2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 1. How This Plan Works
Page 14
Section 1. How This Plan Works
Page 14
- Non-participating providers. Providers who are not Preferred or Participating providers do not have contracts with us, and may or may not accept our allowance. We refer to them as “Non-participating providers” generally, although if they are facilities we refer to them as “Non-member facilities.” When you use Non-participating providers, you may have to file your claims with us. We will then pay our benefits to you, and you must pay the provider.
You must pay any difference between the amount Non-participating providers charge and our allowance (except in certain circumstances – see pages 156-157). In addition, you must pay any applicable coinsurance amounts, copayment amounts, amounts applied to your calendar year deductible, and amounts for noncovered services. Important: Under Standard Option, your out-of-pocket costs may be substantially higher when you use Non-participating providers than when you use Preferred or Participating providers. Under Basic Option, you must use Preferred providers to receive benefits. See page 20 for the exceptions to this requirement.
Note: In Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan allowance as payment in full for covered services. As a result, you are only responsible for applicable coinsurance or copayments (and, under Standard Option only, the applicable deductible), for covered services, and any charges for noncovered services.
- Pilot Programs. We may implement pilot programs in one or more Local Plan areas and overseas to test the feasibility and examine the impact of various initiatives. The pilot programs do not affect all Plan areas. Information on specific pilots is not published in this brochure; it is communicated to members and network providers in accordance with our agreement with OPM. Certain pilot programs may incorporate benefits that are different from those described in this brochure. For example, certain pilot programs may revise the Plan Allowance for Non-participating providers described in Section 10 of this brochure.
Your rights and responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Years in existence
- Profit status
- Care management, including case management and disease management programs
- How we determine if procedures are experimental or investigational
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, at www.fepblue.org/en/rights-and-responsibilities.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.fepblue.org/en/terms-and-privacy/notice-of-privacy-practices/ to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
If you want more information about us, call or write to us. Our phone number is shown on the back of your Service Benefit Plan ID card. You may also visit our website at www.fepblue.org.
Your medical and claims records are confidential
We will keep your medical and claims information confidential.
Note: As part of our administration of this contract, we may disclose your medical and claims information (including your prescription drug utilization) to any treating physicians or dispensing pharmacies. You may view our Notice of Privacy Practice for more information about how we may use and disclose member information by visiting our website at www.fepblue.org.