Health Insurance Plans

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1 Health Insurance Plans for Small Groups (less than 50 employees) from Blue Cross of Idaho Choose coverage that fits. Form No (03-14) Policy Form Numbers: / / / / / / / / / / / / /11

2 The Best Value in Health Insurance As an Idaho employer, you have a difficult job balancing the need to manage healthcare costs while still providing your employees with a quality health insurance plan that offers excellent service and the tools to help them stay healthy. We re here to make your job easier. At Blue Cross of Idaho, we re dedicated to delivering the best value in health insurance to our small business customers. Our goal is to give your employees access to quality care at affordable premiums. We do this by providing: Extensive provider networks Integrated claims management Exceptional customer service Wellness tools and resources Flexible benefit plan design In this guide, we ll introduce you to our product portfolio, describe the services and resources we offer group members, and explain how the Affordable Care Act may impact your business. We know you have options when you look for health insurance. We re confident you ll find that Blue Cross of Idaho offers the best value in health coverage and useful tools to help your employees and your business stay healthy. 2 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

3 Blue cross of Idaho Health Insurance Plans Choosing the Right Plan Choosing the right coverage for your employees and their families depends on their healthcare needs and what your budget will allow. Blue Cross of Idaho has a variety of group medical plans available for small businesses and their employees. Coverage for dental, vision, employee assistance program (EAP) and additional wellness programs are also available. We organize our small group plans into three metal levels based on the amount of coverage provided. These levels are bronze, silver and gold. We offer different network options within each level; PPO (preferred provider organization), POS (point of service) and our Connect plans which are paired with ConnectedCare networks in Southwestern and Eastern Idaho. All plans include essential health benefits, such as emergency room services, maternity and newborn care, annual doctor visits, prescription drugs and medical screenings. Provider Network You ll get the best choice of doctors and hospitals with Blue Cross of Idaho. As you read the descriptions of each of the plans, you ll notice that Choice plans use our PPO network. Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. As you consider which plan is right for you, check to make sure the healthcare providers and facilities, such as hospitals, you like are in the plan s provider network. You can look for specific doctors and hospitals through our Find a Provider link on our homepage at members.bcidaho.com. Things to Consider The metal plans differ based on the percentage of health care cost paid by the employee in deductibles, coinsurance and copayments. In general, out-of-pocket costs like deductibles are highest for bronze plans and lower as you move from silver to gold. Premium payments are lower on the Bronze plans and gradually increase in our Silver and Gold plans. Please see the product table on the following pages for a general benefit outline of commonly used services. Check out Blue Cross of Idaho s insurance products for each metal level to find the plan that s right for you. Choose coverage that fits bcidaho.com 3

4 Metal level Plans bcidaho.com/sbc for a Summary of Benefits and Coverage. Benefit grid outlines coverage for in-network and out-of-network services for small groups. Not a comprehensive list of benefits. Bronze Bronze HSA Saver INDIVIDUAL In-Network (Individual) Out-of-Network (Individual) Bronze HSA Saver FAMILY In-Network (Family) Out-of-Network (Family) Deductible Individual $6,000 Individual $6,000 Family $12,000 Family $12,000 Annual Out-of-Pocket Maximum Costs Coinsurance Individual $6,000 Individual $8,000 Family $12,000 Family $16,000 The individual deductible applies ONLY to an individual plan with one insured member. If more than one member is insured on an individual HSA plan, the family deductible applies and each family member contributes towards the family deductible. Benefits for all family members begin after meeting the family deductible. You pay nothing. ( may be You pay 50% ( may be subject subject to to The claims of all family members accumulate toward the same family deductible and out-of-pocket maximum. Benefits for all family members begin after the family deductible is met. You pay nothing. ( may be subject to You pay 50% ( may be subject to What You ll Pay up to your annual out-of-pocket maximum Preventive Care Doctor s Office Prescription Drugs preventive prescriptions. For other generic and brand-name prescriptions, you pay costs up to your in-network deductible Immunizations immunizations. immunizations. Inpatient Hospital Stays Emergency Room Maternity Outpatient Mental Health 1 1 Pediatric Vision Care (For plan members under age 19) Physician, Surgical & Medical Diabetes Education Chiropractic Care You pay nothing for one eye exam, one You pay nothing for one eye exam, one Outpatient Rehabilitation Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Up to a combined in- and out-of-network total of 18 visits per member, per benefit Up to a combined in- and out-of-network total of 18 visits per member, per benefit Limited to a combined total of 20 visits per member, per benefit 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 4 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

