2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 60
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 60
Benefit Description
Home Health Services (cont.)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Home Health Services (cont.)
- Services provided by a nurse, nursing assistant, health aide, or other similarly licensed or unlicensed person that are billed by a skilled nursing facility, extended care facility,
or nursing home, except as included in the benefits described on pages 88-89.
- Private duty nursing
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Manipulative Treatment
Manipulative treatment performed by a professional provider, when the provider is practicing within the scope of his/her license, limited to:
Note: Benefits for manipulative treatment are limited to the services and combined treatment visits stated here.
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Standard Option - You Pay
Preferred: $25 copayment per visit (no deductible)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 12 visits per person, per calendar year.
Note: Manipulation visits that you pay for while meeting your calendar year deductible count toward the treatment limit cited above.
Basic Option - You Pay
Preferred: $30 copayment per visit
Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 20 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Manipulative Treatment
Manipulative treatment performed by a professional provider, when the provider is practicing within the scope of his/her license, limited to:
- Osteopathic manipulative treatment to any body region
- Chiropractic spinal and/or extraspinal manipulative treatment
Note: Benefits for manipulative treatment are limited to the services and combined treatment visits stated here.
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Standard Option - You Pay
Preferred: $25 copayment per visit (no deductible)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 12 visits per person, per calendar year.
Note: Manipulation visits that you pay for while meeting your calendar year deductible count toward the treatment limit cited above.
Basic Option - You Pay
Preferred: $30 copayment per visit
Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 20 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Benefit Description
Alternative Treatments
Acupuncture
Note: Acupuncture must be performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. See page 17 for more information.
Note: When billed by a facility such as the outpatient department of a hospital, you are limited to the number of visits per calendar year listed on this page. See Section 5(c) for your cost-share.
Note: See page 77 for our coverage of acupuncture when provided as anesthesia for covered surgery.
Note: See page 47 for our coverage of acupuncture when provided as anesthesia for covered maternity care.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Benefits for acupuncture are limited to 24 visits per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: Benefits for acupuncture are limited to 12 visits per calendar year.
Note: You pay 30% of the Plan allowance for drugs and supplies.
Participating/Non-participating: You pay all charges
Alternative Treatments
Acupuncture
Note: Acupuncture must be performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. See page 17 for more information.
Note: When billed by a facility such as the outpatient department of a hospital, you are limited to the number of visits per calendar year listed on this page. See Section 5(c) for your cost-share.
Note: See page 77 for our coverage of acupuncture when provided as anesthesia for covered surgery.
Note: See page 47 for our coverage of acupuncture when provided as anesthesia for covered maternity care.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Benefits for acupuncture are limited to 24 visits per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: Benefits for acupuncture are limited to 12 visits per calendar year.
Note: You pay 30% of the Plan allowance for drugs and supplies.
Participating/Non-participating: You pay all charges
Alternative Treatments - continued on next page