2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 79
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 79
- You must use Preferred providers in order to receive benefits. See page 20 for the exceptions to this requirement.
- Your cost-share for care performed and billed by Preferred professional providers in the outpatient department of a Preferred hospital is waived for services other than surgical services, drugs, supplies, orthopedic and prosthetic devices, and durable medical equipment. You are responsible for the applicable cost-sharing amount(s) for the services performed and billed by the hospital.
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
Inpatient Hospital
Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. If a Preferred or Member hospital only has private rooms, we base our payment on the contractual status of the facility. If a Non-member hospital only has private rooms, we base our payment on the Plan allowance for your type of admission. Please see pages 155-157 for more information.
See pages 87-88 and 100-101 for inpatient residential treatment center.
Other hospital services and supplies, such as:
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use a Preferred facility.
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: If you are admitted to a Member or Non-member facility due to a medical emergency or accidental injury, you pay a $350 per admission copayment for unlimited days and we then provide benefits at 100% of the Plan allowance.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Note: For Preferred facility care related to maternity (including inpatient facility care, care at birthing facilities, and services you receive on an outpatient basis), your responsibility for the covered services you receive is limited to $250 per admission.
Member/Non-member facilities: You pay all charges
Benefit Description
Inpatient Hospital
Room and board, such as:
- Semiprivate or intensive care accommodations
- General nursing care
- Meals and special diets
Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. If a Preferred or Member hospital only has private rooms, we base our payment on the contractual status of the facility. If a Non-member hospital only has private rooms, we base our payment on the Plan allowance for your type of admission. Please see pages 155-157 for more information.
See pages 87-88 and 100-101 for inpatient residential treatment center.
Other hospital services and supplies, such as:
- Operating, recovery, maternity, and other treatment rooms
- Prescribed drugs and medications
- Diagnostic studies, radiology services, laboratory tests, and pathology services
- Administration of blood or blood plasma
- Dressings, splints, casts, and sterile tray services
- Internal prosthetic devices
- Other medical supplies and equipment, including oxygen
- Anesthetics and anesthesia services
- Take-home items
- Pre-admission testing recognized as part of the hospital admissions process
- Nutritional counseling
- Acute inpatient rehabilitation
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use a Preferred facility.
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: If you are admitted to a Member or Non-member facility due to a medical emergency or accidental injury, you pay a $350 per admission copayment for unlimited days and we then provide benefits at 100% of the Plan allowance.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Note: For Preferred facility care related to maternity (including inpatient facility care, care at birthing facilities, and services you receive on an outpatient basis), your responsibility for the covered services you receive is limited to $250 per admission.
Member/Non-member facilities: You pay all charges
Inpatient Hospital - continued on next page