5 Blue cross of Idaho Health Insurance Plans Metal level Bronze Plans Bronze Choice 3000 Bronze Point 3000 Bronze Connect 3000* In-Network Out-of-Network Deductible Individual - $3,000 Family - $6,000 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Doctor s Office Prescription Drugs Immunizations Inpatient Hospital Stays Emergency Room Maternity Outpatient Mental Health Pediatric Vision Care (For plan members under age 19) Physician, Surgical & Medical Diabetes Education Chiropractic Care Outpatient Rehabilitation Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Individual - $6,000 Family - $12,000 Individual - $3,000 Family - $6,000 Individual - $8,000 Family - $16,000 (Separate $6,000 Individual / $12,000 Family Prescription Out-of-Pocket Maximum) You pay 30% of the cost of your You pay 50% of the cost of your care. ( may be subject to care. ( may be subject to What You ll Pay up to your annual out-of-pocket maximum and then you pay $30 copayment for primary care office visits, you pay $50 copayment for specialist office visits. (Bronze Connect members must have referral for non-pcp visits.) You pay $10 copayment for generic drugs. You pay costs up to a separate $250 individual/$500 family deductible for brandname and specialty drugs and then: $30 for preferred brand-name, $45 for non-preferred brand-name, $100 for specialty drugs. Generic prescriptions are not subject to deductible, but this plan has a separate $6,000 Individual / $12,000 Family Prescription Out-of-Pocket Maximum. immunizations. and then 30%., 30% and $150 copayment. and then 30%. and then you pay $30 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to your deductible and then 30%. You pay nothing for one eye exam, one and then 30%. and then $30 copayment. and then 30%., 50% and $150 copayment. 1 Up to a combined in- and out-of-network total of 18 visits per member, per benefit and then 30%. and then 30%. Limited to a combined total of 20 visits per member, per benefit Provider networks in southwest and southeast Idaho support the Bronze, Silver, Gold Connect plans and members must visit doctors or hospitals within a specific service area and receive referrals to see specialists from a Primary Care Provider (PCP). See Connect description on Page 3. Key terms Premium The amount you pay each month for your health insurance plan. Deductible The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won t have to pay any deductible for some services. Coinsurance Your share of the costs you pay, calculated as a percentage. (For example, you pay 20 percent, insurance pays 80 percent). Copayment A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication. Network The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members. Out-of-Pocket Expenses Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions. Out-of-Pocket Maximum After your premium payments, the most in a year you will pay for covered healthcare services. The cost of your care When you use in-network providers, your cost of care is lower because even when you are paying your deductible, you only pay Blue Cross of Idaho s discounted fee. * Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator. You must obtain a referral from your PCP to see a specialist. 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. Choose coverage that fits bcidaho.com 5

