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 84
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 84
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient treatment and therapy services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: $25 copayment per day per facility (no deductible)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Member/Non-member facilities: You pay all charges
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient treatment and therapy services performed and billed by a facility, limited to:
- Cognitive rehabilitation therapy
- Physical, occupational, and speech therapy
- Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
- Basic Option benefits are limited to a combined total of 50 visits per person per calendar year
- Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
- Manipulative treatment services
- Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
- Basic Option benefits are limited to a combined total of 20 visits per person per calendar year
- Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
Standard Option - You Pay
Preferred facilities: $25 copayment per day per facility (no deductible)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Member/Non-member facilities: You pay all charges
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Benefit Description
Outpatient treatment services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Member/Non-member facilities: You pay all charges
Outpatient treatment services performed and billed by a facility, limited to:
- Cardiac rehabilitation
- Pulmonary rehabilitation
- Applied behavior analysis (ABA) for an autism spectrum disorder (see prior approval requirements on page 22)
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $30 copayment per day per facility
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Member/Non-member facilities: You pay all charges
Outpatient Hospital or Ambulatory Surgical Center - continued on next page