-
Outpatient Facility — a licensed facility, not a
nia's payment, plus applicable deductibles and
Physician's office or Hospital, that provides
copayments, as payment in full for covered
medical and/or surgical Services on an Outpa-
Services, except as provided under the Payment
tient basis.
and Subscriber copayment provision in this
Participating Ambulatory Surgery Center — booklet. Certain services of this Plan are not
a licensed Ambulatory Surgery facility which covered or benefits are reduced if the service is
has contracted with Blue Shield to provide sur- provided by a Participating Provider that is not a
gical Services on an Outpatient basis and accept Preferred Provider.
reimbursement at negotiated rates.
NOTE: this definition does not apply to Hos-
Participating Home Health Care and Home pice Program Services. For Participat-
Infusion agency — an agency which has con- ing/Preferred Providers for Hospice Program
tracted with Blue Shield to furnish Services and Services, see the Participating Hospice or Par-
accept reimbursement at negotiated rates, and ticipating Hospice Agency definitions above.
which has been designated as a Participating
Person — either a Subscriber or Dependent.
Home Health Care and Home Infusion agency
by Blue Shield. (See Non-Participating Home Physical Handicap — a physical or mental im-
Health Care and Home Infusion agency defini- pairment that results in anatomical, physiologi-
tion above.) cal, or psychological abnormalities which are
demonstrable by medically acceptable clinical
Participating Hospice or Participating Hos-
or laboratory diagnostic techniques and which
pice Agency — an entity which: 1) provides
are expected to last for a continuous period of
Hospice Services to Terminally Ill Persons and
time not less than 12 months in duration.
holds a license, currently in effect, as a Hospice
pursuant to Health and Safety Code Section Physical Medicine — Services including but
1747, or a home health agency licensed pursuant not limited to physical medicine evaluations and
to Health and Safety Code Sections 1726 and management, office visits, patient training, and
1747.1 which has Medicare certification and 2) treatment utilizing physical agents, such as ul-
has either contracted with Blue Shield of Cali- trasound, heat and massage, rendered by a
fornia or has received prior approval from Blue Doctor of Medicine, registered physical thera-
Shield of California to provide Hospice Service pist or certified occupational therapist to im-
benefits pursuant to the California Health and prove a patient's musculoskeletal, neuromuscu-
Safety Code Section 1368.2. lar and respiratory systems.
Participating Physician — a Physician or a Physician — a licensed Doctor of Medicine,
Physician Member that has contracted with Blue clinical psychologist, research psychoanalyst,
Shield to furnish Services and to accept Blue dentist, licensed clinical social worker, optome-
Shield's payment, plus applicable deductibles trist, chiropractor, podiatrist, audiologist, regis-
and copayments, as payment-in-full for covered tered physical therapist, or licensed marriage
Services, except as provided under the Payment and family therapist.
and Subscriber copayment provision in this
booklet.
-17-
Physician Member — a Doctor of Medicine modalities and are provided for as long as con-
who has enrolled with Blue Shield as a Physi- tinued treatment is Medically Necessary pursu-
cian Member. ant to the treatment plan.
Pre-existing Condition — an illness, injury or Services — includes medically necessary
condition (including Total Disability) which healthcare Services and medically necessary
existed during the 6 months prior to the enroll- supplies furnished incident to those Services.
ment date of coverage if, during that time, any
medical advice, diagnosis, care or treatment was Skilled Nursing Facility — a facility with a
recommended or received from a licensed health valid license issued by the California Depart-
practitioner. ment of Health Services as a Skilled Nursing
Facility or any similar institution licensed under
Preferred Hospital — a Hospital under con- the laws of any other state, territory, or foreign
tract to Blue Shield which has agreed to furnish country.
Services and accept reimbursement at negoti-
ated rates, and which has been designated as a Special Food Products — a food product
Preferred Hospital by Blue Shield. which is both of the following:
Preferred Provider — a Physician Member, a 1. Prescribed by a Physician or nurse practitio-
Preferred Hospital, or a Participating Provider. ner for the treatment of phenylketonuria
(PKU) and is consistent with the recommen-
Prosthesis — an artificial part, appliance or de- dations and best practices of qualified health
vice used to replace a missing part of the body. professionals with expertise germane to, and
experience in the treatment and care of,
Psychiatric Care (Mental Health Services) — phenylketonuria (PKU). It does not include
psychoanalysis, psychotherapy, counseling, a food that is naturally low in protein, but
medical management, or other Services pro- may include a food product that is specially
vided by a psychiatrist, psychologist, licensed formulated to have less than one gram of
clinical social worker, or licensed marriage and protein per serving;
family therapist, for diagnosis or treatment of a
mental or emotional disorder or the mental or 2. Used in place of normal food products, such
emotional problems associated with an illness, as grocery store foods, used by the general
injury, or any other condition. population.
Reconstructive Surgery — surgery to correct Speech Therapy — treatment, under the direc-
or repair abnormal structures of the body caused tion of a Doctor of Medicine and provided by a
by congenital defects, developmental abnor- licensed speech pathologist or speech therapist,
malities, trauma, infection, tumors or disease to to improve or retrain a patient's vocal skills
do either of the following: 1) to improve func- which have been impaired by illness or injury.
tion, or 2) to create a normal appearance to the
extent possible. Subacute Care — skilled nursing or skilled re-
habilitative care provided in a hospital or skilled
Rehabilitation or Rehabilitative Care — care nursing facility to patients who require skilled
furnished to an Inpatient primarily to restore an care such as nursing services, physical, occupa-
individual's ability to function as normally as tional or speech therapy, a coordinated program
possible after a disabling illness or injury. Re- of multiple therapies or who have medical needs
habilitation or Rehabilitative Care services con- that require daily Registered Nurse monitoring.
sist of the combined use of medical, social, edu- A facility which is primarily a rest home, con-
cational, occupational/vocational treatment valescent facility or home for the aged is not in-
cluded.
-18-
Subscriber — an individual who satisfies the You and your Dependents will not be consid-
eligibility requirements of an Employee, who ered to be Late Enrollees if either you or your
has been enrolled and accepted by Blue Shield Dependents lose coverage under another em-
of California as a Subscriber, and has main- ployer health plan and you apply for coverage
tained Blue Shield of California coverage under under this Plan within 31 days of the date of loss
the group contract. of coverage. You will be required to furnish
Blue Shield written proof of the loss of cover-
Total Disability (or Totally Disabled) — age.
1. in the case of an Employee or Person other- Newborn infants of the Subscriber will be eligi-
wise eligible for coverage as an Employee, a ble immediately after birth for the first 31 days.
disability which prevents the individual Children placed for adoption will be eligible
from working with reasonable continuity in immediately upon the date the Subscriber or
the individual's customary employment or in spouse has the right to control the child's health
any other employment in which the individ- care. Evidence of such control includes a health
ual reasonably might be expected to engage, facility minor release report, a medical authori-
in view of the individual's station in life and zation form or a relinquishment form. In order
physical and mental capacity; to have coverage continue beyond the first 31
days without lapse, a written application must
2. in the case of a Dependent, a disability
be submitted to and received by Blue Shield
which prevents the individual from engaging
prior to 31 days from the date of birth or place-
with normal or reasonable continuity in the
ment for adoption of such Dependent.
individual's customary activities or in those
in which the individual otherwise reasonably You may add newly acquired Dependents and
might be expected to engage, in view of the yourself to the plan by submitting a written ap-
individual's station in life and physical and plication on forms furnished by Blue Shield of
mental capacity. California within 31 days from the date of ac-
quisition of the Dependent:
ELIGIBILITY 1. to continue coverage of a newborn or child
If you are an Employee as defined, you are eli- placed for adoption;
gible for coverage as a Subscriber the day fol- 2. to add a Spouse after marriage;
lowing the date you complete the waiting period
established by your Employer. Your spouse and 3. to add yourself and Spouse following birth
all your dependent children are eligible at the of a newborn or placement of a child for
same time. adoption;
When you decline coverage for yourself or your 4. to add yourself and Spouse after marriage;
Dependents during the initial enrollment period
and later request enrollment, you and your De- 5. to add yourself and your newborn or child
pendents will be considered to be Late Enrol- placed for adoption, following birth or
lees. When Late Enrollees decline enrollment placement for adoption.
during the initial enrollment period they will be
Coverage is never automatic; an application is
eligible the earlier of 12 months from the date of
always required.
the request for enrollment or at the Employer’s
next open enrollment period and shall be subject If a husband and wife are both eligible to be
to a 6-month Pre-Existing Condition exclusion. Subscribers, children may be eligible and may
Blue Shield will not consider applications for be enrolled as a Dependent of either parent, but
earlier effective dates. not both.
-19-
Enrolled dependent children who would nor- Pre-Existing Condition exclusion. Blue Shield
mally lose their eligibility under this plan solely will not consider applications for earlier effec-
because of age, but who are Physically Handi- tive dates.
capped or Mentally Retarded, may have their
eligibility extended under the following condi- If you declined coverage for yourself and your
tions: (1) the child must be chiefly dependent Dependents during the initial enrollment period
upon the Employee for support and mainte- because you were covered under another em-
nance, and (2) the Employee must submit a ployer health plan, and subsequently lost cover-
Physician's written certification of Mental Re- age under that plan, you will not be considered a
tardation or Physical Handicap within 31 days Late Enrollee. Coverage for you and your De-
of the request for information by the Employer pendents under this Plan becomes effective on
or by Blue Shield. Proof of continuing disabil- the date of loss of coverage, provided you re-
ity and dependency must be submitted by the quest enrollment in this Plan within 31 days of
Employee 6 months later and annually thereaf- the date of loss of coverage. You will be re-
ter. quired to furnish Blue Shield of California
written evidence of loss of coverage.
Subject to the requirements described under the
Continuation of Group Coverage provision in If you declined coverage for yourself and your
this booklet, if applicable, an Employee and his Dependents during the initial enrollment period
or her Dependents will be eligible to continue because your Dependents were covered under
group coverage under this plan when coverage another employer health plan, and your De-
would otherwise terminate. pendents have lost that coverage, you will not
be considered a Late Enrollee. You and your
Dependents may apply for enrollment within 31
EFFECTIVE DATE OF COVERAGE days from the date of loss of coverage. Cover-
age under this plan will be effective on the date
Your coverage will become effective at 12:01 of loss of coverage. You will be required to
a.m. Pacific Time on the eligibility date estab- furnish Blue Shield of California written evi-
lished by your Employer. You become eligible dence of loss of coverage.
when you submit a written application on the
form furnished by Blue Shield within 31 days of If you declined enrollment during the initial en-
that date. If you enroll during the initial enroll- rollment period and subsequently acquire De-
ment period, you will become eligible on your pendents as a result of marriage, birth, or
eligibility date. placement for adoption, you may request en-
rollment for yourself and your Dependents
If, during the initial enrollment period, you have within 31 days from the date of marriage, birth,
included your eligible Dependents on your ap- or placement for adoption. The effective date of
plication to Blue Shield, their coverage will be enrollment for both you and your Dependents
effective on the same date as yours. If applica- will depend on how you acquire your Depend-
tion is made for Dependent coverage within 31 ent(s):
days after you become eligible, their effective
date of coverage will be the same as yours. 1. For marriage, the effective date will be the
first day of the first month following receipt
If you or your Dependent is a Late Enrollee, of your request for enrollment;
your coverage will become effective the earlier
of 12 months from the date of request for en- 2. For birth, the effective date will be the date
rollment or at the Employer’s next open enroll- of birth;
ment period and shall be subject to a 6-month
3. For a child placed for adoption, the effective
date will be the date the Subscriber or
-20-
Spouse has the right to control the child’s of request for reinstatement or at the Employer’s
health care. next open enrollment period.
Once each calendar year, your employer may If this plan provides benefits within 60 days of
designate a time period as an annual open en- the date of discontinuance of the previous group
rollment period. During that time period, you health plan that was in effect with your Em-
and your dependents may transfer from another ployer;
health plan sponsored by your employer to the
Preferred Plan. A completed enrollment form 1. you and all your Dependents who were val-
must be forwarded to Blue Shield within the idly covered under the previous group health
open enrollment period. Enrollment becomes plan on the date of discontinuance, will be
effective on the anniversary date of this Plan eligible under this plan except that,
following the annual open enrollment period.
2. if you or your Dependents were enrolled in
Any individual who becomes eligible at a time the previous group health plan for less than
other than during the annual open enrollment 6 months and were Totally Disabled on the
(e.g., newborn, child placed for adoption, new date of discontinuance of the previous group
spouse, newly hired or newly transferred em- health plan and were entitled to an extension
ployees) must complete an enrollment form of benefits under Section 1399.62 of the
within 31 days of becoming eligible. California Health and Safety Code or Sec-
tion 10128.2 of the California Insurance
Coverage for a newborn child will become ef- Code, you or your Dependents will not be
fective on the date of birth. Coverage for a entitled to any benefits under this plan for
child placed for adoption is effective the date Services or expenses directly related to any
the Subscriber or spouse has the right to control condition which caused such Total Disabil-
the child's health care. Evidence of such control ity for a period not to exceed 6 months. Blue
includes a health facility minor release report, a Shield will credit the time you or your De-
medical authorization form or a relinquishment pendents were covered under the prior
form. In order to have coverage continue be- Creditable Coverage toward this plan’s Pre-
yond the first 31 days without lapse, a written existing Condition exclusion.
application must be submitted to and received
by Blue Shield prior to 31 days from the date of
birth or placement for adoption of such Depend- RENEWAL OF GROUP HEALTH
ent. A dependent spouse becomes eligible on SERVICE CONTRACT
the date of marriage.
Blue Shield of California will offer to renew the
If a court has ordered that you provide coverage Group Health Service Contract except in the
for your spouse or Dependent child, under your following instances:
health benefit plan, their coverage will become
effective within 31 days of presentation of a 1. non-payment of dues;
court order by the district attorney, or upon 2. fraud, misrepresentations or omissions;
presentation of a court order or request by a
custodial party, as described in Section 3751.5 3. failure to comply with Blue Shield's appli-
of the Family Code. cable eligibility, participation or contribu-
tion rules;
If you or your Dependents voluntarily discon-
tinued coverage under this plan and later request 4. termination of plan type by Blue Shield;
reinstatement, you or your Dependents will be
covered the earlier of 12 months from the date 5. Employer moves out of the service area;
-21-
6. association membership ceases. c. not furnished primarily for the conven-
ience of the patient, the attending Physi-
All groups will renew subject to the above. cian or other provider; and
d. furnished at the most appropriate level
PREPAYMENT FEE which can be provided safely and effec-
1. The monthly dues for you and your Depend- tively to the patient.
ents are indicated in your employer’s group 2. Hospital Inpatient Services which are medi-
contract. The initial dues are payable on the cally necessary include only those Services
effective date of this health plan, and subse- which satisfy the above requirements, re-
quent dues are payable on the same date of quire the acute bed-patient (overnight) set-
each succeeding month. Dues are payable in ting, and which could not have been pro-
full on each transmittal date and must be vided in the Physician's office, the
made for all Subscribers and Dependents. Outpatient department of a Hospital, or in
2. All dues required for coverage for you and another lesser facility without adversely af-
your Dependents will be handled through fecting the patient's condition or the quality
your Employer, and must be paid to Blue of medical care rendered. Inpatient Services
Shield of California. Payment of dues will not medically necessary include hospitaliza-
continue the benefits of this health plan up tion:
to the date immediately before the next a. for diagnostic studies that could have
transmittal date, but not after. been provided on an Outpatient basis;
b. for medical observation or evaluation;
PLAN CHANGES
c. for personal comfort;
The benefits of this plan are subject to change
following at least 30 days' written notice by d. in a pain management center to treat or
Blue Shield. Benefits for Services or supplies cure chronic pain; and
furnished on or after the effective date of any e. for Inpatient Rehabilitation or Rehabili-
change in benefits will be provided based on the tative Care that can be provided on an
change. Outpatient basis.
3. Blue Shield of California reserves the right
MEDICAL NECESSITY to review all claims to determine whether
Services are medically necessary, and may
The benefits of this plan are provided only for
use the services of Physician consultants,
Services which are medically necessary.
peer review committees of professional so-
1. Services which are medically necessary in- cieties or Hospitals, and other consultants.
clude only those which have been estab-
lished as safe and effective, are furnished UTILIZATION REVIEW
under generally accepted professional stan-
dards to treat illness, injury or medical con- State law requires that health plans disclose to
dition, and which, as determined by Blue Subscribers and health plan providers the proc-
Shield, are: ess used to authorize or deny health care serv-
a. consistent with Blue Shield of California ices under the plan.
medical policy; Blue Shield has completed documentation of
b. consistent with the symptoms or diagno- this process (“Utilization Review”), as required
sis;
-22-
under Section 1363.5 of the California Health Lifepath Advisers includes a nurseline (see
and Safety Code. Principal Benefits & Coverages, the Preventive
Care Benefits section).
To request a copy of the document describing
this Utilization Review process, call the Cus-
tomer Service Department at the number listed BLUE SHIELD ONLINE
in the back of this booklet.
Blue Shield’s Internet site is located at
http://www.mylifepath.com. Members with
SECOND MEDICAL OPINION POLICY Internet access and a Web browser may view
and download healthcare information.
If you have a question about your diagnosis or
believe that additional information concerning
your condition would be helpful in determining BENEFITS MANAGEMENT PROGRAM
the most appropriate plan of treatment, you may
make an appointment with another physician for Blue Shield has established the Benefits Man-
a second medical opinion. Your attending phy- agement Program to assist you, your Depend-
sician may also offer to refer you to another ents or provider in identifying the most appro-
physician for a second opinion. priate and cost-effective course of treatment for
which benefits will be provided under this
Remember that the second opinion visit is sub- health plan and for determining whether the
ject to all Plan contract benefit limitations and services are medically necessary. However,
exclusions. Additionally, please see the section you, your Dependents and provider make the fi-
on "Your Blue Shield of California Preferred nal decision concerning treatment. The Benefits
Plan and How to Use It" regarding advantages Management Program includes preservice re-
of selecting a Preferred Physician for these view; prior authorization for certain Services;
services. preadmission review (except for emergency
admissions), emergency admission notification
(for emergency admissions), hospital inpatient
HEALTH EDUCATION AND utilization review; discharge planning; and care
HEALTH PROMOTION SERVICES management if determined to be applicable and
appropriate by Blue Shield. Certain portions
Health education and health promotion services of the Benefits Management Program also
provided by Blue Shield’s Center for Health contain Additional and Reduced Payment
Improvement offer a variety of wellness re- requirements for either not contacting Blue
sources including, but not limited to: a member Shield or not following Blue Shield’s recom-
newsletter and a prenatal health education pro- mendations and may also result in non-
gram. payment if Blue Shield determines the service
was not a covered Service. Please read the
LIFEPATH ADVISERS following sections thoroughly so you under-
stand your responsibilities in reference to the
Blue Shield of California's Lifepath Advisers Benefits Management Program. Remember
provides Persons with no charge, confidential, that all provisions of the Benefit Management
unlimited telephone support for information, Program also apply to your Dependents.
consultations, and referrals for health issues.
