2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Outpatient Hospital or Ambulatory Surgical Center
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Outpatient Hospital or Ambulatory Surgical Center
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center
Outpatient surgical and treatment services performed and billed by a facility, such as:
Notes:
We cover outpatient care related to other types of dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, for additional benefit information.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $150 copayment per day per facility (except as noted below)
Note: You may be responsible for paying a $200 copayment per day per facility if other diagnostic services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for surgical implants, agents, or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Member/Non-member facilities: You pay all charges
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center
Outpatient surgical and treatment services performed and billed by a facility, such as:
- Operating, recovery, and other treatment rooms
- Anesthetics and anesthesia services
- Acupuncture
- Pre-surgical testing performed within one business day of the covered surgical services
- Chemotherapy and radiation therapy
- Colonoscopy, with or without biopsy
Note: Preventive care benefits apply to the facility charges for your first covered colonoscopy of the calendar year (see page 42). We provide diagnostic benefits for services related to subsequent colonoscopy procedures in the same year.
- Intravenous (IV)/infusion therapy
- Renal dialysis
- Visits to the outpatient department of a hospital for non-emergency treatment services
- Diabetic education
- Administration of blood, blood plasma, and other biologicals
- Blood and blood plasma, if not donated or replaced, and other biologicals
- Dressings, splints, casts, and sterile tray services
- Facility supplies for hemophilia home care
- Other medical supplies, including oxygen
- Surgical implants
Notes:
- See pages 95-97 for our payment levels for care related to a medical emergency or accidental injury.
- See page 49 for our coverage of family planning services.
- For our coverage of hospital-based clinic visits, please refer to the professional benefits described on pages 39 , 40 and page 55 for vision services.
- For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.
- For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility. See pages 47-49 for other included maternity services.
- See page 85 for outpatient drugs, medical devices, and durable medical equipment billed for by a facility.
- We cover outpatient hospital services and supplies related to the treatment of children up to age 22 with severe dental caries.
We cover outpatient care related to other types of dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, for additional benefit information.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $150 copayment per day per facility (except as noted below)
Note: You may be responsible for paying a $200 copayment per day per facility if other diagnostic services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for surgical implants, agents, or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Member/Non-member facilities: You pay all charges
Benefit Description
Outpatient observation services performed and billed by a hospital or freestanding ambulatory facility
Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and pages 79-80 for information about benefits for inpatient admissions.
Note: For outpatient observation services related to maternity, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: $350 copayment for the duration of services (no deductible)
Member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500
Member/Non-member facilities: You pay all charges
Outpatient observation services performed and billed by a hospital or freestanding ambulatory facility
Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and pages 79-80 for information about benefits for inpatient admissions.
Note: For outpatient observation services related to maternity, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: $350 copayment for the duration of services (no deductible)
Member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500
Member/Non-member facilities: You pay all charges
Benefit Description
Outpatient diagnostic testing and treatment services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $200 copayment per day per facility
Member facilities: $200 copayment per day per facility
Non-member facilities: $200 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient diagnostic testing and treatment services performed and billed by a facility, limited to:
- Angiographies
- Bone density tests
- CT scans/MRIs/PET scans
- Nuclear medicine
- Facility-based sleep studies (prior approval is required)
- Genetic testing
Note: We cover specialized diagnostic genetic testing billed for by a facility, such as the outpatient department of a hospital, as shown here. See page 41 for coverage criteria and limitations.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $200 copayment per day per facility
Member facilities: $200 copayment per day per facility
Non-member facilities: $200 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Benefit Description
Outpatient diagnostic testing services performed and billed by a facility, such as:
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $40 copayment per day per facility
Member facilities: $40 copayment per day per facility
Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient diagnostic testing services performed and billed by a facility, such as:
- Cardiovascular monitoring
- EEGs
- Home-based/unattended sleep studies
- Ultrasounds
- Neurological testing
- X-rays (including set-up of portable X-ray equipment)
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $40 copayment per day per facility
Member facilities: $40 copayment per day per facility
Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Benefit Description
Outpatient treatment and therapy services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: $25 copayment per day per facility (no deductible)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Member/Non-member facilities: You pay all charges
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient treatment and therapy services performed and billed by a facility, limited to:
- Cognitive rehabilitation therapy
- Physical, occupational, and speech therapy
- Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
- Basic Option benefits are limited to a combined total of 50 visits per person per calendar year
- Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
- Manipulative treatment services
- Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
- Basic Option benefits are limited to a combined total of 20 visits per person per calendar year
- Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
Standard Option - You Pay
Preferred facilities: $25 copayment per day per facility (no deductible)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Member/Non-member facilities: You pay all charges
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Benefit Description
Outpatient treatment services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Member/Non-member facilities: You pay all charges
Outpatient treatment services performed and billed by a facility, limited to:
- Cardiac rehabilitation
- Pulmonary rehabilitation
- Applied behavior analysis (ABA) for an autism spectrum disorder (see prior approval requirements on page 22)
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Member/Non-member facilities: You pay all charges
Benefit Description
Outpatient diagnostic and treatment services performed and billed by a facility, limited to:
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: 15% of the Plan allowance
Member facilities: 15% of the Plan allowance
Non-member facilities: 15% of the Plan allowance plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient diagnostic and treatment services performed and billed by a facility, limited to:
- Laboratory tests and pathology services
- EKGs
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: 15% of the Plan allowance
Member facilities: 15% of the Plan allowance
Non-member facilities: 15% of the Plan allowance plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Benefit Description
Outpatient adult preventive care performed and billed by a facility, limited to:
Note: See page 44 for our coverage requirements for preventive BRCA testing.
Note: See pages 45-46 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.
Standard Option - You Pay
See page 42 for our payment levels for covered preventive care services for adults
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm
Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Outpatient adult preventive care performed and billed by a facility, limited to:
- Visits/exams for preventive care, screening procedures, and routine immunizations described on pages 42-45
- Cancer screenings listed on pages 42-43 and ultrasound screening for abdominal aortic aneurysm
Note: See page 44 for our coverage requirements for preventive BRCA testing.
Note: See pages 45-46 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.
Standard Option - You Pay
See page 42 for our payment levels for covered preventive care services for adults
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm
Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Benefit Description
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: 30% of the Plan allowance
Note: You may also be responsible for paying a copayment per day per facility for outpatient services. See above and pages 81-84 for specific coverage information.
Member/Non-member facilities: You pay all charges
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
- Prescribed drugs
- Orthopedic and prosthetic devices
- Durable medical equipment
- Surgical implants
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: 30% of the Plan allowance
Note: You may also be responsible for paying a copayment per day per facility for outpatient services. See above and pages 81-84 for specific coverage information.
Member/Non-member facilities: You pay all charges