6 bcidaho.com/sbc for a Summary of Benefits and Coverage. Benefit grid outlines coverage for in-network and out-of-network services for small groups. Not a comprehensive list of benefits. Metal level Plans Deductible Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Silver HSA Saver INDIVIDUAL In-Network (Individual) Out-of-Network (Individual) SILVER Silver HSA Saver FAMILY In-Network (Individual) Out-of-Network (Individual) Individual - $2,000 Individual - $2,000 Family - $4,000 Family - $4,000 Individual - $5,000 Individual - $7,000 Family - $10,000 Family - $14,000 The individual deductible applies ONLY to an individual plan with one insured member. If more than one member is insured on an individual HSA plan, the family deductible applies and each family member contributes towards the family deductible. Benefits for all family members begin after meeting the family deductible. The claims of all family members accumulate toward the same family deductible and out-of-pocket maximum. Benefits for all family members begin after the family deductible is met. You pay 20% of the cost of your care. ( may be subject to You pay 40% of the cost of your care. ( may be subject to You pay 20% of the cost of your care. ( may be subject to You pay 40% of the cost of your care. ( may be subject to What You ll Pay up to your annual out-of-pocket maximum Doctor s Office Prescription Drugs generic and brand-name preventive prescriptions. For other generic and brand-name prescriptions, you pay costs up to your innetwork deductible and then you pay 20% coinsurance. Immunizations immunizations. immunizations. Inpatient Hospital Stays Emergency Room Maternity, 20% and $150 copayment. generic and brand-name preventive prescriptions. For other generic and brand-name prescriptions, you pay costs up to your innetwork deductible and then you pay 20% coinsurance.,, 40% and $150 copayment. 1 20% and $150 copayment. then 40%., 40% and $150 copayment. 1 then 40%. Outpatient Mental Health Pediatric Vision Care (For plan members under age 19) Physician, Surgical & Medical Diabetes Education Chiropractic Care You pay nothing for one eye exam, one You pay $30 copayment, then costs up to your deductible and 20%. You pay nothing for one eye exam, one You pay $30 copayment, then costs up to your deductible and 20%. Outpatient Rehabilitation Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Up to a combined in- and out-of-network total of 18 visits per member, per benefit Limited to a combined total of 20 visits per member, per benefit period Up to a combined in- and out-of-network total of 18 visits per member, per benefit Limited to a combined total of 20 visits per member, per benefit period 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 6 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

7 Metal level SILVER Gold Plans Silver Choice 2000 Silver Point 2000 Silver Connect 2000 * In-Network Out-of-Network Deductible Individual - $2,000 Family - $4,000 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Doctor s Office Prescription Drugs Individual - $6,350 Family - $12,700 Individual - $2,000 Family - $4,000 Individual - $8,350 Family - $16,700 (Separate $6, 350 Individual / $12,700 Family Prescription Out-of-Pocket Maximum) You pay 30% of the cost of your You pay 50% of the cost of your care. ( may be subject to care. ( may be subject to In-Network Individual - $2,000 Family - $4,000 Individual - $3,500 Family - $7,000 (Separate $3,500 Individual / $7,000 Family Prescription Out-of-Pocket Maximum) You pay 20% of the cost of your care. ( may be subject to Gold Choice 2000 Gold Point 2000 Gold Connect 2000* Out-of-Network Individual - $2,000 Family - $4,000 Individual - $5,500 Family - $11,000 You pay 40% of the cost of your care. ( may be subject to What You ll Pay up to your annual out-of-pocket maximum then 50%. Silver Choice and Silver Point: You pay $30 copayment for primary care then 50%. office visits and a $50 copayment for specialist office visits. (Silver Connect members must have referral for non- PCP visits.) You pay $10 copayment for generic prescriptions. You pay $50 for preferred brand-name, $65 for non-preferred brand-name, $100 for specialty drugs. Prescriptions are not subject to deductible, but this plan has a separate $2, 350 Individual / $12,700 Family Prescription Out-of-Pocket Maximum. You pay $20 copayment for primary care office visits and $40 copayment for specialist office visits. (Gold Connect members must have referral for non-pcp visits.) You pay a $10 copayment for generic prescriptions. You pay a $20 copayment for preferred brand-name, a $35 copayment for non-preferred brand-name, and a $100 copayment for specialty drugs. Prescriptions are not subject to deductible, but this plan has a separate $3,500 Individual / $7,000 Family Prescription Out-of-Pocket Maximum. Immunizations immunizations. immunizations. Inpatient Hospital Stays Emergency Room Maternity then 30%., 30% and $150 copayment. then 30%. Blue cross of Idaho Health Insurance Plans Provider networks in southwest and southeast Idaho support the Bronze, Silver, Gold Connect plans and members must visit doctors or hospitals within a specific service area and receive referrals to see specialists from a Primary Care Provider (PCP). See Connect description on Page 3. then 50%., 50% and $150 copayment. 1, 20% and $150 copayment. then 50%., 40% and $150 copayment. 1 Outpatient Mental Health Pediatric Vision Care (For plan members under age 19) Physician, Surgical & Medical Diabetes Education Chiropractic Care You pay $30 copayment for outpatient psychotherapy services (not subject to deductible). For facility and other professional services, you pay costs up to your deductible and then 30%. You pay nothing for one eye exam, one then 30%. You pay $30 copayment per visit. then 30%. then 50%. then 50%. then 50%. You pay $20 copayment for outpatient psychotherapy services (not subject to deductible). For facility and other professional services, you pay costs up to your deductible You pay nothing for one eye exam, one pair of eyeglasses or contact lenses and one eyeglasses frame per benefit You pay $20 copayment per visit. Outpatient Rehabilitation Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Up to a combined in- and out-of-network total of 18 visits per member, per benefit then 30%. then 30%. then 50%. Limited to a combined total of 20 visits per member, per benefit period then 50%. Up to a combined in- and out-of-network total of 18 visits per member, per benefit Limited to a combined total of 20 visits per member, per benefit period * Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator. You must obtain a referral from your PCP to see a specialist. 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. Choose coverage that fits bcidaho.com 7

