2015 Health Care Options

Transcription

1 10455 Mill Run Circle Owings Mills, Maryland January 1, 2015 December 31, Health Care Options

2 CareFirst BlueCross BlueShield Your plan for healthy living CareFirst is not only the largest health care insurer in the Mid-Atlantic, we are also your neighbor. As fellow Marylanders, we value our relationship with State of Maryland employees and retirees and look forward to continuing as your health insurance provider for many years to come. This guide outlines the 2015 changes to your plan as well as the many resources and tools available to help you continue on the path to good health. Quality health plans, satisfied members While it s important for us to offer you high-quality health plans, we also strive to keep you happy and healthy. That s the true measure of a health care plan s success. According to a 2013 regional independent study 1, CareFirst ranks first among other major carriers in the region in all key categories including: Overall satisfaction Number of doctors Likelihood to recommend Caring about its members Being there when you need it We help you take charge of your health Whether you re looking for health and wellness tips, discounts on health-related services, or support to manage a health condition, we have resources to help. With our Health + Wellness Program, you can: Identify habits that could put your health at risk with an online Health Risk Assessment. Manage a chronic condition such as diabetes, or deal with unexpected health issues and medical emergencies with the support of a coordinated health care team. Improve your health with programs that target your specific health or lifestyle issues. We connect with you on the move With CareFirst mobile you can access all your plan information from your smartphone. Find a provider Review claims Contact us View your ID card View benefit information Find a nearby urgent care center 1 Comprehensive Satisfaction Survey conducted by Mathew Greenwald & Associates, an independent marketing research firm. Results are among members of large employers (200+) in the CareFirst service region for Survey included other carriers providing health care benefits in the CareFirst service region including Cigna, United and Aetna.

3 New for January 1, 2015 Wellness Program Mental health now administered by CareFirst for all plans EPO copayment out-of-pocket changed to $1,500 individual/$3,000 family Diagnostic and lab related to Diabetes, Hypertension, Coronary Artery Disease, Asthma and COPD including test strips in-network pays at 100% Acupuncture and Chiropractic copayments $30 for all products PPO (Offered to all active employees and retirees with or without Medicare regardless of where they reside.) Office Visit $15 PCP copay / $30 Specialist copay. Emergency Room $75 facility copay plus $75 physician copay, copays waived if admitted. Plan pays 90% of Allowed Benefit in-network and 70% of Allowed Benefit out-of-network for services not associated with a copay. Total Medical out of pocket limits in-network $2,000 individual/$4,000 family; out of network $3,250 individual/$6,500 family Coinsurance and Deductible out-of-pocket in-network $1,000 individual/$2,000 family; out-of-network $3,000 individual/$6,000 family. Copayment out-of-pocket $1,000 individual/$2,000 family; applies to all medical and behavioral health services. Out-of-network benefits subject to deductibles ($250 individual/$500 family). EPO (Offered to all active employees and retirees with or without Medicare regardless of where they reside.) Office visit $15 PCP copay / $30 Specialist copay. Emergency room Copay $75 facility copay plus $75 physician copay; waived if admitted. Plan pays 100% of Allowed Benefit in-network for services not associated with a copay; no out-of-network benefits other than medical emergency services. Copayment out-of-pocket $1,500 individual/ $3,000 family; applies to all medical and behavioral health services. If you are a current Point of Service (POS) member you must select a new plan for 1/1/15 or you won t have coverage. The CareFirst plan most similar to your current coverage is our PPO plan offering out-ofnetwork benefits or consider our EPO with in-network coverage only. As the largest health care insurer in the Mid-Atlantic region, CareFirst BlueCross BlueShield has a lot to offer through our EPO and PPO plans: One of the most widely recognized and accepted health care identification cards. Access to our network of more than 40,000 doctors and specialists and 76 hospitals in Maryland, Washington DC and Northern Virginia. You can take your health care benefits with you across the country and around the world. While EPO members have access to in-network providers, the PPO plan offers the additional freedom for members to visit providers outside of the network so they can receive care from the provider of their choice. No referrals to see a specialist. FirstHelp 24-hour nurse line. Blue 365 delivers great discounts from top national and local retailers on fitness gear, gym memberships, family activities, healthy eating options and more.

