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 92
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 92
Benefit Description
Hospice Care (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Hospice Care (cont.)
Not covered:
- Advanced care planning, except when provided as part of a covered hospice care treatment plan (see page 90)
- Homemaker services
- Home hospice care (e.g., care given by a home health aide) that is provided and billed for by other than the approved home hospice agency when the same type of care is already being provided by the home hospice agency
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Ambulance
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Ambulance
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:
- Associated with covered hospital inpatient care
- Related to medical emergency
- Associated with covered hospice care
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Note: Prior approval is required for all non-emergent air ambulance transport.
Standard Option - You Pay
Nothing (no deductible)
Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Note: Prior approval is required for all non-emergent air ambulance transport.
Standard Option - You Pay
Nothing (no deductible)
Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands
Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GMMI) by calling 804-673-1678. See page 130 for more information.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands
Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GMMI) by calling 804-673-1678. See page 130 for more information.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Wheelchair van services and gurney van services
- Ambulance and any other modes of transportation to or from services including but not limited to physician appointments, dialysis, or diagnostic tests not associated with covered inpatient hospital care
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Ambulance - continued on next page