2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 4. Your Costs for Covered Services
Page 32
Section 4. Your Costs for Covered Services
Page 32
Non-member Ambulatory Surgical Facility* - Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,500
We pay: 65% of our allowance: 1,625
You owe - Coinsurance: 35% of our allowance: 875
You owe - Copayment: Not applicable
+ Difference up to charge? Yes: 2,500
TOTAL YOU PAY: $3,375
Note: If you had not met any of your Standard Option deductible in the above example, $350 of our allowed amount would be applied to your deductible before your coinsurance amount was calculated.
*A Non-member facility may bill you any amount for the services it provides. You are responsible for paying all expenses over our allowance, regardless of the total amount billed, in addition to your calendar year deductible and coinsurance. For example, if you use a Non-member facility that charges $60,000 for facility care related to outpatient bariatric surgery, and we pay the $1,625 amount illustrated above, you would owe $58,375 ($60,000 - $1,625 = $58,375). This example assumes your calendar year deductible has been met.
Important Notice About Surprise Billing — Know Your Rights
The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a Non-participating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you received non-emergency services at participating facilities, but you receive some care from Non-participating providers.
Balance billing happens when you receive a bill from the non-participating provider, facility, or air ambulance service for the difference between the Non-participating provider’s charge and the amount payable by your health plan.
Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.
For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.fepblue.org/NSA or contact the customer service phone number on the back of your ID card.
Your costs for other care
Overseas care. Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands are considered overseas care. Under Standard and Basic Options, we pay overseas claims at Preferred benefit levels. Therefore, the Basic Option requirement to use Preferred providers in order to receive benefits does not apply. See Section 5(i) for specific information about our overseas benefits.
Dental care. Under Standard Option, we pay scheduled amounts for covered dental services and you pay balances as described in Section 5(g). Under Basic Option, you pay $30 for any covered evaluation and we pay the balance for covered services. Basic Option members must use Preferred dentists in order to receive benefits. See Section 5(g) for a listing of covered dental services and additional payment information.
Inpatient facility care. Under Standard and Basic Options, you pay the coinsurance or copayment amounts listed in Section 5(c). Under Standard Option, you must meet your deductible before we begin providing benefits for certain facility-billed services. Under Basic Option, you must use Preferred facilities in order to receive benefits. See page 20 for the exceptions to this requirement.
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
Under Standard and Basic Options, we limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year. For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
Facility’s charge: $5,000
Our allowance: We set it at: 2,500
We pay: 65% of our allowance: 1,625
You owe - Coinsurance: 35% of our allowance: 875
You owe - Copayment: Not applicable
+ Difference up to charge? Yes: 2,500
TOTAL YOU PAY: $3,375
Note: If you had not met any of your Standard Option deductible in the above example, $350 of our allowed amount would be applied to your deductible before your coinsurance amount was calculated.
*A Non-member facility may bill you any amount for the services it provides. You are responsible for paying all expenses over our allowance, regardless of the total amount billed, in addition to your calendar year deductible and coinsurance. For example, if you use a Non-member facility that charges $60,000 for facility care related to outpatient bariatric surgery, and we pay the $1,625 amount illustrated above, you would owe $58,375 ($60,000 - $1,625 = $58,375). This example assumes your calendar year deductible has been met.
Important Notice About Surprise Billing — Know Your Rights
The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a Non-participating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you received non-emergency services at participating facilities, but you receive some care from Non-participating providers.
Balance billing happens when you receive a bill from the non-participating provider, facility, or air ambulance service for the difference between the Non-participating provider’s charge and the amount payable by your health plan.
Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.
For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.fepblue.org/NSA or contact the customer service phone number on the back of your ID card.
Your costs for other care
Overseas care. Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands are considered overseas care. Under Standard and Basic Options, we pay overseas claims at Preferred benefit levels. Therefore, the Basic Option requirement to use Preferred providers in order to receive benefits does not apply. See Section 5(i) for specific information about our overseas benefits.
Dental care. Under Standard Option, we pay scheduled amounts for covered dental services and you pay balances as described in Section 5(g). Under Basic Option, you pay $30 for any covered evaluation and we pay the balance for covered services. Basic Option members must use Preferred dentists in order to receive benefits. See Section 5(g) for a listing of covered dental services and additional payment information.
Inpatient facility care. Under Standard and Basic Options, you pay the coinsurance or copayment amounts listed in Section 5(c). Under Standard Option, you must meet your deductible before we begin providing benefits for certain facility-billed services. Under Basic Option, you must use Preferred facilities in order to receive benefits. See page 20 for the exceptions to this requirement.
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
Under Standard and Basic Options, we limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year. For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.