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 82
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 82
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Notes:
We cover outpatient care related to other types of dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, for additional benefit information.
Standard Option - You Pay
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Basic Option - You Pay
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Outpatient Hospital or Ambulatory Surgical Center (cont.)
- Diabetic education
- Administration of blood, blood plasma, and other biologicals
- Blood and blood plasma, if not donated or replaced, and other biologicals
- Dressings, splints, casts, and sterile tray services
- Facility supplies for hemophilia home care
- Other medical supplies, including oxygen
- Surgical implants
Notes:
- See pages 95-97 for our payment levels for care related to a medical emergency or accidental injury.
- See page 49 for our coverage of family planning services.
- For our coverage of hospital-based clinic visits, please refer to the professional benefits described on pages 39 , 40 and page 55 for vision services.
- For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.
- For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility. See pages 47-49 for other included maternity services.
- See page 85 for outpatient drugs, medical devices, and durable medical equipment billed for by a facility.
- We cover outpatient hospital services and supplies related to the treatment of children up to age 22 with severe dental caries.
We cover outpatient care related to other types of dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, for additional benefit information.
Standard Option - You Pay
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Basic Option - You Pay
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Benefit Description
Outpatient observation services performed and billed by a hospital or freestanding ambulatory facility
Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and pages 79-80 for information about benefits for inpatient admissions.
Standard Option - You Pay
Preferred facilities: $350 copayment for the duration of services (no deductible)
Member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible)
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500
Member/Non-member facilities: You pay all charges
Outpatient observation services performed and billed by a hospital or freestanding ambulatory facility
Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and pages 79-80 for information about benefits for inpatient admissions.
Standard Option - You Pay
Preferred facilities: $350 copayment for the duration of services (no deductible)
Member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible)
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500
Member/Non-member facilities: You pay all charges
Outpatient Hospital or Ambulatory Surgical Center - continued on next page