Persons may obtain these services by calling Blue Shield requires preservice review for
1-866-543-3728, a 24-hour, toll-free telephone selected Inpatient and Outpatient Services,
number. There is no charge for these services. supplies and Home Medical Equipment;
prior authorization for all home health care,
-23-
home infusion/ home injectable services, and plants originally provided for cosmetic
PKU related formulas and Special Food augmentation are not covered;
Products; prior authorization for admission
into an approved Hospice Program; prior 3. Arthroscopic surgery of the temporoman-
authorization for certain radiology proce- dibular joint (TMJ).
dures; preadmission review for all Inpatient
Note: it is to your advantage to contact Blue
Hospital Services (except for Emergency
Shield for preservice review to determine
Services) and notification for Inpatient
whether services are medically necessary and
Emergency Services. In these situations, you
whether they are covered services under your
or your provider need to call Blue Shield as
plan.
described in the following sections. By ob-
taining preservice review or prior authorization
for certain Services or preadmission review PRIOR AUTHORIZATION
prior to receiving Services, you and your pro-
Before Services are provided, you or your pro-
vider will know: whether: (1) Blue Shield con-
vider can determine whether a Procedure or
siders the proposed treatment medically neces-
treatment program is covered and may also re-
sary, (2) if plan benefits will be provided for the
ceive a recommendation for an alternative
proposed treatment, and (3) if the proposed set-
Service.
ting is the most appropriate as determined by
Blue Shield. You and your provider are in- Blue Shield requires prior authorization for
formed about Services that could be performed the following Services:
on an Outpatient basis in a Hospital or Outpa-
tient Facility. 1. Home Health Care, Home Infu-
sion/Injectable Care and PKU related for-
PRESERVICE REVIEW mulas and Special Food Products.
Before Services are provided, you and your pro- Call 1-800-343-1691 for prior authorization
vider can learn whether a procedure or treatment for these services.
program is covered by calling Blue Shield at Failure to receive Prior Authorization or to
1-800-343-1691. follow the recommendations of Blue Shield
Examples of Services for which Blue Shield of for Home Health Care and Home Infu-
California recommends that you or your pro- sion/Injectable Care services may result in
vider contact Blue Shield are: non-payment if the service is determined not
to be a covered Service.
1. Home Medical Equipment, such as motor-
ized wheelchairs, insulin infusion pumps, Failure to receive Prior Authorization or to
and CPAP (Continuous Positive Air Pres- follow the recommendations of Blue Shield
sure) machines; for covered, Medically Necessary enteral
formulas and Special Food Products for the
2. Surgery which may be considered to be treatment of phenylketonuria (PKU) will re-
Cosmetic in nature rather than Reconstruc- sult in a 50% reduction in the amount pay-
tive (e.g., eyelid surgery, rhinoplasty or able by Blue Shield after the calculation of
breast reduction) and those Reconstructive the deductible and any applicable copay-
Surgeries which may result in only minimal ments required by this plan. You will be re-
improvement. Reconstructive Surgeries sponsible for the applicable deductibles
which may result in only minimal improve- and/or copayments and the additional 50% of
ment in function or appearance, Cosmetic the charges that are payable under this plan.
Surgeries and reimplantation of breast im- The additional 50% responsibility will not be
-24-
included in the calculation of the Subscriber’s 3. Admission into an approved Hospice Pro-
Maximum Calendar Year Copayment re- gram as specified under Hospice Program
sponsibility. Services in the Covered Services section.
2. The following radiological procedures when Call 1-800-343-1691 for information on re-
performed in an outpatient setting on a non- questing admission to a Hospice Program.
emergency basis:
Failure to receive Prior Authorization for
CT (Computerized Tomography) scans, hospice services or to follow the recommen-
MRI’s (Magnetic Resonance Imaging), dations of Blue Shield will result in non-
MRA’s (Magnetic Resonance Angiogra- payment of services by Blue Shield.
phy), PET (Positron Emission Tomography)
Scans, Bone Densitometry testing and any 4. Clinical Trial for Cancer.
cardiac diagnostic procedure utilizing Nu-
Persons who have been accepted into an ap-
clear Medicine.
proved clinical trial for cancer as defined
Call 1-888-642-2583 for prior authorization under the Covered Services section must
for these services. obtain prior authorization from Blue Shield
in order for the routine patient care delivered
Failure to receive prior authorization for in a clinical trial to be covered.
these services or to follow the recommenda-
tions of Blue Shield will result in reduced Call 1-800-343-1691 for prior authorization
payment amounts per procedure and non- for these services.
payment for procedures which are deter-
Failure to receive Prior Authorization for a
mined not to be covered services.
clinical trial for cancer will result in non-
♦ For covered services that are not author- payment of services by Blue Shield.
ized in advance, the amount payable will NOTE: Blue Shield will render a decision on
be reduced by 50% after the calculation all requests for pre-service review, prior
of the deductible and any applicable authorization and pre-admission review
copayments required by this plan. You within 5 business days from receipt of the re-
will be responsible for the remaining 50% quest. The treating provider will be notified
and applicable deductible and/or copay- of the decision within 24 hours followed by
ments. This additional 50% responsibility written notice to the provider and Subscriber
will not be included in the calculation of within 2 business days of the decision. For
the subscriber’s maximum calendar year urgent services in situations in which the rou-
copayment responsibility; tine decision making process might seriously
♦ For services provided by a Non-Preferred jeopardize the life or health of a Person or
Provider, the subscriber will also be re- when the Person is experiencing severe pain,
sponsible for all charges in excess of the Blue Shield will respond within 72 hours
allowable amount. from receipt of the request.
Prior Authorization is not required for these PREADMISSION REVIEW –
radiological services when obtained outside HOSPITAL ADMISSIONS
of California. See the "Out-Of-Area Pro-
gram: The BlueCard" section of this booklet Preadmission Review must be used for all Hos-
for an explanation of how payment is made pital admissions (except for Admissions re-
for out of state services. quired for Emergency Services). Included are
Hospitalizations for continuing Inpatient Reha-
-25-
bilitation or Rehabilitative Care. Whenever a *Only one $250 Additional Payment will ap-
Hospital admission is recommended by your ply per Hospital admission for failure to no-
Physician, you or your Physician must con- tify Blue Shield or to follow a recommenda-
tact Blue Shield’s Medical Management Unit tion of Medical Management. These
at 1-800-343-1691 at least 5 business days Additional Payments will be required in ad-
prior to the admission. However, in case of dition to any applicable Calendar Year de-
an admission for Emergency Services, Blue ductible, copayment and amounts in excess of
Shield should receive Emergency Admission benefit dollar maximums specified and will
Notification within 24 hours or by the end of not be included in the calculation of the Sub-
the first business day following the admis- scriber’s Maximum Calendar Year Copay-
sion. Medical Management will discuss the ment responsibility.
benefits available, review the medical informa-
tion provided and may recommend that to ob- EMERGENCY ADMISSION NOTIFICATION
tain the full benefits of this health plan that the
services be performed on an Outpatient basis. If you are admitted for Emergency Services,
Blue Shield should receive Emergency Admis-
Examples of procedures that may be recom- sion Notification within 24 hours or by the end
mended to be performed on an Outpatient basis of the first business day following the admis-
if medical conditions do not indicate Inpatient sion, or as soon as it is reasonably possible to do
care include: so, whichever is later or you may be responsi-
1. Biopsy of lymph node, deep axillary; ble for the Additional Payment as described un-
der the Preadmission Review-Hospital Admis-
2. Hernia repair, inguinal; sions paragraphs of this section.
3. Esophagogastroduodenoscopy with biopsy;
HOSPITAL INPATIENT UTILIZATION
4. Excision of ganglion; REVIEW
5. Repair of tendon; Blue Shield monitors Inpatient stays. The stay
may be extended or reduced as warranted by
6. Heart catheterization; your condition, except in situations of maternity
admissions for which the length of stay is 48
7. Diagnostic bronchoscopy;
hours or less for a normal, vaginal delivery or
8. Creation of arterial venous shunts (for he- 96 hours or less for a Cesarean section unless
modialysis). the attending physician, in consultation with the
mother, determines a shorter hospital length of
Failure to contact medical management as stay is adequate. Also, for mastectomies or
described above or failure to follow the rec- mastectomies with lymph node dissections, the
ommendations of medical management will length of hospital stays will be determined
result in an additional payment per hospital solely by your Physician in consultation with
admission as described below and may also you. When a determination is made that the
result in reduction or non-payment if Blue Person no longer requires the level of care
Shield determines that the admission is not a available only in an Acute Care Hospital, writ-
covered service. ten notification is given to you and your Doctor
of Medicine. You will be responsible for any
♦ *$250 per Hospital admission except for Hospital charges Incurred beyond 24 hours
Hospital Admissions for Inpatient care for of receipt of notification.
diagnosis or treatment of substance abuse.
-26-
DISCHARGE PLANNING satisfied. No more than $3,000 is required of a
family in a Calendar Year. The Calendar Year
If further care at home or in another facility is deductible does not count toward the Maximum
appropriate following discharge from the Hos- Calendar Year Copayment responsibility.
pital, Blue Shield will work with the Physician
and Hospital discharge planners to determine Services Not Subject to the Deductible
whether benefits are available under this plan to
cover such care. The Calendar Year deductible applies to all
covered Services Incurred during a Calendar
CARE MANAGEMENT Year except the following:
The Benefits Management Program may also The Calendar Year deductible does not apply
include care management, which provides as- to:
sistance in making the most efficient use of plan 1. Preventive Care Benefits for the following
benefits. Individual care management may also, Services:
when it is determined to be appropriate through
a Blue Shield of California review, arrange for Annual Health Appraisal Exam Services in-
alternative care benefits in place of prolonged or cluding,
repeated hospitalizations. Such alternative care annual physical examination,
benefits will be available only by mutual con- routine laboratory Services,
sent of all parties and, if approved, will not ex- mammography and Papanicolaou's
ceed the benefit to which you would otherwise test;
have been entitled under this plan. Blue Shield
is not obligated to provide the same or similar Well Baby Care office visits;
alternative care benefits to any other person in the Preventive Care Sigmoidoscopy;
any other instance. The approval of alternative
care benefits will be for a specific period of time 2. Family Planning counseling and consulta-
and will not be construed as a waiver of Blue tion Services;
Shield’s right to thereafter administer this health 3. Preferred Physician office visits, including
plan in strict accordance with its express terms. mammography and Papanicolaou’s test.
However, other covered Services received
DEDUCTIBLE during or in connection with a Preferred
Physician office visit are subject to the Cal-
endar Year deductible;
1. Calendar Year Deductible,
$1,000 per Person 4. Emergency Room Facility Services not re-
sulting in an admission.
After the Calendar Year deductible is satisfied
for those Services to which it applies, benefits
will be provided for covered Services. This de- ADDITIONAL AND REDUCED PAYMENTS
ductible must be made up of charges covered by FOR FAILURE TO USE THE BENEFITS
the plan. Charges in excess of the Allowable
Amount do not apply toward the deductible. The
MANAGEMENT PROGRAM
deductible must be satisfied once during each An Additional Payment of $250 may be re-
Calendar Year by or on behalf of each Person quired in addition to the applicable Calendar
separately, except that the deductible shall be Year payment described above. This Additional
deemed satisfied with respect to the Subscriber Payment will be applicable to Hospital Inpatient
and all of his covered Dependents collectively charges when a Subscriber or Dependent fails to
after the family deductible amount has been follow the procedures described under the Pre-
-27-
admission Review section of the Benefits Man- Maximum Calendar Year Copayment re-
agement Program. sponsibility.
Only one $250 Additional Payment will apply
to each Hospital admission for failure to follow MAXIMUM AGGREGATE PAYMENT
the Benefits Management Program notification AMOUNT
requirements or recommendations.
The maximum aggregate payment amount is
Failure to receive prior authorization for the $2,000,000. Benefits in excess of this amount
radiological procedures listed in the Benefits will not be provided to you or on your behalf.
Management Program section or to follow
the recommendations of Blue Shield will re- This maximum aggregate payment amount is
sult in reduced payment amounts per proce- determined by totaling all Blue Shield benefits
dure and may result in non-payment for pro- provided for you or on your behalf, whether you
cedures which are determined not to be are a Subscriber or a Dependent, while covered
covered Services. under this plan, or any prior or subsequent plan
with Blue Shield.
♦ For covered Services that are not author-
ized in advance, the amount payable will
be reduced by 50% after the calculation PAYMENT
of the deductible and any applicable
copayments required by this plan. You Blue Shield Payment
will be responsible for the remaining 50% and Subscriber Copayment
and applicable deductible and/or copay- Responsibilities for Covered Services
ments. This additional 50% responsibility
will not be included in the calculation of Subject to all requirements of the Benefits Man-
the Subscriber’s Maximum Calendar agement Program as shown in the Summary of
Year Copayment responsibility; Benefits, and after all applicable deductibles
have been satisfied, benefits are provided for
♦ For services provided by a Non-Preferred covered Services as follows:
Provider, the Subscriber will also be re-
sponsible for all charges in excess of the Physician Services
Allowable Amount.
1. Services rendered by a Participating Physi-
Failure to receive Prior Authorization or to cian are paid at 80% of the Allowable
follow the recommendations of Blue Shield Amount. Subscribers are responsible for the
for covered, Medically Necessary enteral remaining 20% of the Allowable Amount.
formulas and Special Food Products for the
treatment of phenylketonuria (PKU) will re- 2. Services rendered by a Non-Participating
sult in a 50% reduction in the amount pay- Physician are paid at 70% of the Allowable
able by Blue Shield after the calculation of Amount. Subscribers are responsible for the
the deductible and any applicable copay- remaining 30% of the Allowable Amount, as
ments required by this plan. You will be re- well as any charges above the Allowable
sponsible for the applicable deductibles Amount.
and/or copayments and the additional 50% of Payment for covered Services is limited to the
the charges that are payable under this plan. lesser of the benefit maximum for Services
The additional 50% responsibility will not be specified under the Covered Services section
included in the calculation of the Subscriber’s of this booklet or the applicable payment for
the Services as specified above.
-28-
Preferred Physicians have agreed to accept Blue Hospital will be less than 24 hours. The
Shield's payment, plus applicable deductibles covered Person or the attending Doctor
and copayments, as payment-in-full for cov- of Medicine must notify Blue Shield of
ered Services. Subscribers are not responsible California within 24 hours or by the end
to Preferred Physicians for payment of covered of the first business day following the
Services, except for applicable deductibles, admission for Emergency Services and
copayments, or amounts in excess of specified make arrangements for the transfer to a
maximums and except as provided under the Preferred Hospital.
Exception for Other Coverage provision. b. For non-Emergency Inpatient and Out-
If the Subscriber or Dependent recovers from a patient Services, benefits are paid at
third party the reasonable value of Services ren- 70% of allowed charges of no more than
dered by a Preferred Physician, the Preferred $600 per Person per day. Subscribers
Physician who rendered such Services is not re- are responsible for the remaining 30% of
quired to accept the amount paid by Blue Shield the $600, as well as all charges in excess
as payment-in-full, but may collect from the of $600.
Subscriber or Dependent the difference, if any,
Benefits for covered Services are substan-
between the amount paid by Blue Shield and the
tially reduced when Services are provided by
amount collected by the Subscriber or Depend-
a Non-Preferred Hospital. To avoid these
ent for such Services.
payment limitations, it is to the Person's ad-
A Physician Member or other Participating Phy- vantage to use Preferred Hospitals. Pre-
sician may seek reimbursement from other third ferred Hospitals accept Blue Shield of Cali-
party payors for the balance of its reasonable fornia's negotiated amount plus the
charges for Services rendered under this plan. applicable deductibles and copayment
amounts as payment-in-full for covered
Hospital Services Services.
1. Rendered by a Preferred Hospital: Additionally, the Person's copayment for
Non-Preferred Hospital Outpatient Services,
Benefits are paid at 80% of the lesser of except for surgery and Emergency Services,
Billed Charges or the negotiated rate. Sub- does not apply toward the Person's maxi-
scribers are responsible for the remaining mum Calendar Year copayment amount.
20%.
Services of Alternate Care Services
2. Rendered by a Non-Preferred Hospital: Providers
a. For Emergency Services or for covered
Alternate Care Services Providers include Home
Services not available in a Preferred
Medical Equipment suppliers, individual certi-
Hospital, subject to Blue Shield's Pre-
fied orthotists, prosthetists and prosthetist-
admission Review and other applicable
orthotists.
requirements, benefits are paid at 80% of
Billed Charges. Subscribers are respon- 1. Services rendered by Participating Alternate
sible for the remaining 20% of Billed Care Services Providers are paid at 80% of
Charges. the Allowable Amount.* Subscribers are re-
If a covered Person is admitted for sponsible for the remaining 20% of the Al-
Emergency Services, he or she should be lowable Amount.
transferred to a Preferred Hospital as 2. Services rendered by Non-Participating Al-
soon as he or she is stable, unless the ternate Care Services Providers are paid at
continued stay in the Non-Preferred 70% of the Allowable Amount.* Subscrib-
-29-
ers are responsible for the remaining 30% of Allowable Amount. Subscribers are respon-
the Allowable Amount, as well as any sible for the remaining 20% of the Allow-
charges above the Allowable Amount. able Amount.
*Note: for all Services covered under the Ortho- 2. Services rendered by Non-Participating
ses Benefit Subscribers have a combined $2,000 Ambulatory Surgery Centers are paid at
per Person per Calendar Year benefit maximum. 70% of the Allowable Amount of no more
This maximum does not apply to Services cov- than $600 per Person per day. Subscribers
ered under the Prosthetic Appliances and Home are responsible for the remaining 30% of the
Medical Equipment Benefits or the Diabetes Allowable Amount, as well as any charges
Care benefit. above the Allowable Amount. (See Covered
Services for Services which are not covered
Services by Participating Home Health when rendered by Non-Participating Provid-
Care and Home Infusion Agencies and ers.)
PKU Related Formulas and Special Food
Benefits are substantially reduced when cov-
Products ered Services are provided by a Non-
1. Services rendered by Participating Home Participating Ambulatory Surgery Center.
Health Care and Home Infusion agencies are To avoid these payment limitations, it is to
paid at 80% of the Allowable Amount. Sub- the Person's advantage to use Participating
scribers are responsible for the remaining Ambulatory Surgery Centers. Participating
20% of the Allowable Amount. Ambulatory Surgery Centers accept Blue
Shield's negotiated rate as payment-in-full
2. Services rendered by Non-Participating for covered Services.
Home Health Care and Home Infusion
agencies are not covered, unless prior Additionally, the Person's copayment for
authorized by Blue Shield.* Non-Participating Ambulatory Surgery Cen-
ter Services does not apply toward the Per-
*If prior authorized by Blue Shield, Non- son's maximum Calendar Year copayment
Participating Providers will be reimbursed at amount.
a rate determined by the agency and Blue
Shield. and the Subscriber copayment will Services by Hospice Agencies
be 20% of the determined rate, the Partici-
pating Provider level 1. Services rendered by Participating Hospice
Agencies are paid as follows:
3. Benefits for Medically Necessary enteral
formulas and Special Food Products for the a. Continuous Home Care provided during
treatment of phenylketonuria (PKU) are paid a Period of Crisis is paid at 80% of the
at 80% of Billed Charges. Subscribers are Allowable Amount. Subscribers are re-
responsible for the remaining 20%. sponsible for the remaining 20% of the
Allowable Amount.