8 Provider networks in southwest and southeast Idaho support the Bronze, Silver, Gold Connect plans and members must visit doctors or hospitals within a specific service area and receive referrals to see specialists from a Primary Care Provider (PCP). See Connect description on Page 3. Metal level Plans Gold Choice 1000 Gold Point 1000 Gold Connect 1000* In-Network Out-of-Network Gold In-Network Gold Choice 500 Gold Point 500 Gold Connect 500* Out-of-Network Deductible Individual - $1,000 Family - $2,000 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Doctor s Office Prescription Drugs Individual - $4,000 Family - $8,000 (Separate $4,000 Individual / $8,000 Family Prescription Out-of-Pocket Maximum) You pay 20% of the cost of your care. ( may be subject to You pay $30 copayment for primary care office visits and $50 copayment for specialist office visits. (Gold Connect members must have referral for non-pcp visits.) Individual - $1,000 Family - $2,000 Individual - $6,000 Family - $12,000 You pay 40% of the cost of your care. ( may be subject to Individual - $500 Family - $1,000 Individual - $4,000 Family - $8,000 (Separate $4,000 Individual / $8,000 Family Prescription Out-of-Pocket Maximum) You pay 20% of the cost of your care. ( may be subject to Individual - $500 Family - $1,000 Individual - $6,000 Family - $12,000 You pay 40% of the cost of your care. ( may be subject to What You ll Pay up to your annual out-of-pocket maximum You pay $10 copayment for generic prescriptions. You pay $30 copayment for preferred brand-name, $45 copayment for non-preferred brand-name, and $100 copayment for specialty drugs. Prescriptions are not subject to deductible, but this plan has a separate $4,000 Individual / $8,000 Family Prescription Out-of-Pocket Maximum. You pay $30 copayment for primary care office visits and $50 copayment for specialist office visits. (Gold Connect members must have referral for non-pcp visits.) You pay $10 copayment for generic prescriptions. You pay $30 copayment for preferred brand-name, $45 copayment for non-preferred brand-name, and $100 copayment for specialty drugs. Prescriptions are not subject to deductible, but this plan has a separate $4,000 Individual / $8,000 Family Prescription Out-of-Pocket Maximum. Immunizations immunizations. immunizations. Inpatient Hospital Stays Emergency Room Maternity, 20% and $150 copayment. You pay costs to your deductible and then 20%.,, 40% and $150 copayment. 1 20% and $150 copayment., 40% and $150 copayment. 1 Outpatient Mental Health Pediatric Vision Care (For plan members under age 19) Physician, Surgical & Medical Diabetes Education Chiropractic Care You pay $30 copayment for outpatient psychotherapy services (not subject to deductible). For facility and other professional services, you pay costs up to your deductible You pay nothing for one eye exam, one pair of eyeglasses or contact lenses and one eyeglasses frame per benefit You pay $30 copayment per visit. You pay $30 copayment for outpatient psychotherapy services (not subject to deductible). For facility and other professional services, you pay costs up to your deductible and 20%. You pay nothing for one eye exam, one pair of eyeglasses or contact lenses and one eyeglasses frame per benefit You pay $30 copayment per visit. Outpatient Rehabilitation Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Up to a combined in- and out-of-network total of 18 visits per member, per benefit Limited to a combined total of 20 visits per member, per benefit period Up to a combined in- and out-of-network total of 18 visits per member, per benefit Limited to a combined total of 20 visits per member, per benefit period * Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator. You must obtain a referral from your PCP to see a specialist. 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 8 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

