2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(d). Emergency Services/Accidents
Page 95
Section 5(d). Emergency Services/Accidents
Page 95
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
Accidental Injury
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Nothing (no deductible)
Basic Option - You Pay
Preferred: Nothing
Participating: Nothing
Non-participating: Nothing
Benefit Description
Accidental Injury
- Professional provider services in the emergency room, hospital outpatient department, including professional care, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Nothing (no deductible)
Basic Option - You Pay
Preferred: Nothing
Participating: Nothing
Non-participating: Nothing
Benefit Description
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Any difference between our allowance and the billed amount (no deductible)
Basic Option - You Pay
Regular benefit levels apply to covered services provided in this setting. See Sections 5(a) and 5(b).
- Professional provider services in the providers office, including diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider
Standard Option - You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Any difference between our allowance and the billed amount (no deductible)
Basic Option - You Pay
Regular benefit levels apply to covered services provided in this setting. See Sections 5(a) and 5(b).
Benefit Description
Standard Option - You Pay
Preferred: Nothing (no deductible)
Member: Nothing (no deductible)
Non-member: Nothing (no deductible)
Basic Option - You Pay
Preferred emergency room: $250 copayment per day per facility
Member emergency room: $250 copayment per day per facility
Non-member emergency room: $250 copayment per day per facility
Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $250 emergency room copayment. However, the $250 per day copayment for Preferred inpatient care still applies.
- Outpatient hospital services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital
Standard Option - You Pay
Preferred: Nothing (no deductible)
Member: Nothing (no deductible)
Non-member: Nothing (no deductible)
Basic Option - You Pay
Preferred emergency room: $250 copayment per day per facility
Member emergency room: $250 copayment per day per facility
Non-member emergency room: $250 copayment per day per facility
Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $250 emergency room copayment. However, the $250 per day copayment for Preferred inpatient care still applies.
Benefit Description
Standard Option - You Pay
Preferred urgent care center: Nothing (no deductible)
Participating urgent care center: Nothing (no deductible)
Non-participating urgent care center: Nothing (no deductible)
Basic Option - You Pay
Preferred urgent care center: $35 copayment per visit
Participating/Non-participating urgent care center: $35 copayment per visit
- Urgent care centers, licensed as and permitted to provide emergency services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider
Note: The urgent care center must be licensed as and permitted to provide emergency services in order to receive protections under the NSA. See page 32 for more information.
Standard Option - You Pay
Preferred urgent care center: Nothing (no deductible)
Participating urgent care center: Nothing (no deductible)
Non-participating urgent care center: Nothing (no deductible)
Basic Option - You Pay
Preferred urgent care center: $35 copayment per visit
Participating/Non-participating urgent care center: $35 copayment per visit
Benefit Description
Standard Option - You Pay
Preferred urgent care center: Nothing (no deductible)
Participating urgent care center: Nothing (no deductible)
Non-participating urgent care center: Any difference between our allowance and the billed amount (no deductible)
Basic Option - You Pay
Preferred urgent care center: $35 copayment per visit
Participating/Non-participating urgent care center: You pay all charges
- Urgent care centers, not licensed as or permitted to provide emergency services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider
Standard Option - You Pay
Preferred urgent care center: Nothing (no deductible)
Participating urgent care center: Nothing (no deductible)
Non-participating urgent care center: Any difference between our allowance and the billed amount (no deductible)
Basic Option - You Pay
Preferred urgent care center: $35 copayment per visit
Participating/Non-participating urgent care center: You pay all charges
Accidental Injury - continued on next page