All Home Health Care and Home Infusion
b. General Inpatient care is paid at 80% of
Services and PKU Related Formulas and
the Allowable Amount. Subscribers are
Special Food Products must be prior author-
responsible for the remaining 20% of the
ized by Blue Shield.
Allowable Amount.
Services by Ambulatory Surgery Centers c. Inpatient Respite Care is paid at 100% of
the Allowable Amount.
1. Services rendered by Participating Ambula-
tory Surgery Centers are paid at 80% of the d. Routine home care is paid at 100% of
the Allowable Amount.
-30-
2. Services rendered by Non-Participating Acupuncture Services
Hospice Agencies are not covered, unless
prior authorized by Blue Shield. Benefits are limited to a maximum of 20 visits.
If Blue Shield prior authorizes Hospice 1. Services rendered by a Preferred Provider
Services from a Non-Participating Hospice are paid at 80% of the Allowable Amount.
Agency, those Hospice Services will be re- Subscribers are responsible for the remain-
imbursed at the Participating Hospice ing 20% of the Allowable Amount.
Agency level, as described in item 1. above
2. Services rendered by a Non- Preferred Pro-
at the payment rates negotiated between
vider are not covered.
Blue Shield and the Non-Participating Hos-
pice Agency.
Chiropractic Services
Note: All Hospice Program Services must be
prior authorized by Blue Shield. See Hospice Benefits are limited to a maximum of 20 visits.
Program Services in the Covered Services sec- 1. Services rendered by a Preferred Provider
tion for a complete description of covered Hos- are paid at 80% of the Allowable Amount.
pice Services and Hospice Program require- Subscribers are responsible for the remain-
ments. ing 20% of the Allowable Amount.
Services by Other Providers 2. Services rendered by a Non- Preferred Pro-
vider are not covered.
Other Providers are paid at 80% of the lesser of
Billed Charges or the amount that Blue Shield Out-of-Area Program: The BlueCard
of California determines was being charged by
the majority of providers of like covered Serv- Benefits will be provided, according to para-
ices and supplies at the time and in the area graphs (1.), (2.) and (3.) below, for covered
where the Services or supplies were provided. Services received outside of California within
Subscribers are responsible for all remaining the United States. Blue Shield of California
amounts. calculates the Subscriber's copayment as a per-
centage of the Allowable Amount, as defined in
Services by Other Providers are benefits only to this booklet. When covered Services are re-
the extent that such Services are covered under ceived in another state, the Subscriber's copay-
the plan. ment will be based on the local Blue Cross Blue
Shield plan's arrangement with its providers.
Radiological Procedures
1. Covered Services received from a provider
The radiological procedures which are listed in who has contracted with the local Blue
the Benefits Management Program section re- Cross Blue Shield plan are paid at the Pre-
quire prior authorization by Blue Shield. Failure ferred level. Subscribers are responsible for
to obtain this authorization will result in the the remaining copayment.
Service being paid at a reduced amount or may
result in non-payment for procedures which are 2. Non-emergency covered Services received
determined not to be covered Services. from providers who have not contracted
with the local Blue Cross Blue Shield plan
See the Benefits Management Program section are paid at the Non-Preferred level of Blue
for complete information. Shield's Allowable Amount. Subscribers are
-31-
responsible for the remaining copayment as directly. You may be asked to pay for your ap-
well as any charges in excess of Blue plicable copayment and plan deductible at the
Shield's Allowable Amount. time you receive the service.
3. Emergency Services received from provid- You will receive an Explanation of Benefits
ers who have not contracted with the local which will show your payment responsibility.
Blue Cross Blue Shield plan are paid at the You are responsible for the copayment and plan
Preferred level of Billed Charges. Subscrib- deductible amounts shown in the Explanation of
ers are responsible for the remaining Benefits.
copayment.
Preadmission review is required for all inpatient
If you do not see a Participating Provider hospital services and notification is required for
through the BlueCard Program, you will have to inpatient emergency services. Preservice review
pay for the entire bill for your medical care and is required for selected inpatient and outpatient
submit a claim form (with a copy of the bill) to services, supplies and home medical equipment.
Blue Shield of California for payment. Blue To receive preadmission or preservice review
Shield will notify you of its determination from Blue Shield of California, the out-of-area
within 30 days after receipt of the claim. Blue provider should call 1-800-343-1691.
Shield will pay you at the Non-Preferred Pro-
vider benefit level. Remember, your copayment If you need Emergency Services, you should
is higher when you see a Non-Preferred Pro- seek immediate care from the nearest medical
vider. You will be responsible for paying the facility. The benefits of this plan will be pro-
entire difference between the amount paid by vided for covered Services received anywhere in
Blue Shield of California and the amount billed. the world for emergency care of an illness or
injury.
Charges for Services which are not covered,
and charges by Non-Preferred Providers in Care for Covered Urgent Care and Emer-
excess of the amount covered by the plan, are gency Services Outside the United States
the Subscriber's responsibility and are not
Benefits will also be provided for covered
included in copayment calculations. Services received outside of the United States
To receive the maximum benefits of your plan, through the BlueCard Worldwide Network. If
please follow the procedure below. you need urgent care while out of the country,
call either the toll-free BlueCard Access number
When you require covered Services while trav- at 1-800-810-2583 or call collect at 1-804-673-
eling outside of California: 1177, 24 hours a day, seven days a week. In an
emergency, go directly to the nearest hospital. If
1. call BlueCard Access at 1-800-810-BLUE your coverage requires precertification or prior
(2583) to locate physicians and hospitals authorization, you should call Blue Shield of
that participate with the local Blue Cross California at 1-800-343-1691. For inpatient
Blue Shield plan; hospital care at participating hospitals, show
your I.D. card to the hospital staff upon arrival.
2. visit the Participating Physician or Hospital
You are responsible for the usual out-of-pocket
and present your membership card.
expenses (non-covered charges, deductibles, and
The Participating Physician or Hospital will copayments).
verify your eligibility and coverage information
When you receive services from a physician,
by calling BlueCard Eligibility at 1-800-676-
you will have to pay the doctor and then submit
BLUE. Once verified and after Services are
a claim. Also for hospitalization, if you do not
provided, a claim is submitted electronically and
use the BlueCard Worldwide Network, you will
the Participating Physician or Hospital is paid
have to pay the entire bill for your medical care
-32-
and submit a claim form (with a copy of the bill) Statutes in a small number of states may require
to Blue Shield of California. the Host Blue to use a basis for calculating Sub-
scriber liability for covered Services that does
Before traveling abroad, call your local Cus- not reflect the entire savings realized, or ex-
tomer Service office for the most current listing pected to be realized, on a particular claim or to
of participating hospitals world-wide wide and add a surcharge. Should any state statutes man-
to obtain a copy of the BlueCard Worldwide date Subscriber liability calculation methods
Network brochure that provides helpful infor- that differ from the usual BlueCard method
mation on receiving covered services in a for- noted above or require a surcharge, Blue Shield
eign country or you can visit Blue Shield’s of California would then calculate your liability
internet site at http://www.mylifepath.com. for any covered health care services in accor-
dance with the applicable state statute in effect
Calculation of your deductibles, copayments
at the time you received your care.
and maximum copayment responsibilities under
the BlueCard Program:
MAXIMUM CALENDAR YEAR
When you obtain health care services through COPAYMENT RESPONSIBILITY
BlueCard outside the geographic area Blue
Shield of California serves, the amount you pay The maximum copayment required each Calen-
for covered services is calculated on the lower dar Year for covered Services by Preferred Pro-
of: viders, and Other Providers is $6,000 per Per-
son, not to exceed $18,000 per family.
1. The billed charges for your covered serv-
ices, or The maximum copayment required each Calen-
dar Year for covered Services by Non-Preferred
2. The negotiated price that the on-site Blue Providers, and Other Providers is $9,000 per
Cross and/or Blue Shield plan (“Host Blue”) Person, not to exceed $27,000 per family.
passes on to us.
The total maximum copayment required each
Often, this "negotiated price" will consist of a Calendar Year for covered Services by any
simple discount which reflects the actual price combination of Preferred Providers, Non-
paid by the Host Blue. But sometimes it is an Preferred Providers and Other Providers is
estimated price that factors into the actual price $9,000 per Person, not to exceed $27,000 per
expected settlements, withholds, any other con- family.
tingent payment arrangements and non-claims
transactions with your health care provider or Once the Subscriber’s Maximum Calendar Year
with a specified group of providers. The nego- Copayment Responsibility has been met, Blue
tiated price may also be billed charges reduced Shield will pay 100% of the Allowable Amount
to reflect an average expected savings with for the Subscriber’s covered Services for the
your health care provider or with a specified remainder of that Calendar Year.
group of providers. The price that reflects aver-
age savings may result in greater variation The following Subscriber financial responsi-
(more or less) from the actual price paid than bilities are not included in the calculation of
will the estimated price. The negotiated price the Maximum Calendar Year Copayment:
will also be adjusted in the future to correct for
1. Preventive Care Benefits Services for the
over- or underestimation of past prices. How-
Annual routine physical exam (includes
ever, the amount you pay is considered a final
eye/ear screening, immunizations, vaccina-
price.
tions);
-33-
2. Well baby care office visits and consulta- procedure for requesting continuity of care from
tions; a terminated provider.
3. Family Planning counseling and consulta- PLEASE READ THE FOLLOWING INFOR-
tion Services; MATION SO YOU WILL KNOW FROM
WHOM OR WHAT GROUP OF PROVIDERS
4. Physician office visits and consultations, HEALTH CARE MAY BE OBTAINED.
specialist visits and consultations;
5. Emergency Room Facility Services not re- PREFERRED PROVIDER BENEFIT
sulting in an admission; FEATURES
6. the Calendar Year deductible; Preferred Providers submit claims for payment
after their services have been received. You or
7. charges by Non-Preferred Providers in ex-
your Non-Preferred Providers also submit
cess of Allowable Amounts;
claims for payment after services have been re-
8. charges in excess of specified benefit maxi- ceived.
mums;
Providers do not receive financial incentives or
9. Non-Preferred Hospital and Professional bonuses from Blue Shield of California.
Services (except for Emergencies);
This plan is most effective and advantageous
10. Non-Preferred Skilled Nursing Facility when the Services of Participating Physicians
Services; and Participating Hospitals are used. You re-
ceive the maximum benefits of the plan when
11. Non-Participating Ambulatory Surgery you select these providers.
Center Services;
You are responsible for a lower copayment per-
12. Additional and Reduced Payments under the
centage when Preferred Providers are seen. Pre-
Benefits Management Program.
ferred Providers include Preferred Physicians,
For those services listed above that do not Participating Alternate Care Services Providers
count toward and are not waived by reaching and Participating Ambulatory Surgery Centers.
a Maximum Calendar Year Copayment re-
Participating Providers and Preferred Providers
sponsibility amount, a Subscriber will con-
have agreed to accept Blue Shield's payment,
tinue to pay for those services after they
plus applicable deductibles and copayments as
reach a Maximum Calendar Year Copay-
payment-in-full for covered Services, except as
ment responsibility amount.
provided under the Exception for Other Cover-
age provision and for amounts in excess of
CONTINUITY OF CARE BY A TERMINATED specified benefit maximums. You are not liable
PROVIDER to these providers for any amounts payable by
Blue Shield for covered Services. Blue Shield
Subscribers who are being treated for acute payment for Services by Non-Preferred Provid-
conditions, serious chronic conditions, high-risk ers generally will be less than payments for the
pregnancies or pregnancies that have reached same Services when provided by a Participating
the second or third trimester can request con- Provider, and could result in substantial addi-
tinuation of covered Services in certain situa- tional out-of-pocket expense. You are responsi-
tions with a provider who is terminated. Contact ble for all balances when Services are rendered
Customer Service to receive information re- by a Non-Preferred Provider.
garding eligibility criteria and the policy and
-34-
You and your Dependent must determine if your PRINCIPAL BENEFITS AND COVERAGES
Physician, Hospital, or other provider is a Par-
ticipating or Preferred Provider. Participating or (COVERED SERVICES)
Preferred Providers are paid directly by Blue Benefits are provided for the following covered
Shield. Services, subject to applicable deductibles,
You are paid directly by Blue Shield if Services copayments and charges in excess of benefit
are rendered by a Non-Preferred Provider. maximums, Preferred Provider provisions,
Payments to you for covered Services are in Benefits Management Program provisions, and
amounts identical to those made directly to pro- other limitations and exclusions.
viders. Requests for payment must be submitted
to Blue Shield within 1 year after the month HOSPITAL BENEFITS
Services were provided. Special claim forms (Other than Hospice Program Services which
are not necessary, but each claim submission is described in a subsequent section.)
must contain your name, home address, group
contract number, Subscriber's number, a copy of Inpatient Services
the provider's billing showing the Services ren- for Treatment of Illness or Injury
dered, dates of treatment and the patient's name.
Blue Shield will notify you of its determination 1. Any accommodation up to the Hospital's
within 30 days after receipt of the claim. established semi-private room rate, or, if
medically necessary as certified by a Doctor
You are not responsible to Participating and of Medicine, the intensive care unit.
Preferred Providers for payment for covered
Services, except for the deductibles, copay- 2. Use of operating room and specialized
ments, and amounts in excess of specified bene- treatment rooms.
fit maximums, and except as provided under the
Exception for Other Coverage provision. 3. In conjunction with a covered delivery, rou-
tine nursery care for a newborn of the Sub-
If you or your Dependent are receiving Services scriber or covered spouse.
from a Participating or Preferred Provider as of
the date that such provider's contract with Blue 4. Surgical supplies, dressings and cast materi-
Shield is terminated, the responsibility of you or als, and anesthetic supplies furnished by the
your Dependent to that provider for Services Hospital.
rendered subsequent to that termination date 5. Physical Medicine - including hydrotherapy
shall be no greater than it was for Services ren- - when furnished by the Hospital, and Reha-
dered immediately prior to that termination date, bilitative Care when furnished by the Hos-
until the first to occur of the following: pital and approved in advance by Blue
1. the date that the Services being rendered by Shield under its Benefits Management Pro-
such provider are completed; gram.
2. the date that Blue Shield makes reasonable 6. Drugs and oxygen.
and medically appropriate provision for the 7. Administration of blood and blood plasma,
assumption of such Services by another Par- including the cost of blood, blood plasma
ticipating or Preferred Provider; and blood processing.
3. the date that coverage for you or your De- 8. X-ray examination and laboratory tests.
pendent is terminated.
-35-
9. Radiation therapy, renal dialysis treatment SKILLED NURSING FACILITIES BENEFITS
and chemotherapy for cancer including (Other than Hospice Program Services which
catheterization, infusion devices, and associ- is described in a subsequent section.)
ated drugs and supplies.
Benefits are provided for confinement in a
10. Use of medical appliances and equipment. Skilled Nursing Facility if necessary in lieu of
Hospital confinement, for the treatment of an
11. Subacute Care. illness or injury, including Subacute Care, up to
12. Inpatient Services including general anes- a benefit maximum of 100 days per Person per
thesia and associated facility charges in con- Calendar Year, except that room and board
nection with dental procedures when hospi- charges in excess of the facility's established
talization is required because of an semi-private room rate are excluded.
underlying medical condition or clinical
status and the Person is under the age of SURGICAL BENEFITS
seven or developmentally disabled regard-
less of age or when the Person’s health is When surgery is performed for the treatment of
compromised and for whom general anes- an illness or injury, benefits are provided for:
thesia is medically necessary regardless of
1. Surgeons (M.D. or D.O.);
age. Excludes dental procedures and serv-
ices of a dentist or oral surgeon. 2. Assistant surgeons;
13. Medically Necessary substance abuse de- 3. Anesthesiologists;
toxification.
4. Consultants — during and after an opera-
Outpatient Services tion;
for Treatment of Illness or Injury
5. Podiatrists.
1. Medically necessary Services provided in
When multiple surgical procedures are per-
the Outpatient Facility of a Hospital.
formed during the same operation, benefits for
2. Outpatient care provided by the admitting the secondary procedure(s) will be determined
Hospital within 24 hours before admission, based on Blue Shield of California Medical
when care is related to the condition for Policy. No benefits are provided for secondary
which Inpatient admission was made. procedures which are incident to, or an integral
part of, the primary procedure.
3. Physical Medicine.
4. Outpatient Services including general anes- AMBULATORY SURGICAL BENEFITS
thesia and associated facility charges in con- The Hospital and surgical benefits of this plan
nection with dental procedures when per- are provided whenever care is rendered in a
formed in the Outpatient Facility of a freestanding ambulatory facility (including a
Hospital because of an underlying medical Physician's office) or a short stay surgical unit,
condition or clinical status and the Person is or Outpatient unit of a Hospital, when those
under the age of seven or developmentally Services are medically necessary as determined
disabled regardless of age or when the Per- by Blue Shield. Ambulatory surgery Services
son’s health is compromised and for whom means surgery which does not require admission
general anesthesia is medically necessary to a Hospital (or similar facility) as a registered
regardless of age. Excludes dental proce- bed patient.
dures and services of a dentist or oral sur-
geon.
-36-
Outpatient Services including general anesthesia 1. One annual Mammography and Papanico-
and associated facility charges in connection laou's Test (Pap test) or other FDA (Food
with dental procedures are covered when per- and Drug Administration) approved cervical
formed in an ambulatory surgery center because cancer screening test for screening purposes.
of an underlying medical condition or clinical
status and the Person is under the age of seven 2. Family planning and consultation Services,
or developmentally disabled regardless of age or including voluntary sterilization (tubal liga-
when the Person’s health is compromised and tion and vasectomy) and elective abortions.
for whom general anesthesia is medically neces- No benefits are provided for contraceptives.
sary regardless of age. Excludes dental proce- Physician office visits for diaphragm fittings
dures and Services of a dentist or oral surgeon. are covered.
3. Colorectal Cancer Screening
MEDICAL BENEFITS
(Other than Preventive Care and Hospice For age 50 and older, benefits are provided
Program Services which are described in a for:
subsequent section.) a. flexible sigmoidoscopy every 5 years,
Benefits are provided for Services of Physicians b. double contrast barium enema every 5 to
for treatment of illness or injury, and for treat- 10 years,
ment of physical complications of a mastec-
tomy, including lymphedemas, including: c. colonoscopy every 10 years.
1. Visits to the office, home, Hospital or 4. For Subscribers and Dependents age 3 and
Skilled Nursing Facility, beginning with the over, Benefits are provided for one Annual
first visit; Health Appraisal Exam in a Calendar Year.
2. Extra time spent when a Physician is de- Annual Health Appraisal Exams include the
tained to treat a Person in critical condition; following Services:
a. annual routine physical examinations;
3. Services of consultants, including those for
second medical opinion consultations; b. routine laboratory Services based on Blue
Shield’s Preventive Health Guidelines.
