Hospice care is an integrated set of services and supplies designed to hinder palliative and supportive care to terminally ill patients in their home

2006 Blue Cross And Blue Shield Service Benefit Plan Quick Reference OPM Privacy Notice Medicare Part D Notice CONTENTS: Section 1 Section 2 Section 3 Section 4 SECTION 5 CONTENTS: Overview Section 5(a) Section 5(b) Section 5(c) Section 5(d) Section 5(e) Section 5(f) Section 5(g) Section 5(h) Section 5(i) Section 5(j) Section 6 Section 7 Section 8 Section 9 Section 10 Section 11 Section 12 Index

Section 5(c):
Services Provided By
A Hospital Or Other Facility,
And Ambulance Services

In This Section:

Inpatient Hospital

Outpatient Hospital Or Ambulatory Surgical Center

Extended Care Benefits/Skilled Nursing Care Facility Benefits

Hospice Care

Ambulance

IMPORTANT

Here are some important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

• In this section unlike Sections 5(a) and 5(b) the Standard Option calendar year deductible applies to only a few benefits. In that case, we added "(calendar year deductible applies)" when it applies. The calendar year deductible is $250 per person ($500 per family) under Standard Option.

• Under Basic Option, there is no calendar year deductible.

• Under Basic Option, you must use Preferred providers in order to receive benefits. See Section 3 for the exception to this requirement.

• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including Medicare.

• YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to be sure which services require precertification.

• You should be aware that some PPO hospitals may have non-PPO professional providers on staff.

• We base payment on whether the facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because how they are paid depends on what type provider bills for the service. For example, physical therapy is paid differently depending on whether it is billed by an inpatient facility, a doctor, a physical therapist, or an outpatient facility.

• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your inpatient surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are listed in Section 5(a) or 5(b).

• PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

BENEFIT DESCRIPTION		YOU PAY
NOTE: The Standard Option calendar year deductible applies ONLY when we say below: "(calendar year deductible applies)." There is no calendar year deductible under Basic Option.
Inpatient Hospital		You Pay Standard Option You Pay Basic Option
Room and board, such as: • semiprivate or intensive care accommodations • general nursing care • meals and special diets Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. If a Non-member hospital only has private rooms, we base our payment on a per diem amount for your type of admission. Please see Section 10 for more information. Other hospital services and supplies, such as: • Operating, recovery, maternity and other treatment rooms • Prescribed drugs • Diagnostic laboratory tests, pathology services, MRIs, machine diagnostic tests and X-rays • Administration of blood or blood plasma • Dressings, splints, casts and sterile tray services • Internal prosthetic devices • Other medical supplies and equipment, including oxygen • Anesthetics and anesthesia services • Take-home items • Pre-admission testing recognized as part of the hospital admissions process • Nutritional counseling • Acute inpatient rehabilitation Note: Here are some things to keep in mind: • You do not need to precertify your normal delivery; see Section 3 for other circumstances, such as extended stays for you or your baby. • If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See Section 3 for information on requesting additional days. • We pay Inpatient hospital benefits for an admission in connection with dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(h). Note: See Section 5(a) for covered maternity services. Note: See Section 5(a) for coverage of blood and blood products.		Preferred: $100 per admission copayment for unlimited days Preferred: $100 per day copayment up to $500 per admission for unlimited days Member: $300 per admission copayment for unlimited days Member: You pay all charges Non-member: $300 per admission copayment for unlimited days, plus 30% of the Plan allowance, and any remaining balance after our payment Note: If you are admitted to a Non- member facility due to a medical emergency or accidental injury, you pay a $300 per admission copayment and we then provide benefits at 100% of the Plan allowance. Non-member: You pay all charges
NOT COVERED: Hospital room and board expenses when in our judgement, a hospital admission or portion of an admission is: • Custodial care • Convalescent care or a rest cure • Domiciliary care provided because care in the home is not available or unsuitable • Not medically necessary, such as when services did not require the acute/subacute hospital inpatient (overnight) setting but could have been provided safely and adequately in a physician's office, the outpatient department of a hospital, or some other setting, without adversely affecting your condition or the quality of medical care you receive. Some examples are: • • Admissions for or consisting primarily of observation and/or evaluation that could have been provided safely and adequately in some other setting (such as a physician's office) • • Admissions primarily for diagnostic studies, laboratory and pathology services, X-rays, MRIs, or machine diagnostic tests that could have been provided safely and adequately in some other setting (such as the outpatient department of a hospital or a physician's office) Note: If we determine that a hospital admission is one of the types listed above, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting. • Admission to non-covered facilities, such as nursing homes, extended care facilities, schools, residential treatment centers • Personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services • Inpatient private duty nursing		All charges All charges
Outpatient Hospital Or Ambulatory Surgical Center		You Pay Standard Option You Pay Basic Option
Outpatient medical services performed and billed for by a hospital or freestanding ambulatory facility, such as: • Use of special treatment rooms • Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic tests and X-rays • Chemotherapy and radiation therapy • Intravenous (IV) infusion therapy • Cardiac rehabilitation • Pulmonary rehabilitation • Physical, occupational, and speech therapy • Renal dialysis • Visits to the outpatient department of a hospital for non - emergency medical care • 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 • Other medical supplies, including oxygen Note: See Section 5(a) for covered preventive services for adults and children. Note: See Section 5(d) for our payment levels for care related to a medical emergency or accidental injury.		Preferred facilities: 10% of the Plan allowance (calendar year deductible applies) Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive the 10% coinsurance amount (and any deductible amount) and pay for covered services in full when you use a Preferred facility. Preferred facilities: $40 copayment per day per facility (except for diagnostic tests as noted below) Member facilities: 25% of the Plan allowance (calendar year deductible applies) Member facilities: You pay all charges (except for diagnostic tests as noted below) Non-member facilities: 25% of the Plan allowance; plus any difference between our allowance and the billed amount (calendar year deductible applies) Note: See Section 5(a) for our coverage of physical, occupational, and speech therapy. Non-member facilities: You pay all charges (except for diagnostic tests as noted below) Note: For outpatient diagnostic tests billed for by a Preferred, Member or Non-member facility, you pay nothing. Note: For outpatient facility care related to maternity, including care at birthing facilities, we provide benefits as shown here, according to the contracting status of the facility.