9 Dental Plans Dental Plans Oral health is important to your employees and we offer a variety of dental plans that are flexible and affordable. Our plans ensure your employees have the dental coverage they need at a price you can afford. Blue Cross of Idaho dental plans offer: Benefit design flexibility Access to the largest preferred provider organization (PPO) and traditional dental provider networks in Idaho Access to the national Dental GRID, a dental network of participating Blue Cross Blue Shield plans, with access to additional networks in states where there are no participating Blue plan networks. Negotiated provider discounts that allow your employees to stretch their benefit dollars and save on dental costs Our dental coverage will make you smile Getting your dental coverage through Blue Cross of Idaho also provides the convenience of having your medical and dental coverage through one insurance company. One customer service telephone number for dental and medical benefit questions One ID card One billing statement One renewal Orthodontic Values If you are a Blue Cross of Idaho member, no matter what your plan covers, you will receive a discount of $400 off the total cost of full orthodontic treatment plans for eligible family members. All you have to do is show the Blue Extras! provider your Blue Cross member ID card. The discount applies to any treatment plan which is initiated after the orthodontist s effective date. Blue Extras! is a discount program and not a part of your insurance coverage. Choose coverage that fits bcidaho.com 9

10 Dental Choice and Dental Choice Plus Our Dental Choice and Dental Choice Plus plans offer benefit designs that protect your employees dental health and meet all dental requirements of the Affordable Care Act. This includes coverage for medically necessary orthodontia and no benefit period maximums for people under age 19. Dental Blue Connect Dental Blue Connect offers extensive dental coverage with: No deductibles No benefit period maximums No waiting periods No claim forms Orthodontia, with no age limit, is available for all eligible members on all Dental Blue Connect plans. All necessary dental services are covered at 100% after applicable co-payments when performed by dentists and specialists at Willamette Dental Group. Essential Dental Essential Dental is our low cost dental care option, providing your employees with benefits for preventive, diagnostic and basic dental services. Major dental services are not covered, which keeps premiums lower than other dental plans. Deductible Dental Deductible Dental has the flexibility you need when providing dental benefits to your employees and their families. Blue Cross of Idaho s contracting dentists agree to recognize our maximum allowance as their maximum fee for eligible services. Members are responsible for any coinsurance, deductibles and costs for noncovered services. Incentive Dental With Incentive Dental, your employees are rewarded for taking care of their smile! Starting at 70%, benefit payments increase 10% each year up to 100% for preventive, diagnostic and basic dental services, as long as they visit a dental provider each consecutive year. For each year that a member does not receive dental services, the amount payable will decrease by 10%. Major dental services are covered at 50% with no deductible. Preferred Blue Dental Preferred Blue Dental plans maximize consumer choice and flexibility, while delivering reduced premiums and lower out-of-pocket expenses. That s because Preferred Blue Dental is a PPO plan that uses our nationwide network of dentists and specialists. Preventive, basic, and major dental services are covered. Voluntary Dental Voluntary Dental is a great way to provide your employees with easy access to dental care coverage. As implied by the name, the plan is entirely voluntary, meaning that your employees decide whether or not they want to participate. And, because the program is voluntary, there are no employee participation or employer contribution requirements. 10 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