4. Necessary preoperative treatment; These guidelines are derived from the US
5. Radiotherapy, radium therapy, radioisotope Preventive Services Task Force, Advisory
therapy and X-ray therapy for treatment of Committee on Immunization Practices and
benign and malignant diseases; Centers for Disease Control and Preven-
tion recommendations. Except for routine
6. Treatment of burns; Pap tests or other FDA (Food and Drug
Administration) approved cervical cancer
7. Services in connection with kidney dialysis; screening tests which are covered as indi-
cated in item c. below, routine laboratory
8. Outpatient Physical Medicine Services;
Services include but are not limited to:
9. Allergy testing and treatment. 1) tuberculin test,
PREVENTIVE CARE BENEFITS 2) screening for blood lead levels in
children at risk for lead poisoning, as
Benefits are provided for the following Services determined and prescribed by a
without illness or injury being present: Doctor of Medicine,
-37-
3) venereal disease tests as recom- (Note: certain radiological procedures require
mended in Blue Shield’s Preventive prior authorization by Blue Shield. See the
Health Guidelines, Benefits Management Program section for com-
plete information.)
4) fecal occult blood test (FOBT) for
age 50 and older.
CHEMOTHERAPY BENEFITS
c. pediatric and adult immunizations and
the immunizing agent as recommended Benefits are provided for Chemotherapy for
by the American Academy of Pediatrics cancer, when provided by a Physician in the
and the United States Public Health Hospital, the Physician's office, or the Person's
Service through its U. S. Preventive home. Benefits include catheterization, Physi-
Services Task Force and/or the Advisory cian visits, drugs and solutions, and infusion de-
Committee on Immunization Practices vices and servicing. High-dose chemotherapy
(ACIP) of the Centers for Disease Con- (which requires collection and reinfusion of a
trol (CDC); patient's own blood products as a supportive
measure) is a benefit only when provided in
e. eye and ear screenings to determine the connection with those certain bone marrow
need for eye refractions or audiograms transplant procedures when authorized under the
when provided to a Dependent child Special Transplant Benefits provision.
through 18 years of age;
5. Osteoporosis Screening ACUPUNCTURE BENEFITS
Benefits are provided for osteoporosis Benefits are provided for acupuncture treatment
screening for age 65 and older or 60 and by a Doctor of Medicine (M.D.) or a certificated
older if at increased risk. acupuncturist up to a benefit maximum of 20
visits for each Person during a Calendar Year.
6. Nurseline
As part of Lifepath Advisers, Persons may PROSTHETIC APPLIANCES AND HOME
call a registered nurse via 1-866-543-3728, a MEDICAL EQUIPMENT BENEFITS
24-hour, toll-free number to receive confi-
dential advice and information about minor Benefits are provided for prosthetic appliances,
illnesses and injuries, chronic conditions, e.g., artificial limbs and eyes and their fitting;
fitness, nutrition and other health related Blom-Singer prostheses for speech following a
topics. Services are provided at no charge to laryngectomy; for oxygen and its administra-
the Subscriber. tion; rental of wheelchair, Hospital bed, and
other Home Medical Equipment, except that no
OUTPATIENT OR OUT-OF-HOSPITAL benefits are provided for rental charges in ex-
cess of the purchase cost. Prosthetic devices
X-RAY AND LABORATORY BENEFITS provided to restore and achieve symmetry inci-
Benefits are provided for diagnostic X-ray dent to a mastectomy are covered.
Services, diagnostic examinations, and clinical
Benefits are provided at the most cost effective
laboratory Services, when provided to diagnose
level of care that is consistent with profession-
illness or injury. Routine laboratory services
ally recognized standards of practice. If there
performed as part of a preventive health
are two or more professionally recognized ap-
screening are covered under the Preventive Care
pliances equally appropriate for a condition,
Benefits section.
-38-
benefits will be based on the most cost effective Benefits are provided only for orthotic de-
appliance. Initial fitting and replacement after vices for maintaining normal Activities of
the expected life of the prosthesis is covered. Daily Living. No benefits are provided for
orthotic devices such as knee braces intended
No benefits are provided for wigs for any to provide additional support for recreational
reason, environmental control equipment, or sports activities or for orthopedic shoes
generators, self-help/educational devices or and other supportive devices for the feet. No
any type of speech or language assistance de- benefits are provided for backup or alternate
vices (except as specifically provided), air items.
conditioners, humidifiers, dehumidifiers, air
purifiers, exercise equipment, or any other There is a combined $2,000 per Person per
equipment not primarily medical in nature. Calendar Year maximum on all Orthotic de-
No benefits are provided for backup or alter- vices covered under this benefit. This maxi-
nate items. mum does not apply to Services covered un-
der the Diabetes Care benefit.
Note: See the Diabetes Care section for de-
vices, equipment and supplies for the man- Note: See the Diabetes Care section for de-
agement and treatment of diabetes. vices, equipment and supplies for the man-
agement and treatment of diabetes.
For Persons in a Hospice Program through a
Participating Hospice Agency, medical
equipment and supplies that are reasonable DIABETES CARE
and necessary for the palliation and man- Benefits are provided for the following diabetes
agement of Terminal Illness and related con- care Services and supplies:
ditions are provided by the Hospice Agency.
1. Devices, equipment and supplies for the
ORTHOSES BENEFITS management and treatment of diabetes when
medically necessary.
Benefits are provided for orthotic appliances,
including: a. blood glucose monitors, including those
designed to assist the visually impaired;
1. shoes only when permanently attached to
such appliances; b. Insulin pumps and all related necessary
supplies;
2. special footwear required for foot disfig-
urement which includes, but is not limited c. podiatric devices to prevent or treat dia-
to, foot disfigurement from cerebral palsy, betes-related complications, including
arthritis, polio, spina bifida, and foot disfig- extra-depth orthopedic shoes;
urement caused by accident or develop-
d. visual aids, excluding eyewear, designed
mental disability;
to assist the visually impaired with
3. Medically necessary knee braces for post- proper dosing of Insulin (excluding
operative rehabilitation following ligament video-assisted visual aids);
surgery, instability due to injury, and to re-
e. Diabetic testing supplies (including lan-
duce pain and instability for patients with
cets, lancet puncture devices, and blood
osteo-arthritis;
and urine testing strips and test tablets).
4. initial fitting and replacement after the ex-
2. Diabetes outpatient self-management train-
pected life of the orthosis is covered.
ing, education and medical nutrition therapy
-39-
that is Medically Necessary to enable a Sub- MEDICAL TREATMENT OF THE TEETH, GUMS,
scriber to properly use the devices, equip- OR JAW JOINTS AND JAW BONES BENEFITS
ment and supplies, and any additional out-
patient self-management training, education Benefits are provided for Hospital and profes-
and medical nutrition therapy when directed sional Services provided for conditions of the
or prescribed by the Person’s Physician. teeth, gums or jaw joints and jaw bones, in-
These benefits shall include, but not be lim- cluding adjacent tissues, only to the extent that
ited to, instruction that will enable diabetic they are provided for:
patients and their families to gain an under-
standing of the diabetic disease process, and 1. the treatment of tumors of the gums;
the daily management of diabetic therapy, in
2. the treatment of damage to natural teeth
order to thereby avoid frequent hospitaliza-
caused solely by an accidental injury is lim-
tions and complications. Services will be
ited to Medically Necessary Services until
covered when provided by Physicians, reg-
the Services result in initial, palliative stabi-
istered dieticians or registered nurses who
lization of the Person as determined by the
are certified diabetes educators.
Plan;
PREGNANCY BENEFITS Note: Dental services provided after initial
medical stabilization, prosthodontics, ortho-
Benefits are provided for pregnancy and com- dontia and cosmetic services are not cov-
plications of pregnancy, including prenatal di- ered. This benefit does not include damage
agnosis of genetic disorders of the fetus by to the natural teeth that is not accidental,
means of diagnostic procedures in cases of high- e.g., resulting from chewing or biting.
risk pregnancy, and post-delivery care. No
benefits are provided for Services after termina- 3. medically necessary non-surgical treatment
tion of coverage under this plan unless the Per- (e.g., splint and physical therapy) of Tempo-
son qualifies for an extension of benefits as de- romandibular Joint Syndrome (TMJ);
scribed elsewhere in this booklet.
4. surgical and arthroscopic treatment of TMJ
Note: The Newborns’ and Mothers’ Health if prior history shows conservative medical
Protection Act requires group health plans to treatment has failed; or
provide a minimum hospital stay for the mother
and newborn child of 48 hours after a normal, 5. orthognathic surgery (surgery to reposition
vaginal delivery and 96 hours after a C-section the upper and/or lower jaw) which is medi-
unless the attending physician, in consultation cally necessary to correct a skeletal deform-
with the mother, determines a shorter hospital ity.
length of stay is adequate.
No benefits are provided for:
If the hospital stay is less than 48 hours after a
normal, vaginal delivery or less than 96 hours 1. Services customarily provided by dentists
after a C-section, a follow-up visit for the and oral surgeons, including hospitaliza-
mother and newborn within 48 hours of dis- tion incident thereto;
charge is covered when prescribed by the treat-
2. orthodontia (dental Services to correct ir-
ing physician. This visit shall be provided by a
regularities or malocclusion of the teeth)
licensed health care provider whose scope of
for any reason, including treatment to al-
practice includes postpartum and newborn care.
leviate TMJ;
The treating physician, in consultation with the
mother, shall determine whether this visit shall 3. dental implants (endosteal, subperiosteal
occur at home, the contracted facility, or the or transosteal);
physician’s office.
-40-
4. any procedure (e.g. vestibuloplasty) in- not Medically Necessary pursuant to the treat-
tended to prepare the mouth for dentures ment plan, Blue Shield will notify the Sub-
or for the more comfortable use of den- scriber of this determination and benefits will
tures. not be provided for Services rendered after the
date of the written notification.
RECONSTRUCTIVE SURGERY Note: See the Home Health Care, Home Infu-
Reconstructive Surgery and associated covered sion Care Benefits, and PKU Related For-
Services when determined by Blue Shield to be mulas and Special Food Products and the
Medically Necessary and only to correct or re- Hospice Program Services sections for infor-
pair abnormal structures of the body and which mation on coverage for Outpatient Physical
result in more than a minimal improvement in Medicine Services rendered in the home, in-
function or appearance. In accordance with the cluding visit limits.
Women’s Health & Cancer Rights Act, Recon-
Services provided by a chiropractor are cov-
structive Surgery on either breast provided to
ered under Chiropractic Services.
restore and achieve symmetry incident to a
mastectomy is covered. Any such Services
must be received while the contract is in force SPEECH THERAPY BENEFITS
with respect to the Person. Benefits will be pro-
Outpatient benefits are provided for Speech
vided in accordance with guidelines established
Therapy Services when referred by a Doctor of
by Blue Shield of California and developed in
Medicine and provided by a speech therapist
conjunction with plastic and reconstructive sur-
who holds an American Speech and Hearing
geons.
Association certificate of competence, pursuant
to a written treatment plan for as long as contin-
CHIROPRACTIC SERVICES ued treatment is Medically Necessary, and when
rendered in the provider's office or Outpatient
Benefits are provided for any Medically Neces-
department of a Hospital. Services are provided
sary Chiropractic Services rendered by a chiro-
for the correction of the following:
practor. Benefits are limited to a maximum of
20 visits per Person per Calendar Year. 1. speech impediment caused by documented
illness or injury to the vocal organs, oral
OUTPATIENT PHYSICAL MEDICINE cavity, or auditory canal; or
BENEFITS 2. speech impediment due to:
Benefits are provided for Outpatient Physical a. stroke or injury to the brain;
Medicine provided by a Doctor of Medicine,
Doctor of Osteopathy, registered physical thera- b. corrective surgery for congenital
pist, certified occupational therapist, or certified anomalies; and/or
respiratory therapist, pursuant to a written
c. cerebral palsy.
treatment plan for as long as continued treat-
ment is Medically Necessary and, when ren- Benefits will be provided for medically neces-
dered in the provider's office or Outpatient de- sary Services as long as continued treatment is
partment of a Hospital. Benefits will be Medically Necessary pursuant to the treatment
provided for medically necessary Services as plan. Blue Shield reserves the right to periodi-
long as continued treatment is Medically Neces- cally review the provider’s treatment plan and
sary pursuant to the treatment plan. Blue Shield records. If Blue Shield determines that contin-
reserves the right to periodically review the pro- ued treatment is not Medically Necessary pursu-
vider’s treatment plan and records. If Blue ant to the treatment plan, Blue Shield will notify
Shield determines that continued treatment is the Member of this determination and benefits
-41-
will not be provided for services rendered after Transplant Facility contracting with Blue Shield
the date of the written notification. of California to provide the procedure, or in the
case of Persons accessing this benefit outside of
Except as specified above and as stated under California, the procedure is performed at a
the Home Health Care and Home Infusion Care transplant facility designated by Blue Shield, (2)
benefit and the Hospice Program Services bene- prior authorization is obtained, in writing, from
fit, no benefits are provided for Speech Therapy, Blue Shield's Medical Director and (3) the re-
speech correction, or speech pathology Services. cipient of the transplant is a Subscriber or De-
No benefits are provided for the correction pendent.
of:
Blue Shield of California reserves the right to
1. stammering, stuttering, lisping, tongue review all requests for prior authorization for
thrust, etc., these Special Transplant Benefits, and to make a
decision regarding benefits based on (1) the
2. speech impediments caused by functional
medical circumstances of each Person, and (2)
nervous disorders, or
consistency between the treatment proposed and
3. developmental speech delays. Blue Shield of California medical policy. Fail-
ure to obtain prior written authorization as
Note: See the Home Health Care, Home Infu- described above and/or failure to have the
sion Care Benefits, and PKU Related For- procedure performed at a contracting Special
mulas and Special Food Products and the Transplant Facility will result in denial of
Hospice Program Services sections for infor- claims for this benefit.
mation on coverage for Speech Therapy Serv-
ices rendered in the home, including visit limits. The following procedures are eligible for cover-
age under this provision:
TRANSPLANT BENEFITS 1. Human heart transplants;
Organ Transplants 2. Human lung transplants;
Benefits are provided for Hospital and profes- 3. Human heart and lung transplants in combi-
sional Services provided in connection with nation;
human organ transplants only to the extent that:
4. Human liver transplants;
1. they are provided in connection with the
transplant of a cornea, kidney or skin; and 5. Human kidney and pancreas transplants in
combination (pancreas only transplants are
2. the recipient of such transplant is a Sub- not covered);
scriber or Dependent.
6. Human bone marrow transplants, including
Benefits are provided for Services incident to autologous bone marrow transplantation
obtaining the human organ transplant material (ABMT) or autologous peripheral stem cell
from a living donor or an organ transplant bank transplantation used to support high-dose
and will be charged against the maximum ag- chemotherapy when such treatment is Medi-
gregate payment amount. cally Necessary and is not Experimental or
Investigational;
Special Transplant Benefits 7. Pediatric human small bowel transplants;
Benefits are provided for certain procedures,
8. Pediatric and adult human small bowel and
listed below, only if (1) performed at a Special
liver transplants in combination;
-42-
9. Autologous Chondrocyte Implantation/ 2. Licensed vocational nurse;Physical Medi-
Transplantation. cine, occupational therapy, Speech Therapy
or respiratory therapy, medical social serv-
Benefits are provided for Services incident to ices and nutritional counseling provided in
obtaining the transplant material from a living the home.
donor or an organ transplant bank. Benefits will
be charged against the maximum aggregate 3. Physical -therapist, occupational therapist,
payment amount. speech therapist or respiratory therapist;
4. Certified home health aide in conjunction
HOME HEALTH CARE/HOME INFUSION CARE with the services of 1, 2 or 3 above;
BENEFITS, AND PKU RELATED FORMULAS
AND SPECIAL FOOD PRODUCTS 5. Medical social services provided by a li-
censed medical social worker for consulta-
Benefits are provided for Services of a Partici- tion and evaluation and services of a nutri-
pating Home Health Care or Home Infusion tional counselor.
agency when medically necessary, ordered by
the attending Physician, and included in a writ- Note: For information concerning diabetes self-
ten treatment plan, when prior authorized by management training, see the Diabetes Care
Blue Shield. section.
Benefits are provided only to a Person who is HOME INFUSION/HOME INJECTABLE THERAPY
home-bound and would otherwise require hos- BENEFITS
pitalization (except in the case of benefits for
enteral formulas and Special Food Products that Benefits are provided for home infusion ther-
are Medically Necessary for the treatment of apy, medical supplies, and pharmaceuticals ad-
phenylketonuria [PKU]). Benefits include visits ministered intravenously, when medically nec-
for chemotherapy for cancer, catheterization, essary and prescribed by a Doctor of Medicine.
and associated drugs and supplies. All Services must be prior authorized by Blue
Shield.
Benefits for home health care and home infu-
sion care will be payable up to a maximum Certain injectable medications are subject to
benefit of 100 visits for each Person during a conditions and limitations applicable to other
Calendar Year. For the purpose of this benefit, benefits of this plan. Insulin, insulin syringes
a visit shall be considered a single visit of any and certain Home Self-Administered Injectables
length, except for visits from home health aides are covered under the Outpatient Prescription
for whom a visit of 4 hours or less shall be con- Drug Benefit.
sidered as one visit. NOTE: Services rendered by Non-
Note: See the Hospice Program Services sec- Participating Home Health Care and Home
tion for Services provided when a Person is ad- Infusion Agencies are not covered, unless
mitted into a Hospice Program through a Par- prior authorized by Blue Shield.
ticipating Hospice Agency.
PKU RELATED FORMULAS AND SPECIAL FOOD
Intermittent and part-time visits by a home PRODUCTS
health agency to provide skilled nursing services
Benefits are provided for enteral formulas and
by any of the following professional providers
Special Food Products that are Medically Nec-
are payable subject to applicable deductibles
essary to avert the development of serious
and copayments:
physical or mental disabilities or to promote
1. Registered nurse; normal development or function as a conse-
-43-
quence of phenylketonuria (PKU). All benefits 2. Skilled Nursing Services, certified health
must be prior authorized by Blue Shield and aide services and homemaker services under
must be prescribed and/or ordered by the appro- the supervision of a qualified registered
priate health care professional. nurse.
Other services: physician, hospital, ambu- 3. Bereavement Services.
lance, hemodialysis, home medical equipment,
medical supplies, drugs and medicines when 4. Social Services/Counseling Services with
prescribed and authorized by the attending doc- medical social services provided by a quali-
tor of medicine, and related pharmaceutical and fied social worker. Dietary counseling, by a
laboratory services to the extent benefits would qualified provider, shall also be provided
have been provided had the person remained in when needed.
the hospital will be provided as stated under
5. Medical Direction with the medical director
covered services, and are not subject to the
being also responsible for meeting the gen-
maximum benefit provided under this section.
eral medical needs for the Terminal Illness
of the Person to the extent that these needs
HOSPICE PROGRAM SERVICES are not met by the Person’s other providers.
