Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Save to My Library
Look up keyword
Like this
1Activity
0 of .
Results for:
No results containing your search query
P. 1
UC Care Benefits Outline 2014 as of 09/27/13

UC Care Benefits Outline 2014 as of 09/27/13

Ratings: (0)|Views: 47 |Likes:
Published by Chris Newfield
Description of new University of California PPO insurance policy benefits, with 3 tiers outlined
Description of new University of California PPO insurance policy benefits, with 3 tiers outlined

More info:

Published by: Chris Newfield on Oct 09, 2013
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

11/07/2013

pdf

text

original

 
 
University of California
 – 
UC Care
Blue Shield of California
 
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS ASUMMARY ONLY. THE PLAN CONTRACT SHOULDBE CONSULTED FOR A DETAILED DESCRIPTIONOF COVERAGE BENEFITS AND
 
LIMITATIONS.
 
Highlights: A description of the prescription drug coverage is provided separately
 
Effective: January 1, 2014
 UC Select Blue ShieldPreferred
1
 Non-PreferredProviders
1
 Calendar Year Medical Deductible
 
(Deductible amounts do not cross accumulate)
None $250 per individual/$750 per family$500 per individual/$1,500 per family
Calendar year copayment maximum
 
(UC Select and Blue Shield Preferred Copayment Maximum amounts crossaccumulate. UC Select/Blue Shield Preferred and Non-Preferred CopaymentMaximums do not cross accumulate)
$1,500 per individual/$4,500 per family$3,000 per individual/$9,000 per family$5,000 per individual/$15,000 per family
LIFETIME BENEFIT MAXIMUM
 
None None None
Covered Services Member Copayment
PROFESSIONAL SERVICESUC Select Blue ShieldPreferred
1
 Non-PreferredProviders
1
 
Professional (Physician) Benefits
 
 
Physician office visits
(Includes Internist, Family Practice, OB/GYN,Pediatrician, General Practice)
 
$20 per visit 20%
 
50%
Specialist office visits
(Includes all other provider designations)
 $20 per visit 20% 50%
 
CT scans, MRIs, MRAs, PET scans, and cardiacdiagnostic procedures utilizing nuclear medicine
3
(prior authorization is required)
 
N/A
(services covered under BlueShield Preferred)
20% 50%
 
Other outpatient X-ray, pathology and laboratory
 
(Diagnostic testing by providers other than outpatient laboratory,pathology, and imaging departments of hospitals/facilities)
3
 
N/A
(services covered under BlueShield Preferred)
 20% 50%
Allergy Testing and Treatment Benefits
 
 
Office visits
(includes visits for allergy serum injections)
$20 per visit 20% 50%
Preventive Health Benefits
 
 
Preventive Health Services
 
(As required by applicable federallaw.)
 
No Charge No Charge
(Not subject to the Calendar Year-Deductible)
 50%
 
OUTPATIENT SERVICES
 
Hospital Benefits (Facility Services)
 
 
Outpatient surgery performed at an Ambulatory SurgeryCenter 
3, 4
 
N/A
(services covered under BlueShield Preferred)
 20% 50%
 
Outpatient surgery in a hospital
 
$100 per surgery 20% 50%
 
Outpatient Services for treatment of illness or injury andnecessary supplies
 
(Except as described under "Rehabilitationbenefits" and "Speech therapy benefits")
 
$20 per visit 20% 50%
 
CT scans, MRIs, MRAs, PET scans, and cardiacdiagnostic procedures utilizing nuclear medicineperformed in a hospital
(prior authorization is required)
3
 
$20 per visit 20% 50%
 
Other outpatient X-ray, pathology and laboratoryperformed in a hospital
3
 
 
Bariatric Surgery
 
(prior authorization required by the Plan; medicallynecessary surgery for weight loss, for morbid obesity only)
6
 
$20 per visit$100 per surgery20%20%50%
 
 
 
HOSPITALIZATION SERVICES
 
Hospital Benefits (Facility Services)
 
 
Inpatient Physician Services
 
No Charge 20% 50%
 
Inpatient Non-emergency Facility Services
 
(semi-privateroom and board, medically necessary services and supplies)
 
 
Bariatric Surgery
 
(prior authorization required by the Plan; medicallynecessary surgery for weight loss, for morbid obesity only)
6
 
$250 per admission$250 per admission20%20%50%
 
50%
7
Skilled Nursing Facility Benefits
 (Combined maximum of up to 100 prior authorized days per calendar year; semi-private accommodations)
 
 
Services by a free-standing Skilled Nursing Facility
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
Skilled Nursing Unit of a Hospital
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
EMERGENCY HEALTH COVERAGE
 
 
Emergency room Services not resulting in admission
 
(ERfacility copay does not apply if the member is directly admitted to thehospital for inpatient services)
 
$100 per visit
(Not subject to theCalendar Year-Deductible)
 $100 per visit
(Not subject to the Calendar Year-Deductible)
 $100 per visit
(Not subject to theCalendar Year-Deductible)
 
