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 87
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 87
Benefit Description
Outpatient facility services related to specific covered bariatric surgical procedures, when the surgery is performed at a designated Blue Distinction Center for Bariatric Surgery.
Outpatient facility services related to specific covered hip and knee replacement or revision surgeries and certain spine surgery procedures, when performed at a designated Blue Distinction Center for hip/knee/spine surgery.
Note: You must meet the pre-surgical requirements listed on pages 64-65 for bariatric surgeries.
Note: In addition, you must obtain prior approval and verify the facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to the procedure at the customer service phone number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefits do not apply to other types of outpatient surgical services, even when performed at a Blue Distinction Center. See pages 81-82 for the benefits we provide.
Note: See pages 18-19 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $100 per day per facility (no deductible)
Basic Option - You Pay
Blue Distinction Center: $25 per day per facility
Outpatient facility services related to specific covered bariatric surgical procedures, when the surgery is performed at a designated Blue Distinction Center for Bariatric Surgery.
Outpatient facility services related to specific covered hip and knee replacement or revision surgeries and certain spine surgery procedures, when performed at a designated Blue Distinction Center for hip/knee/spine surgery.
Note: You must meet the pre-surgical requirements listed on pages 64-65 for bariatric surgeries.
Note: In addition, you must obtain prior approval and verify the facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to the procedure at the customer service phone number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefits do not apply to other types of outpatient surgical services, even when performed at a Blue Distinction Center. See pages 81-82 for the benefits we provide.
Note: See pages 18-19 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $100 per day per facility (no deductible)
Basic Option - You Pay
Blue Distinction Center: $25 per day per facility
Benefit Description
Residential Treatment Center
Precertification prior to admission is required.
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission.
We cover inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: Non-member RTCs must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center
Precertification prior to admission is required.
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission.
We cover inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:
- Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility (see page 39 for services billed by professional providers).
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: Non-member RTCs must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center - continued on next page