Benefits are provided for the following Services 6. Volunteer Services.
through a Participating Hospice Agency when
an eligible Person requests admission to and is 7. Short-term Inpatient care arrangements.
formally admitted to an approved Hospice Pro-
gram. The Person must have a Terminal Illness 8. Pharmaceuticals, medical equipment and
as determined by their Physician‘s certification supplies that are reasonable and necessary
and the admission must receive prior approval for the palliation and management of Termi-
from Blue Shield. Covered Services are avail- nal Illness and related conditions.
able on a 24-hour basis to the extent necessary 9. Physical therapy, occupational therapy, and
to meet the needs of individuals for care that is speech-language pathology services for pur-
reasonable and necessary for the palliation and poses of symptom control, or to enable the
management of Terminal Illness and related enrollee to maintain activities of daily living
conditions. Persons can continue to receive cov- and basic functional skills.
ered Services that are not related to the pallia-
tion and management of the Terminal Illness 10. Nursing care Services are covered on a con-
from the appropriate provider. tinuous basis for as much as 24 hours a day
during Periods Of Crisis as necessary to
All of the Services listed below must be re- maintain a Person at home. Hospitalization
ceived through the Participating Hospice is covered when the Interdisciplinary Team
Agency. Note: hospice services provided by a makes the determination that skilled nursing
Non-Participating hospice agency are not care is required at a level that can’t be pro-
covered except in certain circumstances in vided in the home. Either Homemaker
counties in California in which there are no Services or Home Health Aide Services or
Participating Hospice Agencies and only both may be covered on a 24 hour continu-
when prior authorized by Blue Shield. ous basis during Periods Of Crisis but the
care provided during these periods must be
1. Interdisciplinary Team care with develop-
ment and maintenance of an appropriate predominantly nursing care.
Plan of Care and management of Terminal 11. Respite Care Services are limited to an oc-
Illness and related conditions. casional basis and to no more than five con-
secutive days at a time.
-44-
Persons are allowed to change their Participat- HOMEMAKER SERVICES – Services that as-
ing Hospice Agency only once during each Pe- sist in the maintenance of a safe and healthy en-
riod of Care. Persons can receive care for two vironment and Services to enable the Person to
90-day periods followed by an unlimited num- carry out the treatment plan.
ber of 60-day periods. The care continues
through another Period of Care if the Partici- HOSPICE SERVICE OR HOSPICE PRO-
pating Provider recertifies that the Person is GRAM – a specialized form of interdisciplinary
Terminally ill. health care that is designed to provide palliative
care, alleviate the physical, emotional, social
DEFINITIONS: and spiritual discomforts of a Person who is ex-
periencing the last phases of life due to the ex-
BEREAVEMENT SERVICES – Services avail- istence of a Terminal Disease, to provide sup-
able to the immediate surviving family members portive care to the primary caregiver and the
for a period of at least one year after the death family of the hospice patient, and which meets
of the Person. These Services shall include an all of the following criteria:
assessment of the needs of the bereaved family
and the development of a care plan that meets a) Considers the Person and the Person’s fam-
these needs, both prior to, and following the ily in addition to the Person, as the unit of
death of the Person. care.
CONTINUOUS HOME CARE – home care b) Utilizes an Interdisciplinary Team to assess
provided during a Period of Crisis. A minimum the physical, medical, psychological, social
of 8 hours of continuous care, during a 24-hour and spiritual needs of the Person and their
day, beginning and ending at midnight is re- family.
quired. This care could be 4 hours in the morn-
ing and another 4 hours in the evening. Nursing c) Requires the interdisciplinary team to de-
care must be provided for more than half of the velop an overall Plan Of Care and to provide
period of care and must be provided by either a coordinated care which emphasizes suppor-
registered nurse or licensed practical nurse. tive Services, including , but not limited to,
Homemaker Services or Home Health Aide home care, pain control, and short-term In-
Services may be provided to supplement the patient Services. Short-term Inpatient Serv-
nursing care. When fewer than 8 hours of nurs- ices are intended to ensure both continuity
ing care are required, the services are covered as of care and appropriateness of services for
routine home care rather than Continuous Home those Persons who cannot be managed at
Care. home because of acute complications or the
temporary absence of a capable primary
HOME HEALTH AIDE SERVICES – Services caregiver.
providing for the personal care of the Termi-
nally Ill Person and the performance of related d) Provides for the palliative medical treatment
tasks in the Person’s home in accordance with of pain and other symptoms associated with
the Plan Of Care in order to increase the level of a Terminal Disease, but does not provide for
comfort and to maintain personal hygiene and a efforts to cure the disease.
safe, healthy environment for the patient. Home
e) Provides for Bereavement Services follow-
Health Aide Services shall be provided by a per-
ing the Person’s death to assist the family to
son who is certified by the state Department of
cope with social and emotional needs asso-
Health Services as a home health aide pursuant
ciated with the death.
to Chapter 8 of Division 2 of the Health and
Safety Code.
-45-
f) Actively utilizes volunteers in the delivery RESPITE CARE SERVICES – short–term In-
of Hospice Services. patient care provided to the Person only when
necessary to relieve the family members or
g) Provides Services in the Person’s home or other persons caring for the Person.
primary place of residence to the extent ap-
propriate based on the medical needs of the SKILLED NURSING SERVICES – nursing
Person. Services provided by or under the supervision of
a registered nurse under a Plan of Care devel-
h) Is provided through a Participating Hospice. oped by the Interdisciplinary Team and the Per-
son’s provider to the Person and his family that
INTERDISCIPLINARY TEAM – the hospice
pertain to the palliative, supportive services re-
care team that includes, but is not limited to, the
quired by the Person with a Terminal Illness.
Person and their family, a physician and sur-
Skilled Nursing Services include, but are not
geon, a registered nurse, a social worker, a vol-
limited to, Subscriber or Dependent assessment,
unteer, and a spiritual caregiver.
evaluation and case management of the medical
MEDICAL DIRECTION – Services provided nursing needs of the Person, the performance of
by a licensed physician and surgeon who is prescribed medical treatment for pain and
charged with the responsibility of acting as a symptom control, the provision of emotional
consultant to the Interdisciplinary Team, a con- support to both the Person and his family, and
sultant to the Person’s Participating Provider, as the instruction of caregivers in providing per-
requested, with regard to pain and symptom sonal care to the enrollee. Skilled Nursing
management, and liaison with physicians and Services provide for the continuity of Services
surgeons in the community. For purposes of this for the Person and his family and are available
section, the person providing these Services on a 24-hour on-call basis.
shall be referred to as the “medical director”.
SOCIAL SERVICE/COUNSELING SERV-
PERIOD OF CARE – the time when the Par- ICES - those counseling and spiritual Services
ticipating Provider recertifies that the Person that assist the Person and his family to minimize
still needs and remains eligible for hospice care stresses and problems that arise from social,
even if the Person lives longer than one year. A economic, psychological, or spiritual needs by
Period Of Care starts the day the Person begins utilizing appropriate community resources, and
to receive hospice care and ends when the 90 or maximize positive aspects and opportunities for
60- day period has ended. growth.
PERIOD OF CRISIS – a period in which the TERMINAL DISEASE OR TERMINAL ILL-
Person requires continuous care to achieve pal- NESS – a medical condition resulting in a prog-
liation or management of acute medical symp- nosis of life of one year or less, if the disease
toms. follows its natural course.
PLAN OF CARE – a written plan developed by VOLUNTEER SERVICES – services provided
the attending physician and surgeon, the “medi- by trained hospice volunteers who have agreed
cal director” (as defined under “Medical Direc- to provide service under the direction of a hos-
tion”) or physician and surgeon designee, and pice staff member who has been designated by
the Interdisciplinary Team that addresses the the Hospice to provide direction to hospice vol-
needs of a Person and family admitted to the unteers. Hospice volunteers may provide sup-
Hospice Program. The Hospice shall retain port and companionship to the Person and his
overall responsibility for the development and family during the remaining days of the Mem-
maintenance of the Plan of Care and quality of ber’s life and to the surviving family following
Services delivered. the Person’s death.
-46-
AMBULANCE BENEFITS 2. Services other than health care services,
such as travel, housing, companion expenses
Benefits are provided for (1) Medically Neces- and other non-clinical expenses;
sary ambulance services (surface and air) when
used to transport a Person from place of illness 3. Any item or service that is provided solely
or injury to the closest medical facility where to satisfy data collection and analysis needs
appropriate treatment can be received, or (2) and that is not used in the clinical manage-
Medically Necessary ambulance transportation ment of the patient;
from one medical facility to another.
4. Services that, except for the fact that they
are being provided in a clinical trial, are
PODIATRIC SERVICES specifically excluded under the Plan;
Benefits are provided for office visits, surgical 5. Services customarily provided by the re-
procedures, and other covered Services custom- search sponsor free of charge for any enrol-
arily provided by a licensed doctor of podiatric lee in the trial.
medicine.
An approved clinical trial is limited to a trial
CLINICAL TRIAL FOR CANCER that is:
Benefits are provided for routine patient care for 1. Approved by one of the following:
Persons who have been accepted into an ap-
proved clinical trial for cancer when prior a. one of the National Institutes of Health;
authorized by Blue Shield, and: b. the federal Food and Drug Administra-
1. the clinical trial has a therapeutic intent and tion, in the form of an investigational
the Person’s treating Physician determines new drug application;
that participation in the clinical trial has a
c. the United States Department of De-
meaningful potential to benefit the Person
fense;
with a therapeutic intent and;
2. the Person’s treating Physician recommends d. the United States Veterans’ Administra-
participation in the clinical trial; and tion; or
3. the Hospital and/or Physician conducting the 2. Involves a drug that is exempt under federal
clinical trial is a Participating Provider, un- regulations from a new drug application.
less the protocol for the trial is not available
through a Participating Provider. WELL BABY CARE BENEFITS
Services for routine patient care will be paid on Benefits are provided for Services of a Physi-
the same basis and at the same benefit levels as cian for a newborn or Dependent child less than
other covered Services shown in the Summary three years of age of the Subscriber or the cov-
of Benefits. ered spouse, including:
Routine patient care consists of those Services 1. routine newborn care in the Hospital in-
that would otherwise be covered by the Plan if cluding physical examination of the baby
those Services were not provided in connection and counseling with the mother concerning
with an approved clinical trial, but does not in- the baby during the Hospital stay;
clude:
2. office visits;
1. Drugs or devices that have not been ap-
proved by the federal Food and Drug Ad- 3. tuberculin tests;
ministration (FDA);
-47-
4. immunizations and the immunizing agent, as c. surgically implanted hearing devices.
recommended by the American Academy of
Pediatrics and the United States Public MENTAL HEALTH AND SUBSTANCE
Health Service through its U. S. Preventive
ABUSE BENEFITS
Services Task Force and/or the Advisory
Committee on Immunization Practices Your employer has made arrangements for cov-
(ACIP) of the Centers for Disease Control erage of mental health services as required by
(CDC). state law and any covered substance abuse
No benefits are provided for routine cir- services through a separate health plan. Please
cumcision. contact your employer for instructions on how
to obtain these services. If for any reason, the
HEARING AID SERVICES arrangement with that other health plan is ter-
minated or the other plan fails to provide the
1. Benefits are provided for Audiological minimum mental health coverage as required by
Evaluation to measure the extent of hearing California law, your employers' group health
loss and a hearing aid evaluation to deter- service contract with Blue Shield of California
mine the most appropriate make and model will be automatically amended to provide cov-
of hearing aid. erage for these services. In that event, you will
Evaluation is in addition to the $1,000.00 receive notification and an insert to your Evi-
maximum payment every 36 months for the dence of Coverage booklet that will provide the
hearing aid and ancillary equipment. benefits as required by law.
2. Benefits are provided for Hearing Aid, mon-
aural or binaural including ear mold(s), the SUBSTANCE ABUSE BENEFITS
hearing aid instrument, the initial battery, (For Acute Conditions)
cords and other ancillary equipment. Bene- Benefits are provided for Inpatient treatment of
fits include visits for fitting, counseling, ad- substance abuse detoxification rendered in a
justments, repairs, etc. at no charge for a Hospital when confinement is certified by the
one-year period following the provision of a attending Physician as medically necessary by
covered hearing aid. reason of the Person's acute condition. (Note:
2. Benefits are limited to a maximum of for Subscriber copayments for Medically Nec-
$1,000.00 per Person every 36 months for essary Inpatient substance abuse detoxification,
the hearing aid instrument, and ancillary see Hospital Benefits, Inpatient Services for
equipment. Treatment of Illness or Injury.)
3. The following services and supplies are ex-
cluded: PRINCIPAL LIMITATIONS, EXCEPTIONS,
a. purchase of batteries or other ancillary
EXCLUSIONS AND REDUCTIONS
equipment, except those covered under
the terms of the initial hearing aid pur- GENERAL EXCLUSIONS
chase and charges for a hearing aid
which exceed specifications prescribed Unless exceptions to the following are specifi-
for correction of a hearing loss; cally made elsewhere in this booklet, no bene-
fits are provided for services:
b. replacement parts for hearing aids, repair
of hearing aid after the covered one-year 1. for or incident to hospitalization or con-
warranty period and replacement of a finement in a pain management center to
hearing aid more than once in any period treat or cure chronic pain, except as may
of 36 months; be provided through a Participating Hos-
-48-
pice Agency and except as Medically Nec- ARRANGEMENT YOUR EMPLOYER
essary; HAS MADE WITH ANOTHER
HEALTH PLAN TO PROVIDE THESE
2. for Rehabilitation or Rehabilitative Care, BENEFITS);
except for Services for which benefits
have been expressly pre-approved under 8. for hearing aids, except as specifically
the Benefits Management Program, when provided;
services are the result of the following
conditions: psychosocial speech delay in- 9. for routine eye refractions;
cluding delayed language development,
10. for eyeglasses, contact lenses or surgery
mental retardation or dyslexia, syn-
for refractive error (e.g. radial keratot-
dromes associated with diagnosed disor-
omy), except as specifically listed;
ders attributed to perceptual and concep-
tual dysfunctions, and developmental 11. for any type of communicator, voice en-
articulation and language disorders; hancer, voice prosthesis or any other lan-
guage assistive devices, except as specifi-
3. for or incident to services rendered in the
cally listed under Prosthetic Appliances
home or hospitalization or confinement in
and Home Medical Equipment Benefits;
a health facility primarily for rest, Custo-
dial, Maintenance or Domiciliary Care, 12. for routine physical examinations, except
except as provided under the Hospice as specifically listed under Preventive
Program Services (see the Hospice Pro- Care Benefits or for examinations re-
gram Services benefit for exception); quired for licensure, employment, or in-
surance unless the examination is substi-
4. performed in a Hospital by house officers, tuted for the Annual Health Appraisal
residents, interns and others in training;
Exam;
5. performed by a Close Relative or by a
13. for or incident to acupuncture, except as
person who ordinarily resides in the cov-
specifically listed;
ered Person's home;
14. for or incident to Speech Therapy, except
6. for substance abuse care or rehabilitation
as specifically listed under Speech Ther-
on an Inpatient or Outpatient basis ex-
apy Benefits;
cept for the Inpatient treatment of sub-
stance abuse when confinement is certi- 15. for drugs and medicines which cannot be
fied by the attending Physician as lawfully marketed without approval of
medically necessary by reason of the Per- the U.S. Food and Drug Administration
son's acute condition (SEE THE SEC- (the FDA); however, drugs and medicines
TION ENTITLED "MENTAL HEALTH which have received FDA approval for
AND SUBSTANCE ABUSE BENEFITS" marketing for one or more uses will not
FOR INFORMATION REGARDING be denied on the basis that they are being
THE ARRANGEMENT YOUR EM- prescribed for an off-label use if the con-
PLOYER HAS MADE WITH AN- ditions set forth in California Health &
OTHER HEALTH PLAN TO PROVIDE Safety Code, Section 1367.21 have been
THESE BENEFITS); met;
7. for Mental Health (SEE THE SECTION 16. for or incident to vocational, educational,
ENTITLED" MENTAL HEALTH AND recreational, art, dance, music or reading
SUBSTANCE ABUSE BENEFITS" FOR therapy; weight control programs; or ex-
INFORMATION REGARDING THE ercise programs;
-49-
17. for or incident to intersex surgery (trans- agnostic, preventive, periodontic and or-
sexual operations), or any resulting medi- thodontic services; dental implants;
cal complications, except for treatment of braces, crowns, dental orthoses and pros-
medical complications that is medically theses; except as specifically provided un-
necessary; der Medical Treatment of Teeth, Gums,
Jaw Joints or Jaw Bones Benefits and
18. for sexual dysfunctions and sexual inade- Hospital Benefits;
quacies, except as provided for treatment
of organically based conditions; 26. incident to organ transplant, except as
explicitly listed under the Organ Trans-
19. for or incident to Infertility, including but plant Benefit and Special Transplant
not limited to reversal of surgical sterili- Benefit;
zation, in vitro fertilization, or complica-
tions of any such procedures; 27. for Cosmetic Surgery or any resulting
complications, except that benefits are
20. for callus, corn paring or excision and provided for medically necessary Services
toenail trimming except as may be pro- to treat complications of cosmetic surgery
vided through a Participating Hospice (e.g., infections or hemorrhages), when
Agency; treatment (other than surgery) of reviewed and approved by a Blue Shield
chronic conditions of the foot, e.g., weak of California consultant. No benefits will
or fallen arches; flat or pronated foot; be provided for reimplantation of breast
pain or cramp of the foot; for special implants originally provided for cosmetic
footwear required for foot disfigurement, augmentation;
except as specifically listed under Ortho-
ses Benefits and Diabetes Care; bunions; 28. for Reconstructive Surgery, and proce-
or muscle trauma due to exertion; or any dures in situations: 1) where there is an-
type of massage procedure on the foot; other more appropriate surgical proce-
dure that is approved by a Blue Shield
21. which are Experimental or Investiga- physician consultant, or 2) when the sur-
tional in nature, except for Services for gery or procedure offers only a minimal
Persons who have been accepted into an improvement in function or in the ap-
approved clinical trial for cancer as pro- pearance of the enrollees, e.g., spider
vided under Clinical Trial for Cancer; veins;
22. for the treatment of learning disabilities 29. for penile implant devices and surgery,
or behavioral problems; and any related services, except for any
resulting complications and medically
23. hospitalization primarily for X-ray, labo-
necessary Services;
ratory or any other diagnostic studies or
medical observation; 30. in connection with the treatment of a Pre-
existing Condition, except as specifically
24. for dental care or Services incident to the
listed;
treatment, prevention or relief of pain or
dysfunction of the Temporomandibular 31. for patient convenience items such as
Joint and/or muscles of mastication, ex- telephone, television, guest trays, and per-
cept as specifically provided under the sonal hygiene items;
Medical Treatment of Teeth, Gums, Jaw
Joints or Jawbones and Hospital Benefits; 32. for which the Person is not legally obli-
gated to pay, or for Services for which no
25. for or incident to dental care and dental charge is made;
supplies including but not limited to di-
-50-
33. incident to any injury or disease arising MEDICAL NECESSITY EXCLUSION
out of, or in the course of, any employ-
ment for salary, wage or profit if such in- The benefits of this plan are intended only
jury or disease is covered by any worker's for Services that are medically necessary.
compensation law, occupational disease Because a Physician or other provider may
law or similar legislation. However, if prescribe, order, recommend, or approve a
Blue Shield of California provides pay- service or supply does not, in itself, make it
ment for such Services, it will be entitled medically necessary even though it is not spe-
to establish a lien upon such other bene- cifically listed as an exclusion or limitation.
fits up to the amount paid by Blue Shield Blue Shield of California reserves the right to
of California for the treatment of such in- review all claims to determine if a service or
jury or disease; supply is medically necessary. Blue Shield of
California may use the Services of Doctor of
34. in connection with private duty nursing, Medicine consultants, peer review commit-
except as provided under the Home tees of professional societies or Hospitals and
Health Care, Home Infusion Care Bene- other consultants to evaluate claims. Blue
fits and PKU Related Formulas and Spe- Shield of California may limit or exclude
cial Food Products covered Services and benefits for Services which are not necessary.
except as provided through a Participat-
ing Hospice Agency;
PRE-EXISTING CONDITIONS
35. for prescription and non-prescription
Pre-existing Conditions are covered immedi-
food and nutritional supplements, except
ately if you were validly covered under your
as provided under the Home Health Care,
present employer's previous group health plan
Home Infusion Care Benefits, and PKU
when that plan was terminated and are enrolled
Related Formulas and Special Food
on the original effective date of this plan within
Products benefit and except as provided
60 days of the termination of that previous plan,
through a Participating Hospice Agency;
except that:
36. for home testing devices and monitoring
If you or your Dependents were enrolled in the
equipment except for use of the peak flow
previous group health plan for less than 6
monitor for self-management of asthma,
months and were Totally Disabled on the date of
the glucose monitor for self-management
discontinuance of the previous group health plan
of diabetes and the apnea monitor for
and were entitled to an extension of benefits un-
management of newborn’s apnea when
der Section 1399.62 of the California Health and
authorized as home medical equipment;
Safety Code or Section 10128.2 of the Califor-
37. for contraceptives and contraceptive de- nia Insurance Code, you or your Dependents
vices, except as specifically included in the will not be entitled to any benefits under this
Family Planning Services benefit; oral plan for Services or expenses directly related to
contraceptives and diaphragms are ex- any condition which caused such Total Disabil-
cluded; no benefits are provided for con- ity for a period not to exceed 6 months. Blue
traceptive implants. Shield will credit the time you or your Depend-
ents were covered under the prior Creditable
38. for Outpatient prescription drugs. Coverage toward this plan’s Pre-existing Con-
dition exclusion.
