2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 4. Your Costs for Covered Services
Page 30
Section 4. Your Costs for Covered Services
Page 30
- Participating providers. These types of Non-preferred providers have agreements with the Local Plan to limit what they bill our members.
Under Standard Option, when you use a Participating provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example: You see a Participating physician who charges $250, but the Plan allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, under Standard Option, you pay just 35% of our $100 allowance ($35). Because of the agreement, your Participating physician will not bill you for the $150 difference between our allowance and the bill.
Under Basic Option, there are no benefits for care performed by Participating providers; you pay all charges. See page 20 for the exceptions to this requirement.
- Non-participating providers. These Non-preferred providers have no agreement to limit what they will bill you. As a result, your share of the provider’s bill could be significantly more than what you would pay for covered care from a Preferred provider. If you plan to use a Non-participating provider for your care, we encourage you to ask the provider about the expected costs and visit our website, www.fepblue.org, or call us at the customer service phone number on the back of your ID card for assistance in estimating your total out-of-pocket expenses.
Under Standard Option, when you use a Non-participating provider, you will pay your deductible and coinsurance – plus any difference between our allowance and the charges on the bill (except in certain circumstances – see pages 156-158). For example, you see a Non-participating physician who charges $250. The Plan allowance is again $100, and you have met your deductible. You are responsible for your coinsurance, so you pay 35% of the $100 Plan allowance or $35. Plus, because there is no agreement between the Non-participating physician and us, the physician can bill you for the $150 difference between our allowance and the bill. This means you would pay a total of $185 ($35 + $150) for the Non-participating physician’s services, rather than $15 for the same services when performed by a Preferred physician. We encourage you to always visit Preferred providers for your care. Using Non-participating or Non-member providers could result in your having to pay significantly greater amounts for the services you receive.
Under Basic Option, there are no benefits for care performed by Non-participating providers; you pay all charges. See page 20 for the exceptions to this requirement.
The following examplesillustrate how much Standard Option members have to pay out-of-pocket for services performed by Preferred providers, Participating/Member providers, and Non-participating/Non-member providers. The first example shows services provided by a physician and the second example shows facility care billed by an ambulatory surgical facility. In both examples, your calendar year deductible has already been met. Use this information for illustrative purposes only.
Basic Option benefit levels for physician care begin on page 39; see page 81 for Basic Option benefit levels that apply to outpatient hospital or ambulatory surgical facility care.
In the following example, we compare how much you have to pay out-of-pocket for services provided by a Preferred physician, a Participating physician, and a Non-participating physician. The table uses our example of a service for which the physician charges $250 and the Plan allowance is $100.