Emergency Room Services resulting in admission
(Whenthe member is admitted directly from the ER)
 $250 per admission $250 per admission $250 per admission
 
Emergency room Physician Services
 
20%
 
20%
 
20%
 
Urgent Care Benefits
Urgent care services
(For urgent care services performed at acenter affiliated with a licensed hospital please refer to the EmergencyRoom services.)
 $20 per visit 20% 50%
AMBULANCE SERVICES
 
 
Emergency or authorized transport N/A
(services covered under Blue Shield Preferred)
 20% 20%
PRESCRIPTION DRUG COVERAGE
 
Outpatient Prescription Drug Benefits
 A description of your outpatient prescription drug coverage is provided separately. If youdo not have the separate drug summary that goes with this benefit summary, pleasecontact your benefits administrator or call Customer Service.
 PROSTHETICS/ORTHOTICS
 
 
Prosthetic equipment and devices
 
(Separate office visit copaymay apply)
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
Orthotic equipment and devices
 
(Separate office visit copay mayapply.)
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
DURABLE MEDICAL EQUIPMENT
 
 
Durable Medical Equipment
 
 
Breast Pump
 
N/A
(services covered under Blue Shield Preferred)
 N/A
(services covered under Blue Shield Preferred)
 20%No Charge
(Not subject to the Calendar Year-Deductible)
 50%Not Covered
MENTAL HEALTH SERVICES (PSYCHIATRIC)
 
 
Inpatient Hospital Services
 
Carved out to Optum
 
Outpatient Mental Health Services
 
CHEMICAL DEPENDENCY SERVICES
Chemical Dependency and Substance Abuse ServicesCarved out to Optum
 
HOME HEALTH SERVICES
 
 
Home health care agency Services
(up to 100 prior authorizedvisits per Calendar Year)
11
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
Home infusion/home intravenous injectable therapy andinfusion nursing visits provided by a Home Infusion Agency
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
 
OTHER
 
Hospice Program Benefits
 
Routine home care
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
Inpatient Respite Care
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
24-hour Continuous Home Care
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
 
General Inpatient care
 
N/A
(services covered under Blue Shield Preferred)
 20% 50%
Chiropractic Benefits
Chiropractic services
 –
provided by a chiropractor 
(Up to 24 visits per calendar year combined with acupuncture visits)
 N/A
(services covered under Blue Shield Preferred)
 20% Not Covered
Acupuncture Benefits
Acupuncture services
(Up to 24 visits per calendar year combined with chiropractic services)
 N/A
(services covered under Blue Shield Preferred)
 20% 20%
Pregnancy and Maternity Care Benefits
 
 
Prenatal and Postnatal Physician Office Visits
 
(For inpatient hospital services, see "Hospitalization Services.")
 
$20initial visit only20% 50%
Family Planning
 
Counseling and consulting
 
No Charge No Charge
(Not subject to the Calendar Year-Deductible)
 50%
 
Tubal ligation
 
No Charge No Charge
(Not subject to the Calendar Year-Deductible)
 50%
 
Elective abortion
 
20% 20% 50%
 
Vasectomy
 
20% 20% 50%
Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy)
 
 
Outpatient visits
(Office or outpatient facility location)
 
$20 per visit 20% 50%
Speech Therapy Benefits
 
 
Outpatient visits
( Office or outpatient facility location)
 
$20 per visit 20% 50%
Diabetes Care Benefits
 
 
Devices, equipment, and non-testing supplies
 
(For testingsupplies, please see "Outpatient Prescription Drug Coverage Summary.")
 
20% 20% 50%
 
Diabetes self-management training
(If billed by your provider,you will also be responsible for the office visit copayment)
 
$20 per visit 20%
 
50%
Care Outside of Plan Service Area 
Within US: BlueCard Program All covered services provided through BlueCard Program, for out-of-state emergency and non-emergency care, are provided at thepreferred level of the local Blue Plan allowable amount when you use aBlue Cross/BlueShield provider.
Outside of US: BlueCard Worldwide All covered services for emergency and non-emergency care will beeligible for reimbursement when received outside of the US. Pleaserefer to the Blue Shield Preferred Tier for covered services andcorresponding member liability.
1 Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts.Preferred providers accept Blue Shield's allowable amount as full payment for covered services. Non-preferred providers can charge more than these amounts. Whenmembers use non-preferred providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield's allowable amount. Charges above theallowable amount do not count toward the calendar-year deductible or copayment maximum.2 Preferred Deductible does apply toward the Preferred calendar-year copayment maximum. Please refer to the Plan Contract for exact terms and conditions of coverage.3 Participating non Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with paymentaccording to your health plan's hospital services benefits.4 Participating ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from ahospital or an ambulatory surgery center affiliated with a hospital with payment according to your health plan's hospital services benefits.5 The maximum allowed charges for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350.6 Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, SanDiego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatricsurgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the

You're Reading a Free Preview

Download
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->