See the Grievance Process for information on
filing a grievance, your right to seek If you or any Dependent was not validly cov-
assistance from the Department of Managed ered under your present employer's previous
Health Care, and your rights to independent group health plan, then coverage under this plan
medical review is provided for Pre-existing Conditions only af-
-51-
ter you have been continuously covered for 6 This exclusion is applicable to benefits received
consecutive months, including your present em- from any of the following sources:
ployer's waiting period, if any.
1. Benefits provided under Title XVIII of the
However, if you or your Dependents had prior Social Security Act (commonly known as
Creditable Coverage and you enrolled in this Medicare). If a covered Person receives
plan within 63 days after termination (exclusive Services for which he is entitled to benefits
of any waiting period) of the prior Creditable under Medicare and those Services are also
Coverage or within 180 days (exclusive of the covered under this plan, the benefits of this
waiting period) if your prior Creditable Cover- plan will be provided less the amount paid
age was Employer-sponsored, then Blue Shield under Medicare. Any deductible or copay-
will credit the time you or your Dependents ment requirement of this plan will be waived
were covered under the prior Creditable Cover- when Medicare is primary and the provider
age toward this plan's Pre-existing Condition of Services has accepted Medicare assign-
exclusion. ment. This exclusion for Medicare does not
apply when the Employer is subject to the
To receive credit for your prior Creditable Cov- Medicare Secondary Payer laws and the
erage, submit to Blue Shield a certificate from Employer maintains:
your prior employer, insurer, or health plan
which shows the period of time you were cov- a. an employer group health plan that cov-
ered under the prior Creditable Coverage. If ers Persons entitled to Medicare solely
you are unable to obtain the certificate, you because of end-stage renal disease and
should contact Blue Shield of California's Cus- active Employees or spouses entitled to
tomer Service area for assistance. Medicare by reason of age; and/or
This plan's Pre-existing Condition exclusion b. a large group health plan as defined un-
does not apply to: der the Medicare Secondary Payer laws
that covers Persons entitled to Medicare
1. pregnancy benefits; by reason of disability.
2. newborns or children placed for adoption This paragraph shall also apply to an indi-
who had prior Creditable Coverage within vidual who becomes eligible for Medicare
30 days of the birth or placement for adop- benefits prior to age 65, but who had not en-
tion, who enrolled in this plan within 63 rolled under Medicare on the date that he re-
days of that prior Creditable Coverage (ex- ceived notice from Blue Shield of California
clusive of any waiting period). of eligibility for such enrollment.
2. Any Services, including room and board,
EXCLUSION FOR DUPLICATE COVERAGE provided by any other Federal or State gov-
ernmental agency, or by any Municipality,
In the event that you are covered under this plan
County or other political subdivision except
and are also entitled to benefits under any of the
that this exclusion does not apply to the
conditions listed below, Blue Shield's liability
Medi-Cal program, or Subchapter 19 (com-
for Services (including room and board) pro-
mencing with Section 1396) of Chapter 7 of
vided for the treatment of any one illness or in-
Title 42 of the United States Code or for
jury will be reduced by the amount of benefits
reasonable costs of Services provided to the
paid, or the reasonable value or the amount of
Person at a Veterans' Administration facility
Blue Shield’s fee-for-service payment to the
for a condition unrelated to military Service
provider, whichever is less, of the Services or
or at a Department of Defense facility, pro-
supplies provided without any cost to you, be-
vided the Person is not on active duty.
cause of your entitlement to such other benefits.
-52-
EXCEPTION FOR OTHER COVERAGE vided, calculated in accordance with Cali-
fornia Civil Code section 3040. The lien
Participating Providers and Preferred Providers may be filed with the third party, the third
may seek reimbursement from other third party party's agent or attorney, or the court, unless
payers for the balance of their reasonable otherwise prohibited by law.
charges for Services rendered under this plan.
A covered Person’s failure to comply with 1
through 3, above, shall not in any way act as a
CLAIMS REVIEW
waiver, release, or relinquishment of the rights
Blue Shield of California reserves the right to of Blue Shield.
review all claims to determine if any exclusions
or other limitations apply. Blue Shield of Cali- GENERAL PROVISIONS
fornia may use the Services of Physician con-
sultants, peer review committees of professional
societies or Hospitals and other consultants to COORDINATION OF BENEFITS
evaluate claims.
When a Person who is covered under this group
plan is also covered under another group plan,
REDUCTIONS or selected group, or blanket disability insurance
contract, or any other contractual arrangement
Third-Party Liability — If a covered Person is or any portion of any such arrangement whereby
injured through the act or omission of another the members of a group are entitled to payment
person (a “third party”), Blue Shield of Califor- of or reimbursement for Hospital or medical ex-
nia shall, with respect to Services required as a penses, such Person will not be permitted to
result of that injury, provide the benefits of the make a “profit” on a disability by collecting
plan and have an equitable right to restitution or benefits in excess of actual cost during any Cal-
other available remedy to recover the reasonable endar Year. Instead, payments will be coordi-
costs of the Services provided to the covered nated between the plans in order to provide for
Person paid by Blue Shield on a fee-for-service “allowable expenses” (these are the expenses
basis. that are Incurred for Services and supplies cov-
The covered Person is required to: ered under at least one of the plans involved) up
to the maximum benefit amount payable by
1. Notify Blue Shield in writing of any actual each plan separately.
or potential claim or legal action which such
covered Person anticipates bringing or has If the covered Person is also entitled to benefits
brought against the third party arising from under any of the conditions as outlined under
the alleged acts or omissions causing the the “Exclusion for Duplicate Coverage” provi-
injury or illness, not later than 30 days after sion, benefits received under any such condition
submitting or filing a claim or legal action will not be coordinated with the benefits of this
against the third party; and plan.
2. Agree to fully cooperate with Blue Shield to The following rules determine the order of
execute any forms or documents needed to benefit payments:
assist them in exercising their equitable right When the other plan does not have a coordina-
to restitution or other available remedies; tion of benefits provision it will always provide
and its benefits first. Otherwise, the plan covering
3. Provide Blue Shield with a lien, in the the Person as an Employee will provide its
amount of reasonable costs of benefits pro- benefits before the plan covering the Person as a
Dependent.
-53-
The plan which covers the Person as a Depend- b. if either plan does not have a provision
ent of a Person whose date of birth, (excluding regarding laid-off or retired Employees,
year of birth), occurs earlier in a Calendar Year, which results in each plan determining
will determine its benefits before a plan which its benefits after the other, then para-
covers that Person as a Dependent of a Person graph (a.) above will not apply.
whose date of birth, (excluding year of birth),
occurs later in a Calendar Year. If either plan If this plan is the primary carrier in the case of a
does not have the provisions of this paragraph covered Person, then this plan will provide its
regarding Dependents, which results either in benefits without making any reduction because
each plan determining its benefits before the of benefits available from any other plan, except
other or in each plan determining its benefits that Physician Members and other Participating
after the other, the provisions of this paragraph Providers may collect any difference between
will not apply, and the rule set forth in the plan their Billed Charges and this plan's payment,
which does not have the provisions of this para- from the secondary carrier(s).
graph will determine the order of benefits.
If this plan is the secondary carrier in the order
1. In the case of a claim involving expenses for of payments, and Blue Shield of California is
a dependent child whose parents are sepa- notified that there is a dispute as to which plan
rated or divorced, plans covering the child as is primary, or that the primary plan has not paid
a Dependent will determine their respective within a reasonable period of time, this plan will
benefits in the following order: pay the benefits that would be due as if it were
the primary plan, provided that the covered Per-
First, the plan of the parent with custody of son (1) assigns to Blue Shield of California the
the child; then, if that parent has remarried, right to receive benefits from the other plan to
the plan of the stepparent with custody of the extent of the difference between the benefits
the child; and finally the plan(s) of the par- which Blue Shield of California actually pays
ent(s) without custody of the child. and the amount that Blue Shield of California
would have been obligated to pay as the secon-
2. Regardless of (1.) above, if there is a court
dary plan, (2) agrees to cooperate fully with
decree which otherwise establishes financial
Blue Shield of California in obtaining payment
responsibility for the medical, dental or
of benefits from the other plan, and (3) allows
other health care expenses of the child, then
Blue Shield of California to obtain confirmation
the plan which covers the child as a De-
from the other plan that the benefits which are
pendent of that parent will determine its
claimed have not previously been paid.
benefits before any other plan which covers
the child as a dependent child. If payments which should have been made un-
der this plan in accordance with these provisions
3. If the above rules do not apply, the plan have been made by another plan, Blue Shield
which has covered the Person for the longer may pay to the other plan the amount necessary
period of time will determine its benefits to satisfy the intent of these provisions. This
first, provided that: amount shall be considered as benefits paid un-
der this plan. Blue Shield shall be fully dis-
a. a plan covering a Person as a laid-off or
charged from liability under this plan to the ex-
retired Employee, or as a Dependent of
tent of these payments.
that Person will determine its benefits
after any other plan covering that Person If payments have been made by Blue Shield in
as an Employee, other than a laid-off or excess of the maximum amount of payment
retired Employee, or such Dependent; necessary to satisfy these provisions, Blue
and Shield shall have the right to recover the excess
-54-
from any person or other entity to or with re- son is entitled to benefits if at the time of the
spect to whom such payments were made. qualifying event such Person is entitled to
Medicare. However, if Medicare entitlement
Blue Shield may release to or obtain from any arises after COBRA coverage begins, it will
organization or person any information which cease.
Blue Shield considers necessary for the purpose
of determining the applicability of and imple- Qualifying Event
menting the terms of these provisions or any
provisions of similar purpose of any other plan. A Qualifying Event is defined as a loss of cov-
Any person claiming benefits under this plan erage as a result of any one of the following oc-
shall furnish Blue Shield with such information currences.
as may be necessary to implement these provi-
sions. 1. With respect to the Subscriber:
a. the termination of employment (other
CONTINUATION OF GROUP COVERAGE than by reason of gross misconduct); or
Applicable to Persons when the Subscriber’s b. the reduction of hours of employment to
Employer (Contractholder) is subject to ei- less than the number of hours required
ther Title X of the Consolidated Omnibus for eligibility.
Budget Reconciliation Act (COBRA) as
amended or the California Continuation 2. With respect to the Dependent spouse and
Benefits Replacement Act (Cal-COBRA). Dependent children (children born to or
The Subscriber’s Employer should be con- placed for adoption with the Subscriber
tacted for more information. during a COBRA or Cal-COBRA continua-
tion period may be immediately added as
In accordance with the Consolidated Omnibus Dependents, provided the Contractholder is
Budget Reconciliation Act (COBRA) as properly notified of the birth or placement
amended and the California Continuation Bene- for adoption, and such children are enrolled
fits Replacement Act (Cal-COBRA), a Person within 30 days of the birth or placement for
will be entitled to elect to continue group cover- adoption):
age under this plan if the Person would other-
wise lose coverage because of a Qualifying a. the death of the Subscriber; or
Event that occurs while the contract holder is b. the termination of the Subscriber’s em-
subject to the continuation of group coverage ployment (other than by reason of such
provisions of COBRA or Cal-COBRA. The Subscriber’s gross misconduct); or
benefits under the group continuation of cover-
age will be identical to the benefits that would c. the reduction of the Subscriber’s hours
be provided to the Person if the Qualifying of employment to less than the number
Event had not occurred (including any changes of hours required for eligibility; or
in such coverage).
d. the divorce or legal separation of the
Note: A Person will not be entitled to benefits Subscriber from the Dependent spouse;
under Cal-COBRA if at the time of the qualify- or
ing event such Person is entitled to benefits un-
der Title XVIII of the Social Security Act e. the Subscriber’s entitlement to benefits
(“Medicare”) or is covered under another under Title XVIII of the Social Security
group health plan that provides coverage with- Act (“Medicare”); or
out exclusions or limitations with respect to any f. a Dependent child’s loss of Dependent
Pre-existing condition. Under COBRA, a Per- status under this plan.
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3. For COBRA only, with respect to a Sub- 2. With respect to Cal-COBRA enrollees:
scriber who is covered as a retiree, that re-
tiree’s Dependent spouse and Dependent The Person is responsible for notifying Blue
children, the Employer's filing for reorgani- Shield in writing of the Subscriber’s death
zation under Title XI, United States Code, or Medicare entitlement, of divorce, legal
commencing on or after July 1, 1986. separation or a child’s loss of Dependent
status under this plan. Such notice must be
4. With respect to any of the above, such other given within 60 days of the date of the later
Qualifying Event as may be added to Title X of the Qualifying Event or the date on which
of COBRA or the California Continuation coverage would otherwise terminate under
Benefits Replacement Act (Cal-COBRA). this plan because of a Qualifying Event.
Failure to provide such notice within 60
Notification of a Qualifying Event days will disqualify the Person from receiv-
ing continuation coverage under Cal-
1. With respect to COBRA enrollees: COBRA.
The Person is responsible for notifying the The Employer is responsible for notifying
Employer of divorce, legal separation or a Blue Shield in writing of the Subscriber’s
child’s loss of Dependent status under this termination or reduction of hours of em-
plan, within 60 days of the date of the later ployment within 30 days of the Qualifying
of the Qualifying Event or the date on which Event.
coverage would otherwise terminate under
this plan because of a Qualifying Event. When Blue Shield is notified that a Quali-
fying Event has occurred, Blue Shield will
The Employer is responsible for notifying its inform the Person within 14 days of the Per-
COBRA administrator (or plan administrator son’s right to continue group coverage under
if the Employer does not have a COBRA this plan. The Person must then give Blue
administrator) of the Subscriber’s death, Shield notice in writing of the Person’s
termination or reduction of hours of em- election of continuation coverage within 60
ployment, the Subscriber’s Medicare enti- days of the later of (1) the date of the notice
tlement or the Employer’s filing for reor- of the Person’s right to continue group cov-
ganization under Title XI, United States erage or (2) the date coverage terminates
Code. due to the Qualifying Event. The written
election notice must be delivered to Blue
When the COBRA administrator is notified
Shield by first-class mail or other reliable
that a Qualifying Event has occurred, the
means.
COBRA administrator will inform the Per-
son within 14 days of the Person’s right to If the Person does not notify Blue Shield
continue group coverage under this plan. within 60 days, the Person’s coverage will
The Person must then notify the COBRA terminate on the date the Person would
administrator within 60 days of the later of have lost coverage because of the Quali-
(1) the date of the notice of the Person’s fying Event.
right to continue group coverage or (2) the
date coverage terminates due to the Quali- If this plan replaces a previous group plan
fying Event. that was in effect with the Employer, and the
Person had elected Cal-COBRA continua-
If the Person does not notify the COBRA tion coverage under the previous plan, the
administrator within 60 days, the Per- Person may choose to continue to be cov-
son’s coverage will terminate on the date ered by this plan for the balance of the pe-
the Person would have lost coverage be- riod that the Person could have continued to
cause of the Qualifying Event.
-56-
be covered under the previous plan, pro- period. The Person is responsible for notifying
vided that the Person notify Blue Shield Blue Shield within 30 days of any final determi-
within 30 days of receiving notice of the nation that he or she is no longer disabled.
termination of the previous group plan.
For COBRA and Cal-COBRA enrollees who
Duration and Extension became eligible for COBRA or Cal-COBRA
coverage on or after January 1, 2003:
of Continuation of Group Coverage
Cal-COBRA enrollees who became eligible for
For COBRA or Cal-COBRA enrollees who
Cal-COBRA coverage on or after January 1,
became eligible for COBRA or Cal-COBRA
2003, will be eligible to continue Cal-COBRA
prior to January 1, 2003:
coverage under this plan for up to a maximum
The Person will be entitled to continue group of 36 months regardless of the type of Qualify-
coverage under this plan up to a maximum of 36 ing Event.
months, except when the Subscriber has lost
COBRA enrollees who became eligible for
coverage because of termination or reduction of
COBRA coverage on or after January 1, 2003,
work hours required for eligibility. For these
and who reach the 18-month or 29-month
Subscribers and their Dependents, group cover-
maximum available under COBRA, may elect
age may only be continued for a maximum of
to continue coverage under Cal-COBRA for a
18 months. This 18-month period may be ex-
maximum period of 36 months from the date the
tended to 36 months if a second Qualifying
Person’s continuation coverage began under
Event such as death, divorce, legal separation,
COBRA. If elected, the Cal-COBRA coverage
loss of dependent status or Medicare entitlement
will begin after the COBRA coverage ends.
occurs during the first 18-month period.