11 ? Tools for Maintaining and Improving Health By choosing Blue Cross of Idaho, you can not only choose from a variety of benefit plans, but you give your employees access to a variety of support tools, including: WellConnected sm, a collection of health and well-being services to help members make positive lifestyle changes and informed decisions about their healthcare. Blue Extras! sm offers a variety of discounted of non-covered health services to assist employees in achieving personal health, wellness and fitness goals. PHM helps members with chronic diseases, such as diabetes, asthma, and congestive heart failure or learn about their condition and better manage their own care. Case management helps employees with complex care conditions use services in the most cost effective and appropriate manner. Integrated behavioral health case management and pharmacy case management also help control costs while ensuring your employees are receiving appropriate, quality healthcare. Wellness is not only good for your employees, it s good for your business. Healthier employees tend to be more productive, with lower rates of disability and absenteeism. Research shows that a significant portion of total healthcare costs are due to modifiable behaviors, so over the long run, a healthier workplace can help contain healthcare costs. Choose coverage that fits bcidaho.com 11

12 ACA Effects on Small Business The Affordable Care Act began changing the healthcare delivery and health insurance landscape in However, beginning in 2014, employers face the difficult task of determining whether it makes better financial sense to offer coverage to employees or to leave it to employees to purchase individual or family coverage on the public exchange. To help employers quantify the cost impacts of these options, Blue Cross of Idaho has purchased a software tool from Milliman, a consulting firm with considerable experience in the healthcare marketplace. With employee and business information, we can create a strategic impact report specific to a small business like yours. This resource helps our existing group accounts see how healthcare reform affects both your employees and your bottom line now and in the future. To receive an assessment of the ACA s impact on your organization, contact your Blue Cross of Idaho broker or account representative. Highlights will include information on: Projected tax risks Premium and cost sharing estimates for employer-based plans vs. the Exchange Anticipated tax credits for employers with fewer than 25 employees Estimated impact on rates for employers with fewer than 50 employees Estimates of ACA eligibility and affordability for employees Estimates on employee compensation needed to replace the value of the health plan Employer pre and post-tax cost of terminating coverage. 12 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

13 Affordable Care act at a Glance ACA at a Glance The new healthcare law, passed in 2010 and upheld by the Supreme Court 2012, brings many changes to health insurance purchased by individuals and families or by small and large businesses. The Affordable Care Act changes how we purchase and pay for insurance, and brings new plan options and even financial assistance to those who qualify. Here s a snapshot of the major changes: You can t be denied coverage because of a pre-existing health condition. Insurance companies can t drop your coverage if you get sick. All health plans must cover a standard set of essential health benefits, including emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services. Essential health benefits carry no annual or lifetime dollar maximums. Parents can keep their kids on their plans until those dependents are 26 years old. All Idahoans, with few exceptions, are required to have health insurance or pay a tax penalty. Monthly premium tax credits and/or cost sharing subsidies may be available to offset out-of-pocket costs for those who qualify. The Idaho Health Insurance Exchange is an online marketplace where both individuals and small businesses can compare and purchase plans. Blue Cross of Idaho is your health insurance partner. We re committed to helping you understand the complex health insurance and healthcare delivery systems so you can find the best coverage for your company and your employees. We know you have options when you look for health insurance, but trust that you ll find that Blue Cross of Idaho offers the best value in health coverage, along with many useful tools to help your employees and your business stay healthy. Preventive care, such as annual doctor visits or regular health screenings, is now covered with no out-ofpocket costs through your insurance plan. The annual out-of-pocket maximum (after premiums) for in-network healthcare services is $6,350 for individuals and $12,700 for families. Did You Know? The Affordable Care Act changes how we purchase and pay for insurance, and brings new plan options and even financial assistance to those who qualify. Choose coverage that fits bcidaho.com 13