Outpatient surgery and related services performed and billed for by a hospital or freestanding ambulatory facility, such as: • Operating, recovery, and other treatment rooms • Anesthesia and anesthesia services • Pre-surgical testing performed within one business day of the covered surgical services • Facility supplies for hemophilia home care • Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic tests and X-rays • Visits to the outpatient department of a hospital for non - emergency surgical care • 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 • Other medical supplies, including oxygen Note: See below for outpatient drugs, medical devices, and durable medical equipment billed for by a hospital or freestanding ambulatory facility. Note: See Section 5(d) for our payment levels for care related to a medical emergency or accidental injury. Note: We cover outpatient hospital services and supplies related to 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(h), Dental benefits, for additional benefit information. Note: See Section 5(a) for covered maternity services.		Preferred facilities: 10% of the Plan allowance Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive the 10% coinsurance amount and pay for covered services in full when you use a Preferred facility. Preferred facilities: $40 copayment per day per facility (except for diagnostic tests as noted below) Member facilities: 25% of the Plan allowance Member facilities: You pay all charges (except for diagnostic tests as noted below) Non-member facilities: 25% of the Plan allowance; plus any difference between our allowance and the billed amount Non-member facilities: You pay all charges (except for diagnostic tests as noted below) Note: For outpatient diagnostic tests billed for by a Preferred Member, or Non-member facility, you pay nothing. Note: For outpatient facility care related to maternity, including care at birthing facilities, we provide benefits as shown here, according to the contracting status of the facility.
Outpatient drugs, medical devices, and durable medical equipment billed for by a hospital or freestanding ambulatory facility, such as: • Prescribed drugs • Orthopedic and prosthetic devices • Durable medical equipment		Preferred facilities: 10% of the Plan allowance (calendar year deductible applies) Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive the 10% coinsurance amount (and any deductible amount) and pay for covered services in full when you use a Preferred facility. Preferred facilities: 30% of the Plan allowance Note: You may also be responsible for paying a $40 copayment per day per facility for outpatient services. Member facilities: 25% of the Plan allowance (calendar year deductible applies) Member facilities: You pay all charges Non-member facilities: 25% of the Plan allowance; plus any difference between our allowance and the billed amount (calendar year deductible applies) Non-member facilities: You pay all charges Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we provide benefits as shown here, according to the contracting status of the facility.
Extended Care Benefits/Skilled Nursing Care Facility Benefits		You Pay Standard Option You Pay Basic Option
Limited to the following benefits for Medicare Part A copayments: When Medicare Part A is the primary payer (meaning that it pays first) and has made payment, Standard Option provides limited secondary benefits. We pay the applicable Medicare Part A copayments incurred in full during the first through the 30th day of confinement for each benefit period (as defined by Medicare) in a qualified skilled nursing facility. A qualified skilled nursing facility is a facility that specializes in skilled nursing care performed by or under the supervision of licensed nurses, skilled rehabilitation services, and other related care and meets Medicare's special qualifying criteria, but is not an institution that primarily cares for and treats mental diseases. If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day (when Medicare Part A copayments begin) and will end on the 30th day. Note: See Section 5(a) for benefits provided for outpatient physical, occupational and speech therapy when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs. Note: If you do not have Medicare Part A, we do not provide benefits for skilled nursing facility care.		Preferred: Nothing All charges Participating/ Member: Nothing Non- participating/ Non-member: Nothing Note: You pay all charges not paid by Medicare after the 30th day.
Hospice Care		You Pay Standard Option You Pay Basic Option
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to terminally ill patients in their homes. We provide the following home hospice care benefits for members with a life expectancy of six months or less when prior approval is obtained from the Local Plan and the home hospice agency is approved by the Local Plan: • Physician visits • Nursing care • Medical social services • Physical therapy • Services of home health aides • Durable medical equipment rental • Prescription drugs • Medical supplies		Nothing Nothing
Inpatient hospice for members receiving home hospice care benefits: Benefits are provided for up to five (5) consecutive days in a hospital or a freestanding hospice inpatient facility. Each inpatient stay must be separated by at least 21 days. These covered inpatient hospice benefits are available only when inpatient services are necessary to: • control pain and manage the patient's symptoms; or • provide an interval of relief (respite) to the family. Note: You are responsible for making sure that the home hospice care provider has received prior approval from the Local Plan (see Section 3 for instructions). Please check with your Local Plan and/or your PPO directory for listings of approved agencies.		Preferred: $100 per admission copayment Preferred: $100 per day copayment up to $500 per admission Member: $300 per admission copayment Member: You pay all charges Non-member: $300 per admission copayment plus 30% of the Plan allowance, and any remaining balance after our payment Non-member: You pay all charges
NOT COVERED: • Homemaker or bereavement services		All charges All charges
Ambulance		You Pay Standard Option You Pay Basic Option
Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and: • Associated with covered hospital inpatient care • Related to medical emergency • Associated with covered hospice care		Preferred: 10% of the Plan allowance Preferred: $50 copayment per trip Participating/ Member: 10% of the Plan allowance Participating/ Member: $50 copayment per trip Non-participating/ Non-member: 10% of the Plan allowance; plus any difference between our allowance and the billed amount Non-Participating/ Non-member: $50 copayment per trip
Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and when related to accidental injury		Preferred: Nothing (No deductible) Preferred: $50 copayment per trip Participating/ Member: Nothing (No deductible) Participating/ Member: $50 copayment per trip Non-participating/ Non-member: Any difference between the Plan allowance and the billed amount (No deductible) Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above. Non-Participating/ Non-member: $50 copayment per trip

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2006 BENEFITS

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