Note: COBRA enrollees must exhaust all the
The Person’s 18-month period may also be ex-
COBRA coverage to which they are entitled
tended to 29 months if under the Social Security
before they can become eligible to continue
Act the Person was determined to be disabled on
coverage under Cal-COBRA.
or before the date of termination or reduction in
hours of employment, or is determined to be In no event will continuation of group coverage
disabled under the Social Security Act within under COBRA, Cal-COBRA or a combination
the first 60 days of the initial Qualifying Event of COBRA and Cal-COBRA be extended for
and notification is given to the Employer or more than 3 years from the date the Qualifying
Blue Shield as indicated below before the end of Event has occurred which originally entitled the
the 18-month period (non-disabled eligible Person to continue group coverage under this
family members are also entitled to this 29- plan. However, a Person may qualify for con-
month extension). tinuation of group coverage after COBRA
and/or Cal-COBRA. This coverage is explained
For COBRA enrollees: The Employer must be
under Continuation of Group Coverage After
notified of the Social Security Act determination
COBRA and/or Cal-COBRA.
within 60 days of the date of the determination
letter and before the end of the 18-month period.
The Person is responsible for notifying the Em- Notification Requirements
ployer within 30 days of any final determination The Employer or its COBRA administrator is
that he or she is no longer disabled. responsible for notifying COBRA enrollees of
For Cal-COBRA enrollees: Blue Shield must their right to possibly continue coverage under
be notified of the Social Security Act determi- Cal-COBRA at least 90 calendar days before
nation within 60 days of the date of the determi- their COBRA coverage will end. The COBRA
nation letter and before the end of the 18-month enrollee should contact Blue Shield for more in-
-57-
formation about continuing coverage. If the en- Effective Date
rollee elects to apply for continuation of cover- of the Continuation of Coverage
age under Cal-COBRA, the enrollee must notify
Blue Shield at least 30 days before COBRA The continuation of coverage will begin on the
termination. date the Person’s coverage under this plan
would otherwise terminate due to the occurrence
Payment of Dues of a Qualifying Event and it will continue for up
to the applicable period, provided that coverage
Dues for the Person continuing coverage shall is timely elected and so long as dues are timely
be 102 percent of the applicable group dues rate paid.
if the Person is a COBRA enrollee, or 110 per-
cent of the applicable group dues rate if the Per- Termination
son is a Cal-COBRA enrollee, except for the of Continuation of Group Coverage
Person who is eligible to continue group cover-
age to 29 months because of a Social Security The continuation of group coverage will cease if
disability determination, in which case, the dues any one of the following events occurs prior to
for months 19 through 29 shall be 150 percent the expiration of the applicable period of con-
of the applicable group dues rate. tinuation of group coverage:
1. discontinuance of this group health service
Note: For COBRA enrollees who became eligi-
contract (if the Employer continues to pro-
ble for COBRA coverage on or after January 1,
vide any group benefit plan for employees,
2003, and who are eligible to extend group cov-
the Person may be able to continue coverage
erage under COBRA to 29 months because of a
with another plan);
Social Security disability determination, dues
for Cal-COBRA coverage shall be 110 percent 2. failure to timely and fully pay the amount of
of the applicable group dues rate for months 30 required dues to the COBRA administrator
through 36. or the Employer or to Blue Shield of Cali-
fornia as applicable. Coverage will end as of
If the Person is enrolled in COBRA and is con- the end of the period for which dues were
tributing to the cost of coverage, the Employer paid;
shall be responsible for collecting and submit-
ting all dues contributions to Blue Shield of 3. the Person becomes covered under another
California in the manner and for the period es- group health plan that does not include a
tablished under this plan. Pre-existing Condition exclusion or limita-
tion provision that applies to the Person;
Cal-COBRA enrollees must submit dues di-
rectly to Blue Shield of California. The initial 4. the Person becomes entitled to Medicare;
dues must be paid within 45 days of the date the 5. the Person no longer resides in Blue Shield’s
Person provided written notification to the plan service area;
of the election to continue coverage and be sent
to Blue Shield by first-class mail or other reli- 6. the Person commits fraud or deception in the
able means. The dues payment must equal an use of the Services of this plan.
amount sufficient to pay any required amounts
Continuation of group coverage in accordance
that are due. Failure to submit the correct
with COBRA or Cal-COBRA will not be termi-
amount within the 45-day period will disqualify
nated except as described in this provision. In
the Person from continuation coverage.
no event will coverage extend beyond 36
months.
-58-
CONTINUATION OF GROUP COVERAGE or 102 percent of the applicable age adjusted
AFTER COBRA AND/OR CAL-COBRA group dues rate. For Persons who transfer to
this coverage from Cal-COBRA, dues for this
Certain former Employees and their Dependent coverage shall be 213 percent of the applica-
spouses (including a spouse who is divorced ble group dues rate, or 110 percent of the ap-
from the current Employee/former Employee plicable age adjusted group dues rate. Pay-
and/or a spouse who was married to the Em- ment is due at the time the Employer’s
ployee/former Employee at the time of that Em- payment is due.
ployee/former Employee’s death) may be eligi-
ble to continue group coverage beyond the date Notification Requirements
their COBRA and/or Cal-COBRA coverage
ends. Blue Shield will offer the extended cov- The Employer is solely responsible for notifying
erage to former Employees of employers that former Employees or Dependent spouses (in-
are subject to the existing COBRA or Cal- cluding former spouses as defined above) of the
COBRA, and to the former Employees’ De- availability of the coverage at least 90 calendar
pendent spouses, including divorced or wid- days before COBRA or Cal-COBRA is sched-
owed spouses as defined above. This coverage uled to end. To elect this coverage, the former
is subject to the following conditions: Employee (and/or former spouse) must notify
the plan in writing at least 30 calendar days be-
1. The former Employee worked for the Em- fore COBRA or Cal-COBRA is scheduled to
ployer for the prior 5 years and was 60 years end.
of age or older on the date his/her employ-
ment ended. Termination of Continuation Coverage after
2. The former Employee was eligible for and COBRA and/or Cal-COBRA
elected COBRA and/or Cal-COBRA for This coverage will end automatically on the
himself and his Dependent spouse (a former earliest of the following dates:
spouse, i.e., a divorced or widowed spouse
as defined above, is also eligible for con- 1. the date the former Employee, spouse, or
tinuation of group coverage after COBRA former spouse reaches 65;
and/or Cal-COBRA. The former spouse
2. the date the Employer discontinues this
must elect such coverage by notifying the
Group Health Service Contract and ceases to
plan in writing within 30 calendar days prior
maintain any group health plan for any ac-
to the date that the former spouse’s initial
tive Employees;
COBRA and/or Cal-COBRA benefits are
scheduled to end). 3. the date the former Employee, spouse or
former spouse transfers to another health
Items 1. and 2. above are not applicable to a plan, whether or not the benefits of the other
former spouse electing continuation coverage. health plan are less valuable than those of
If elected, this coverage will begin after the the health plan maintained by the Employer;
COBRA and/or Cal-COBRA coverage ends and 4. the date the former Employee, spouse or
will be administered under the same terms and former spouse becomes entitled to Medi-
conditions as if COBRA and/or Cal-COBRA care;
had remained in force.
5. for a spouse or former spouse, five years
For Persons who transfer to this coverage from the date the spouse’s COBRA or Cal-
from COBRA, dues for this coverage shall be COBRA coverage would end.
213 percent of the applicable group dues rate,
-59-
Availability of Blue Shield of 4. You are covered or eligible for Medicare;
California Individual Conversion Plan
5. You are covered or eligible for Hospital,
Blue Shield’s Individual Conversion Plan de- medical or surgical benefits under state or
scribed below will be available to Persons federal law or under any arrangement of
whose continuation of group coverage is termi- coverage for individuals in a group, whether
nated or expires while covered under this group insured or self-insured; and,
plan.
6. You are covered for similar benefits under
an individual policy or contract.
INDIVIDUAL CONVERSION PLAN
Benefits or rates of an individual conversion
Continued Protection health plan are different from those in your
group plan.
Regardless of age, physical condition or em-
ployment status, you may continue Blue Shield A conversion plan is also available to:
of California protection when you retire, leave
the job or become ineligible for group coverage. 1. Dependents, if the Subscriber dies;
If you have held group coverage for three or 2. Dependents who marry or exceed the maxi-
more consecutive months, you and your en- mum age for Dependent coverage under the
rolled Dependents may apply to transfer to an group plan;
individual conversion plan then being issued by
Blue Shield. 3. Dependents, if the Subscriber enters military
service;
Your Employer is solely responsible for notify-
ing you of the availability, terms and conditions 4. Spouse of a Subscriber if their marriage has
of the individual conversion plan within 15 days been terminated;
of termination of the plan contract.
5. Dependents, when continuation of coverage
An application and first dues payment for the under COBRA and/or Cal-COBRA expires,
individual conversion plan must be received by or is terminated.
Blue Shield of California within 63 days of the
date of termination of your group coverage. When a Dependent reaches the limiting age for
However, if the group contract is replaced by coverage as a Dependent, or if a Dependent be-
your Employer with similar coverage under an- comes ineligible for any of the other reasons
other contract within 15 days, transfer to the in- given above, it is your responsibility to inform
dividual conversion health plan will not be per- Blue Shield. Upon receiving notification, Blue
mitted. You will not be permitted to transfer to Shield of California will offer such Dependent
the individual conversion plan, and coverage an individual conversion plan for purposes of
under the individual conversion plan will end, continuous coverage.
under any of the following circumstances:
EXTENSION OF BENEFITS
1. You failed to pay amounts due the plan;
If a Person becomes Totally Disabled while
2. You were terminated by the plan for good validly covered under this plan and continues to
cause or for fraud or misrepresentation; be Totally Disabled on the date the group con-
3. You knowingly furnished incorrect infor- tract terminates, Blue Shield of California will
mation or otherwise improperly obtained the extend the benefits of this plan, subject to all
benefits of the plan; limitations and restrictions, for covered Services
and supplies directly related to the condition,
-60-
illness or injury causing such Total Disability continuing group coverage. Also see the Indi-
until the first to occur of the following: (1) vidual Conversion Plan provision, and, if appli-
12:01 a.m. on the day following a period of 12 cable, the Continuation of Group Coverage pro-
months from the date coverage terminated; (2) vision in this booklet for information on
the date the covered Person is no longer Totally continuation of coverage.
Disabled; (3) the date on which the covered Per-
son's maximum benefits are reached; (4) the If your employer is subject to the California
date on which a replacement carrier provides Family Rights Act of 1991 and/or the federal
coverage to the Person that is not subject to a Family & Medical Leave Act of 1993, and the
Pre-Existing Condition exclusion. The time the approved leave of absence is for family leave
Person was covered under this plan will apply under the terms of such Act(s), your payment of
toward the replacement plan’s pre-existing con- dues will keep your coverage in force for such
dition exclusion. period of time as specified in such Act(s). Your
employer is solely responsible for notifying you
No extension will be granted unless Blue Shield of the availability and duration of family leaves.
of California receives written certification of
such Total Disability from a licensed Doctor of Blue Shield of California may terminate your
Medicine (M.D.) within 90 days of the date on and your Dependent’s coverage for cause im-
which coverage was terminated, and thereafter mediately upon written notice to you and your
at such reasonable intervals as determined by Employer for the following:
Blue Shield of California.
1. Material information that is false, or misrep-
resented information provided on the en-
TERMINATION OF BENEFITS rollment application or given to your Em-
ployer or Blue Shield of California; see the
Except as specifically provided under the Exten- Cancellation/Rescission for Fraud, Mis-
sion of Benefits provision, and, if applicable, the representations or Omissions provision;
Continuation of Group Coverage provision,
there is no right to receive benefits for Services 2. Permitting use of your Subscriber identifi-
provided following termination of this health cation card by someone other than yourself
plan. or your Dependents to obtain Services;
Coverage for you or your Dependents termi- 3. Obtaining or attempting to obtain Services
nates at 12:01 a.m. Pacific Time on the earliest under the group contract by means of false,
of these dates: (1) the date the group contract is materially misleading, or fraudulent infor-
discontinued, (2) the last day of the month in mation, acts or omissions;
which your status as an Employee terminates,
unless a different date on which you no longer 4. Abusive or disruptive behavior which: (1)
meet the requirements for eligibility has been threatens the life or well-being of Blue
agreed to between Blue Shield and your Em- Shield of California personnel and providers
ployer, (3) the end of the last period for which of Services, or, (2) substantially impairs the
dues are paid, or (4) the date you or your De- ability of Blue Shield of California to ar-
pendents become ineligible. A spouse also be- range for services to the Person, or, (3) sub-
comes ineligible following entry of a final de- stantially impairs the ability of providers of
cree of divorce, annulment or dissolution of Service to furnish Services to the Person or
marriage from the Subscriber. See the “Defini- to other patients.
tions” provision.
If a written application for the addition of a
If you cease work because of retirement, dis- newborn or a child placed for adoption is not
ability, leave of absence, temporary layoff or submitted to and received by Blue Shield within
termination, see your Employer about possibly 31 days following that Dependent's effective
-61-
date of coverage, benefits under this plan will be payment of dues, no benefits will be provided
terminated on the 32nd day at 12:01 a.m. Pacific unless you obtain an Extension of Benefits.
Time.
Misrepresentations or omissions on an applica-
tion or a health statement (if a health statement
REINSTATEMENT, CANCELLATION is required by the Employer) may result in the
AND RESCISSION PROVISIONS cancellation or rescission of this group health
plan. Cancellations are effective on receipt or
Reinstatement on such later date as specified in the cancella-
tion notice.
If you had been making contributions toward
coverage for you and your Dependents and vol- In the event the contract is rescinded or can-
untarily canceled such coverage, you may apply celed, either by Blue Shield of California or
for reinstatement. You or your Dependents your Employer, it is your Employer's responsi-
must wait until the earlier of 12 months from the bility to notify you of the rescission or cancella-
date of application to be reinstated or at the Em- tion.
ployer’s next open enrollment period. Blue
Shield will not consider applications for earlier Right of Cancellation
effective dates.
If you are making any contributions toward
Cancellation Without Cause coverage for yourself or your Dependents, you
may cancel such coverage to be effective at the
This group health plan may be canceled by your end of any period for which dues have been
employer at any time provided written notice is paid.
given to Blue Shield of California to become ef-
fective upon receipt, or on a later date as may be Any dues paid Blue Shield of California for a
specified by the notice. period extending beyond the cancellation date
will be refunded to your Employer. Your Em-
Cancellation for Non-Payment of Dues ployer will be responsible to Blue Shield of
California for unpaid dues prior to the date of
Blue Shield of California may cancel this group cancellation.
health plan for non-payment of dues, after hav-
ing given at least 15 days’ written notice to your Blue Shield of California will honor all claims
Employer, stating when such cancellation will for covered Services provided prior to the ef-
become effective, retroactive to the last day of fective date of cancellation.
the period for which dues are paid.
See the Cancellation and Rescission provision
for termination for misrepresentations or omis-
Cancellation/Rescission for Fraud, sions.
Misrepresentations or Omissions
Blue Shield of California may cancel the group LIABILITY OF SUBSCRIBERS IN THE EVENT OF
contract for fraud or misrepresentation by your NON-PAYMENT BY BLUE SHIELD
Employer, or with respect to coverage of Em-
ployees or Dependents, for fraud or misrepre- In accordance with Blue Shield's established
sentation of the Employee, Dependent, or their policies, and by statute, every contract between
representative. Blue Shield of California and its Participating
Providers and Preferred Providers stipulates that
If you are hospitalized or undergoing treatment the Subscriber shall not be responsible to the
for an ongoing condition and the group contract Participating Provider or Preferred Provider for
is canceled for any reason, including non- compensation for any Services to the extent that
-62-
they are provided in the Subscriber's group con- PLAN INTERPRETATION
tract. When Services are provided by a Partici-
pating Provider or Preferred Provider, the Sub- Blue Shield of California shall have the power
scriber is responsible for applicable deductibles, and discretionary authority to construe and in-
copayments and charges in excess of the benefit terpret the provisions of this plan, to determine
maximums. the benefits of this plan and determine eligibility
to receive benefits under this plan. Blue Shield
If Services are provided by a Non-Preferred of California shall exercise this authority for the
Provider, the Subscriber is responsible for all benefit of all Persons entitled to receive benefits
amounts Blue Shield of California does not pay. under this plan.
When a benefit specifies a benefit maximum
and that benefit maximum has been reached, the CUSTOMER SERVICE
Subscriber is responsible for any charges above
If you have a question about Services, provid-
the benefit maximums.
ers, benefits, how to use this plan, or concerns
regarding the quality of care or access to care
NON-ASSIGNABILITY that you have experienced, you may contact
Blue Shield’s Customer Service Department as
Coverage or any benefits of this plan may not be noted on the last page of this booklet.
assigned without the written consent of Blue
Shield of California. The hearing impaired may contact Blue Shield’s
Customer Service Department through Blue
Possession of a Blue Shield of California ID Shield’s toll-free TTY number, 1-800-241-1823.
card confers no right to Services or other bene-
fits of this plan. To be entitled to Services, the Customer Service can answer many questions
Person must be a Subscriber who has been ac- over the telephone.
cepted by the Employer and enrolled by Blue
Shield of California and who has maintained en- Note: Blue Shield of California has established
rollment under the terms of this plan. a procedure for our Subscribers and Dependents
to request an expedited decision. A Person,
Participating Providers and Preferred Providers Physician, or representative of a Person may
are paid directly by Blue Shield. The Person or request an expedited decision when the routine
the provider of Service may not request that decision making process might seriously
payment be made directly to any other party. jeopardize the life or health of a Person, or when
the Person is experiencing severe pain. Blue
If the Person receives Services from a Non- Shield shall make a decision and notify the
Preferred Provider, payment will be made di-
Person and Physician within 72 hours following
rectly to the Subscriber, and the Subscriber is
the receipt of the request. An expedited
responsible for payment to the Non-Preferred
decision may involve admissions, continued
Provider. The Person or the provider of Service
stay or other healthcare Services. If you would
may not request that the payment be made di-
like additional information regarding the
rectly to the provider of service.
expedited decision process, or if you believe
your particular situation qualifies for an
SERVICES FOR EMERGENCY CARE expedited decision, please contact our Customer
Service Department at the number provided on
The benefits of this plan will be provided for
the last page of this booklet.
covered Services received anywhere in the
world for the emergency care of an illness or
injury.