14 Exclusions & Limitations In addition to the exclusions and limitations listed elsewhere in this booklet, the following exclusions and limitations apply to the entire Policy, unless otherwise specified: There are no benefits for services, supplies, drugs, or other charges that are: not Medically Necessary. If services requiring Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Insured. However, the Insured could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider. In excess of the Maximum Allowance. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Insured has a non-dental, life-endangering condition which makes hospitalization necessary to safeguard the Insured s health and life. not prescribed by or upon the direction of a Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed General Hospitals, Physicians, and other Providers. Investigational in nature. Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party. Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefore would vary, or are or would be affected by the existence of coverage under this Policy. Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured s household. received from a dental, vision, or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group. For Surgery intended mainly to improve appearance or for complications arising from Surgery intended mainly to improve appearance, except for: reconstructive Surgery necessary to treat an Accidental Injury, infection or other Disease of the involved part; or reconstructive Surgery to correct Congenital Anomalies in an Insured who is a dependent child. Benefits for reconstructive Surgery to correct an Accidental Injury are available even though the accident occurred while the Insured was covered under a prior insurer s coverage, if there is no lapse of more than sixty-three (63) days between the prior coverage and coverage under this Policy. rendered prior to the Insured s Effective Date. For personal hygiene, comfort, beautification (including non-surgical services, drugs, and supplies intended to enhance the appearance), or convenience items or services even if prescribed by a Physician, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, homeopathic, or naturopathic, massage, or music. For telephone consultations, and all computer or Internet communications. For failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider. For Inpatient admissions that are primarily for Diagnostic or Therapy ; or for Inpatient admissions when the Insured is ambulatory and/or confined primarily for bed rest, special diet, behavioral problems, environmental change or for treatment not requiring continuous bed care. For Inpatient or Outpatient Custodial Care; or for Inpatient or Outpatient services consisting mainly of educational therapy, behavioral modification, self-care or self-help training, except as specified as a Covered Service in this Policy. For any cosmetic foot care, including but not limited to, treatment of corns, calluses, and toenails (except for surgical care of ingrown or Diseased toenails). related to Dentistry or Dental Treatment, even if related to a medical condition; or orthoptics, eyeglasses or contact Lenses, or the vision examination for prescribing or fitting eyeglasses or contact Lenses, unless specified as a Covered Service in this Policy. 14 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Small Groups