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GRIEVANCE PROCESS External Independent Medical Review
Blue Shield of California has established an ap- If your appeal involves a claim or services for
peals procedure for receiving, resolving and which coverage was denied by Blue Shield or
tracking Subscribers’ grievances with Blue by a contracting provider in whole or in part on
Shield of California. the grounds that the service is not Medically
Necessary or is experimental/investigational
Subscribers may contact the Customer Service (including the external review available under
Department by telephone, letter or on-line to re- the Friedman-Knowles Experimental Treatment
quest a review of an initial determination con- Act of 1996), you may choose to make a request
cerning a claim or service. Subscribers may to the Department of Managed Health Care to
contact the Plan at the telephone number as have the matter submitted to an independent
noted on the enclosed Supplement. If the tele- agency for external review in accordance with
phone inquiry to Customer Service does not re- California law. You normally must first request
solve the question or issue to the Subscriber’s an appeal from Blue Shield and wait for at least
satisfaction, the Subscriber may request a griev- 30 days before you request external review;
ance at that time, which the Customer Service however, if your matter would qualify for an
Representative will initiate on the Subscriber’s expedited decision as described above or in-
behalf. volves a determination that the requested service
is experimental/investigational, you may imme-
The Subscriber may also initiate a grievance by
diately request an external review following re-
submitting a letter or a completed “Grievance
ceipt of notice of denial. You may initiate this
Form”. The Subscriber may request this Form
review by completing an application for external
from Customer Service. The completed form
review, a copy of which can be obtained by
should be submitted to Customer Service at the
contacting Customer Service. The Department
address as noted on the enclosed Supplement.
of Managed Health Care will review the appli-
The Subscriber may also submit the grievance
cation and, if the request qualifies for external
online by visiting our web site at
review, will select an external review agency
http://www.mylifepath.com.
and have your records submitted to a qualified
Blue Shield will acknowledge receipt of a specialist for an independent determination of
grievance within 5 calendar days. Grievances whether the care is Medically Necessary. You
are resolved within 30 days. The grievance may choose to submit additional records to the
system allows Subscribers to file grievances for external review agency for review. There is no
at least 180 days following any incident or ac- cost to you for this external review. You and
tion that is the subject of the Subscriber’s dis- your physician will receive copies of the opin-
satisfaction. See the previous Customer Service ions of the external review agency. The deci-
section for information on the expedited deci- sion of the external review agency is binding on
sion process. Blue Shield; if the external reviewer determines
that the service is Medically Necessary, Blue
NOTE: If your Employer’s health Plan is gov- Shield will promptly arrange for the service to
erned by the Employee Retirement Income Se- be provided. This external review process is in
curity Act (“ERISA”), you may have the right to addition to any other procedures or remedies
bring a civil action under Section 502(a) of available to you and is completely voluntary on
ERISA if all required reviews of your claim your part; you are not obligated to request ex-
have been completed and your claim has not ternal review. However, failure to participate in
been approved. external review may cause you to give up any
statutory right to pursue legal action against
-64-
Blue Shield regarding the disputed service. For PUBLIC POLICY PARTICIPATION
more information regarding the external review PROCEDURE
process, or to request an application form,
please contact Customer Service. This procedure enables you to participate in es-
tablished public policy of Blue Shield of Cali-
DEPARTMENT OF MANAGED HEALTH fornia. It is not to be used as a substitute for the
CARE REVIEW appeal procedure, complaints, inquiries or re-
quests for information.
The California Department of Managed Health
Care is responsible for regulating health care Public policy means acts performed by a plan or
its Employees and staff to assure the comfort,
service plans. If you have a grievance against
dignity, and convenience of Persons who rely on
your health plan, you should first telephone your
the plan's facilities to provide health care Serv-
health plan at the number provided on the last
ices to them, their families, and the public (Cali-
page of this booklet and use your health plan’s
fornia Health and Safety Code, §1369).
grievance process before contacting the De-
partment. Utilizing this grievance procedure At least one third of the Board of Directors of
does not prohibit any potential legal rights or Blue Shield of California is comprised of Sub-
remedies that may be available to you. If you scribers who are not Employees, providers, sub-
need help with a grievance involving an emer- contractors or group contract brokers and who
gency, a grievance that has not been satisfacto- do not have financial interests in Blue Shield.
rily resolved by your health plan, or a grievance The names of the members of the Board of Di-
that has remained unresolved for more than 30 rectors may be obtained from:
days, you may call the Department for assis-
tance. You may also be eligible for an Inde- Director, Consumer Affairs
pendent Medical Review (IMR). If you are eli- Blue Shield of California
gible for IMR, the IMR process will provide an 50 Beale Street
impartial review of medical decisions made by a San Francisco, CA 94105
health plan related to the medical necessity of a Phone: 1-415-229-5104
proposed service or treatment, coverage deci-
sions for treatments that are experimental or in- Procedure:
vestigational in nature and payment disputes for
emergency or urgent medical services. The 1. Your recommendations, suggestions or
Department also has a toll-free telephone comments should be submitted in writing to
number (1-888-HMO-2219) and a TDD line the Director, Consumer Affairs, at the above
(1-877-688-9891) for the hearing and speech address, who will acknowledge receipt of
impaired. The Department’s Internet Web your letter.
site (http://www.hmohelp.ca.gov) has com-
plaint forms, IMR application forms and in- 2. Your name, address, phone number, Sub-
scriber number and group number should be
structions online.
included with each communication.
In the event that Blue Shield should cancel or
3. The policy issue should be stated so that it
refuse to renew the enrollment for you or your
will be readily understood. Submit all rele-
Dependents and you feel that such action was
vant information and reasons for the policy
due to health or utilization of Benefits, you or
issue with your letter.
your Dependents may request a review by the
Department of Managed Health Care Director. 4. Policy issues will be heard at least quarterly
as agenda items for meetings of the Board of
-65-
Directors. Minutes of Board meetings will the last page of this booklet, or by accessing
reflect decisions on public policy issues that Blue Shield of California’s internet site located
were considered. If you have initiated a at http://www.mylifepath.com and printing a
policy issue, appropriate extracts of the copy.
minutes will be furnished to you within 10
business days after the minutes have been If you are concerned that Blue Shield may have
approved. violated your confidentiality/privacy rights, or
you disagree with a decision we made about ac-
cess to your personal and health information,
CONFIDENTIALITY OF PERSONAL AND you may contact us at:
HEALTH INFORMATION
Correspondence Address:
Blue Shield of California protects the confiden-
tiality/privacy of your personal and health in- Blue Shield of California Privacy Official
formation. Personal and health information in- P.O. Box 272540
cludes both medical information and Chico, CA 95927-2540
individually identifiable information, such as Toll-Free Telephone:
your name, address, telephone number or social
security number. Blue Shield will not disclose 1-888-266-8080
this information without your authorization, ex-
cept as permitted by law. Email Address:
blueshieldca_privacy@blueshieldca.com
A STATEMENT DESCRIBING BLUE SHIELD'S
POLICIES AND PROCEDURES FOR PRESERV-
ING THE CONFIDENTIALITY OF MEDICAL INDEPENDENT CONTRACTORS
RECORDS IS AVAILABLE AND WILL BE FUR- Providers are neither agents nor employees of
NISHED TO YOU UPON REQUEST. Blue the plan but are independent contractors. In no
Shield’s policies and procedures regarding our instance shall the plan be liable for the negli-
confidentiality/privacy practices are contained gence, wrongful acts or omissions of any person
in the “Notice of Privacy Practices”, which you receiving or providing services, including any
may obtain either by calling the Customer physician, hospital, or other provider or their
Service Department at the number provided on employees.
-66-
Blue Shield of California
Vision Plan
The vision benefits provided pursuant to this
Vision Plan Supplement are separate from the
medical benefits provided pursuant to the
Group Health Service Contract. The vision
benefits are not subject to the Group Health
Service Contract's Deductible requirements
nor do they cumulate towards the Maximum
Calendar Year Copayment responsibility.
Further, the Group Health Service Contract's
Individual Conversion Plan and Extension of
Benefits provisions do not apply. Otherwise,
the Group Health Service Contract's general
provisions and exclusions shall apply.
67
INTRODUCTION ELIGIBILITY, EFFECTIVE DATE,
AND TERMINATION PROVISIONS
The vision benefits are designed to reduce the cost
of vision care while promoting quality eye care The date of eligibility, the effective date of bene-
coverage services. In order to reduce costs, respon- fits, and the date of discontinuance of benefits for
sibility is placed on the Subscriber for managing the Subscribers and Dependents follow the same eli-
benefits provided for under this Vision Plan. gibility, effective date, and discontinuance of
benefits provisions of the Group Health Service
The Subscriber is responsible for assuring that the Contract.
eye care professional chosen is a Participating
Provider in order to maximize benefit allowances.
CLAIMS REVIEW
DEFINITIONS Medical Eye Services and Blue Shield of Califor-
nia reserve the right to review all claims to de-
Whenever any of the following terms are capital- termine whether any exclusions or limitations ap-
ized in this Vision Plan, they will have the ply.
meaning below:
Medical Eye Services and Blue Shield of Califor-
Allowed Amount – the Blue Shield of California nia may use the services of physician consultants,
Allowance for covered eye services as de-
peer review committees of professional societies
scribed herein. For Participating Providers,
and other consultants to evaluate claims.
the Allowance agreed upon between Blue
Shield of California and Medical Eye Serv-
ices, Inc. and which Participating Providers BENEFITS
have agreed to accept as payment in full for Blue Shield will pay for covered Services
covered Services as set forth in this Supple- rendered by ECN Participating Providers in full,
ment. except for charges for cosmetic/convenience
ECN — Eye Care Network (ECN) is a California contact lenses and frames which Blue Shield will
corporation which makes available to Blue reimburse up to the Allowed Amounts listed in
Shield its contracting network of Participating the Schedule of Allowances. Subscribers will be
Provider ophthalmologists, optometrists and responsible for charges which exceed the
opticians for the provision of services under Allowed Amount. Charges for frames or unusual
this Vision Plan. lenses, such as oversize, which exceed the
Allowed Amount will be the responsibility of the
MES — Medical Eye Services, Inc. (MES) is a Subscriber.
California corporation which has an agree-
ment with Blue Shield to administer claims on For covered Services rendered by non-
Blue Shield's behalf for eyewear and eye ex- Participating Providers, Blue Shield will pay up
ams covered under this Vision Plan. The to the amounts listed in the Schedule of
MES address is P.O. Box 25208, Santa Ana, Allowances. Subscribers will be responsible for
CA 92799-5208, telephone 1-714-619-4660 all charges in excess of those amounts.
or 1-800-877-6372. Covered Services under this Supplement are
Participating Provider — a licensed ophthal- limited to the following:
mologist, optometrist or optician who has 1. One comprehensive eye examination in a 12
certified his willingness to accept the terms consecutive month period. A comprehensive
and conditions and compensations as payment examination represents a level of service in
in full for covered Services as set forth in this which a general evaluation of the complete
Supplement. visual system is made. The comprehensive
68
services constitute a single service entity but sion, Blue Shield's liability for services
need not be performed at one session. The provided for the treatment of any one ill-
service includes history, general medical ob- ness or injury shall be reduced by the
servation, external and opthalmoscopic exami- amount of benefits paid, or the reasonable
nation, gross visual fields and basic sensori- value or the amount of Blue Shield's fee-
motor examination. It often includes as for-service payment to the provider,
indicated: biomicroscopy, examination for cy- whichever is less, of the services provided
cloplegia or mydriasis, tonometry, and, usu- without any liability for the cost thereof,
ally, determination of the refractive state un- for the treatment of that same illness or in-
less known, or unless the condition of the jury as a result of the Subscriber's entitle-
media precludes this or it is otherwise contra- ment to such other benefits.
indicated, as in presence of trauma or severe
inflammation. This exclusion is applicable to:
2. One pair of lenses in a 24 consecutive month a. any services and supplies provided to
period, or at a 12 month interval if the exami- the Subscriber by any federal or state
nation indicates a prescription change. governmental agency, or by any mu-
nicipality, county, or other political
3. One frame in a 24 consecutive month period. subdivision. However, this paragraph
does not apply to benefits provided un-
4. Medically necessary contact lenses, when re- der Chapters 7 and 8 of Part 3, Division
quired for severe anisometropia, keratoconus 9 of the California Welfare and Institu-
following cataract surgery, or for severe high tions Code ("Medi-Cal"), or Subchap-
myopia, hyperopia or astigmatism. ter 19 (commencing with Section 1396)
of Chapter 7 of Title 42 of the United
5. Contact lenses for cosmetic reasons or for
States Code or for the reasonable costs
convenience when provided in lieu of other
of Services provided to the Subscriber
eyewear once every 24 consecutive months,
at a Veterans Administration facility
or at a 12 month interval if the examination
for a condition unrelated to military
indicates a prescription change.
service or at a Department of Defense
NOTE: A prescription change means any facility, provided the Subscriber is not
of the following: on active duty;
a. A change in prescription of 0.50 diopter b. benefits provided under any other vi-
or more in one or both eyes; sion plan, but only to the extent that
such benefits are provided in the form
b. A shift in axis of astigmatism of 15 de- of vision care services and supplies
grees; or rather than payment of or reimburse-
ment for the cost of such services and
c. A difference in vertical prism greater than supplies.
1 prism diopter
2. Unless exemptions to the following General
GENERAL EXCLUSIONS Exclusions are specifically made elsewhere
in this Supplement, this Vision Plan does
1. Exclusion for Duplicate Coverage. In the not provide benefits for:
event that the Subscriber is both enrolled
under this Vision Plan and entitled to bene- a. orthoptics or vision training, subnormal
fits under any of the conditions described vision aids or non-prescription lenses
in paragraphs (a.) and (b.) of this exclu- for glasses when no prescription change
is indicated;
69
b. coated lenses, no-line bifocal (blended pay, or services and materials for which
type) lenses or oversized lenses exceed- no charge is made to the Subscriber.
ing the allowance for covered lenses;
PAYMENT OF BENEFITS
c. replacement or repair of lost or broken
lenses or frames, except at the normal Prior to service, a Subscriber should obtain a vi-
intervals; sion service report form (Form C-4669), which
must be completed by the Participating Provider
d. any eye examination required by the and submitted directly to MES. (C-4669 forms
employer as a condition of employment;
are available from your group administrator.)
e. medical or surgical treatment of the Participating Providers will accept Blue Shield's
eyes; payment for covered services as payment in full,
except as noted in the Schedule of Allowances.
f. services performed by a Close Relative The Subscriber will be responsible for any differ-
or by an individual who ordinarily re- ence between the amount billed by a Non-
sides in the Subscriber’s or Dependent's Participating Provider and the amount paid by
home; Blue Shield. MES will make payment directly to a
Participating Provider, or to the Subscriber for the
g. services performed incident to any in- services of a Non-Participating Provider, by means
jury or disease arising out of, or in the of a Blue Shield check. A list of Participating
course of, any employment for salary, Providers may be obtained from the Subscriber’s
wage or profit if such injury or disease group administrator or from MES.
is covered by any workers' compensa-
tion law, occupational disease law or Every contract between ECN and its Participating
similar legislation. However, if Blue Providers stipulates that the Subscriber shall not
Shield provides payment for such serv- be responsible to the Participating Provider for
ices, it shall be entitled to establish a compensation with respect to any services to the
lien upon such other benefits up to the extent that they are provided in this Vision Plan.
amount paid by Blue Shield for the When services are provided by a Non-Participating
treatment of the injury or disease; Provider, the Subscriber is responsible for any
amount Blue Shield does not pay, provided how-
h. contact lenses, except as specifically ever that if a Subscriber is receiving services from
provided; a Participating Provider as of the date that such
provider's contract with ECN is terminated, the
i. services required by any government
Subscriber's responsibility to that provider for
agency or program, Federal, State or
services rendered subsequent to that termination
subdivision thereof;
date shall be no greater than it was for services
j. treatment directly related to any totally rendered immediately prior to that termination
disabling condition, illness or injury for date, until the first to occur of the following:
which an extension of benefits is pro-
1. the date that the services being rendered by
vided under a contract or policy pro-
such provider are completed;
viding hospital, medical or surgical ex-
pense or service benefits that was in 2. the date that ECN makes reasonable and ap-
effect with the employer within 60 days propriate provision for the assumption of such
immediately before the effective date of services by another Participating Provider;
this contract;
3. the date that coverage for such Subscriber is
k. services and materials for which the terminated.
Subscriber is not legally obligated to
70
Participating Providers submit claims for pay- ered services hereunder, including such providers
ment after their services have been received. You outside of California. The Subscriber may con-
or your Non-Participating Providers also submit tact the group administrator or MES for a Direc-
claims for payment after services have been re- tory of Participating Providers.
ceived.
CUSTOMER SERVICE
Providers do not receive financial incentives or
bonuses from Blue Shield of California. If you have a question about services, your bene-
fits, or a provider, or concerns regarding the
PLEASE READ THE FOLLOWING INFOR-
quality of care or access to care that you have ex-
MATION SO YOU WILL KNOW FROM
perienced, you may contact:
WHOM OR WHAT GROUP OF PROVIDERS
CARE MAY BE OBTAINED. Medical Eye Services
Customer Service Department
CHOICE OF PROVIDERS P.O. Box 25208
Santa Ana, CA 92799-5208
A Subscriber may select any licensed ophthal- 1-714-619-4660 or 1-800-877-6372.
mologist, optometrist or optician to provide cov-
71
SCHEDULE OF ALLOWANCES
Procedure Participating Provider Non-Participating Provider
Services are covered up to the fol-
lowing Allowed Amounts with
Subscribers being responsible for
all charges in excess of these
amounts.
Comprehensive examination:
Ophthalmologic $60
Optometric 50
Brief visit1 20
Limited visit1 These 25
Intermediate visit1 Services 30
Lenses*: are
Single Vision covered 43
Bifocal in full 60
Trifocal when 75
7.25 Diopter, or more received 12
Aphakic Monofocal from 120
Aphakic Multifocal Participating 200
Lenticular Monofocal Providers. 120
Lenticular Multifocal 200
Prism 1 1/2 to 4 Diopters 10
Prism 4 1/2 to 10 Diopters 16
Slab-off prism (per lens) 35
Contact Lenses:
Medically necessary (Hard) 200
Medically necessary (Soft) 250
Cosmetic/Convenience Contact Lenses Covered up to a maximum 1202
(Hard/Soft) of $1202
Frame Covered up to a maximum 40
of $100
1
When in lieu of a comprehensive exam.
2
Allowance toward the cost is in lieu of other eyewear benefits — the difference between the Allowance and
the provider's charge is the responsibility of the Subscriber, whether dispensed by a Participating Provider or
by a Non-Participating Provider.
*Each pair of lenses includes Pink or Rose tint #1 or #2 in the allowance.
NOTE: The difference between the Allowed Amount and the charges for more expensive frames or unusual
lenses, such as oversize, will be the responsibility of the Subscriber, whether dispensed by a Participating Pro-
vider or by a Non-Participating Provider. Participating Providers allow a selection from frame styles that retail to
$100 with lenses that fit an eye size less than 61 millimeters. If a more expensive frame is selected, the Subscriber
is responsible for the additional cost above $100. If the lenses are 61 millimeters or over, any difference between the
Allowance and the provider's charge is the responsibility of the Subscriber.
72
NOTES
73
NOTES
74
NOTES
75
Blue Shield of California Customer Service Office to Serve You
For claims submission and information contact:
BLUE SHIELD OF CALIFORNIA
P.O. Box 272540
Chico, CA 95927-2540
You may call toll free:
Customer Service: 1-800-200-3242
The hearing impaired may contact Blue Shield’s Cus-
tomer Service Department through Blue Shield’s toll-
free TTY number at 1-800-241-1823.
Benefits Management Program Telephone Numbers
For Preadmission Review: 1-800-343-1691
For Prior Authorization of Benefits Management
Program Radiological Services: 1-888-642-2583
Please refer to the Benefits Management Program section of this
Evidence of Coverage and Disclosure Form booklet for information.
977662 (1/04)
PPOCov (7/01)
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