15 Exclusions and limitations For hearing aids or examinations for the prescription or fitting of hearing aids. For any treatment of either gender leading to or in connection with transsexual Surgery, gender transformation, sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition. Made by a Licensed General Hospital for the Insured s failure to vacate a room on or before the Licensed General Hospital s established discharge hour. not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. Furnished by a facility that is primarily a place for treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home. For Acute Care, Rehabilitative care, diagnostic testing except as specified as a Covered Service in this Policy; for Mental or Nervous Conditions and Substance Abuse or Addiction services not recognized by the American Psychiatric and American Psychological Associations. For any of the following: For appliances, splints or restorations necessary to increase vertical tooth dimensions or restore the occlusion, except as specified as a Covered Service in this Policy; For orthognathic Surgery, including services and supplies to augment or reduce the upper or lower jaw; For implants in the jaw; for pain, treatment, or diagnostic testing or evaluation related to the misalignment or discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies; For alveolectomy or alveoloplasty when related to tooth extraction. For weight control or treatment of obesity or morbid obesity, even if Medically Necessary, including but not limited to Surgery for obesity. For reversals or revisions of Surgery for obesity, except when required to correct a life-endangering condition. For use of operating, cast, examination, or treatment rooms or for equipment located in a Contracting or Noncontracting Provider s office or facility, except for Emergency room facility charges in a Licensed General Hospital unless specified as a Covered Service in this Policy. For the reversal of sterilization procedures, including but not limited to, vasovasostomies or salpingoplasties. treatment for infertility and fertilization procedures, including but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance an Insured s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures. For Transplant services and Artificial Organs, except as specified as a Covered Service under this Policy. For acupuncture. For surgical procedures that alter the refractive character of the eye, including but not limited to, radial keratotomy, myopic keratomileusis, Laser-In-Situ Keratomileusis (LASIK), and other surgical procedures of the refractive-keratoplasty type, to cure or reduce myopia or astigmatism, even if Medically Necessary, unless specified as a Covered Service in a Vision Benefits Section of this Policy, if any. Additionally, reversals, revisions, and/or complications of such surgical procedures are excluded, except when required to correct an immediately lifeendangering condition. For Hospice, except as specified as a Covered Service in this Policy. For pastoral, spiritual, bereavement, or marriage counseling. For homemaker and housekeeping services or home-delivered meals. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence. For treatment or other health care of any Insured in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Insured to Covered under this Policy, if and to the extent those benefits are payable to or due the Insured under any medical payments provision, no fault provision, uninsured motorist provision, underinsured motorist provision, or other first party or no fault provision of any automobile, homeowner s, or other similar policy of insurance, contract, or underwriting plan. In the event Blue Cross of Idaho (BCI) for any reason makes payment for or otherwise provides benefits excluded by the above provisions, it shall succeed to the rights of payment or reimbursement of the compensated Provider, the Insured, and the Insured s heirs and personal representative against all insurers, underwriters, selfinsurers or other such obligors contractually liable or obliged to the Insured, or his or her estate for such services, supplies, drugs or other charges so provided by BCI in connection with such Illness, Disease, Accidental Injury or other condition. any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party. For a routine or periodic mental or physical examination that is not connected with the care and treatment of an actual Illness, Disease or Accidental Injury or for an examination required on account of employment; or related to an occupational injury; for a marriage license; or for insurance, school or camp application; or for sports participation physicals; or a screening examination including routine hearing examinations, except as specified as a Covered Service in this Policy. For immunizations, except as specified as a Covered Service in this Policy. For breast reduction Surgery or Surgery for gynecomastia. For nutritional supplements. For replacements or nutritional formulas except, when administered enterally due to impairment in digestion and absorption of an oral diet and is the sole source of caloric need or nutrition in an Insured. For vitamins and minerals, unless required through a written prescription and cannot be purchased over the counter. For an elective abortion, except to preserve the life of the female upon whom the abortion is performed, unless benefits for an elective abortion are specifically provided by a separate Endorsement to this Policy. For alterations or modifications to a home or vehicle. For special clothing, including shoes (unless permanently attached to a brace). Provided to a person enrolled as an Eligible Dependent, but who no longer qualifies as an Eligible Dependent due to a change in eligibility status that occurred after enrollment. Provided outside the United States, which if had been provided in the United States, would not be a Covered Service under this Policy. Furnished by a Provider or caregiver that is not listed as a Covered Provider, including but not limited to, naturopaths and homeopaths. For Outpatient pulmonary and/or cardiac Rehabilitation. For complications arising from the acceptance or utilization of noncovered services. For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service. For dental implants, appliances (with the exception of sleep apnea devices), and/or prosthetics, and/or treatment related to Orthodontia, even when Medically Necessary unless specified as a Covered Service in this Policy. For arch supports, orthopedic shoes, and other foot devices. For wigs. For cranial molding helmets, unless used to protect post cranial vault surgery. For surgical removal of excess skin that is the result of weight loss or gain, including but not limited to association with prior weight reduction (obesity) Surgery. For the purchase of Therapy or Service Dogs/ Animals and the cost of training/maintaining said animals. Choose coverage that fits bcidaho.com 15

16 P.O. Box 7408 Boise, ID GO CROSS ( ) bcidaho.com Street Address 3000 East Pine Avenue Meridian, ID Meridian Mailing Address P.O. Box 7408 Boise, ID Claims Inquiries (208) (800) Coeur d Alene 1450 Northwest Boulevard, Suite 106 Coeur d Alene, ID Street Address 1910 Channing Way Idaho Falls, ID Idaho Falls Mailing Address P.O. Box 2287 Idaho Falls, ID Street Address th Street Lewiston, ID Street Address 275 South 5th Avenue Suite 150 Pocatello, ID Street Address 1431 North Fillmore Street Suite 200 Twin Falls, ID Lewiston Pocatello Twin Falls Mailing Address P.O. Box 1468 Lewiston, ID Mailing Address P.O. Box 2578 Pocatello, ID Mailing Address P.O. Box 5025 Twin Falls, ID Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association.

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