4 How to locate a provider 1. Go to 2. Click the Find a Doctor link at the top of the Home page. 3. Click the Find a Doctor button on the landing page. 4. Choose your health plan and click Continue. If you need assistance finding a provider, call Customer Service at / My Account Online access to your claims Features of My Account Request replacement ID card. Find out who s covered on your policy and the effective date of your coverage. Check your deductible and out-of-pocket costs for your current and previous plan year. Review up to one year of medical claims total charges, benefits paid, and costs for a specific date range. a nurse and receive a secure, online response within 24 hours. Plan for surgeries and other procedures by comparing outcomes and other quality measures for nearby hospitals. Signing up is easy Visit My Account and set up your User ID and Password. You ll just need information from your member ID card. Secure Your log-in information is completely secure. Select your own User ID and Password, which you can change at any time. Our staff will never ask you for your password and to protect your security you ll be logged out automatically after 15 minutes of inactivity. Paperless You can help control rising health care costs, while protecting the environment, by switching to paperless communications through My Account. CONNECT WITH US: Customer Service: / BOK5314-1S (9/14) CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

5 Benefits PPO Preferred Provider Option (using the PPO national network) CareFirst EPO Benefit Period 1/1/ /31/2015 In-Network Out-of-Network In-Network (using the PPO national network) TOTAL MEDICAL OUT-OF-POCKET $2,000 individual/$4,000 family $3,250 individual/$6,500 family $1,500 individual/$3,000 family COPAY OUT-OF-POCKET $1,000 individual/$2,000 family $1,500 individual/$3,000 family COINSURANCE/DEDUCTIBLE OUT-OF-POCKET $1,000 individual/$2,000 family $3,000 individual/$6,000 family None DEDUCTIBLE None $250 individual/$500 family None LIFETIME MAXIMUM None None None PREVENTIVE/WELL CARE (ROUTINE) Well Baby/Child Visits and associated lab (0 36 months, up to 13 visits; 3 years 21 years, 1 visit per plan year) Immunizations for adults and children as recommended by the Centers for Disease Control, U.S. Task Force of Preventive Care, and American Academy of Pediatrics including Lyme Disease, but excluding recommendations for travelers. Annual Adult Physicals and associated lab (22+ years) 1 per plan year Flu Shots 100% of Allowed Benefit Not covered 100% of Allowed Benefit Routine GYN Services (includes pap) Nutritional Counseling and Health Education for Chronic Disease (contact CareFirst for more information) Screening Mammography (One screening every year 35+) INPATIENT HOSPITAL/FACILITY SERVICES (Preauthorization required) Room & Board (includes maternity) and Ancillary Services (includes nursery charges) 100% of Allowed Benefit 70% of Allowed Benefit 100% of Allowed Benefit Organ Transplants (preauthorization required) 90% of Allowed Benefit for cornea, kidney, bone marrow, heart, heart-lung, single or double lung, liver and pancreas 70% of Allowed Benefit after deductible for cornea, kidney, bone marrow, heart, heart-lung, single or double lung, liver and pancreas 100% of Allowed Benefit for cornea, kidney, bone marrow, heart, heart-lung, single or double lung, liver and pancreas Acute Inpatient Rehab for Stroke and Traumatic Brain Injury (when medically necessary) 90% of Allowed Benefit Not covered 100% of Allowed Benefit Extended Care Facility (ECF) 180 days per plan year (preauthorization required) Hospice Care (inpatient or at home; preauthorization required) INPATIENT PROFESSIONAL/PRACTITIONER SERVICES Physician Surgical Services Anesthesia Consultations (including follow-visits) & Physician Visits (includes ECF) Radiation Therapy, Chemotherapy, and Renal Dialysis OUTPATIENT HOSPITAL/FACILITY SERVICES Emergency Room Services In-network and out-of-network 100% of Allowed Benefit after $75 facility copay and $75 physician copay. 100% of Allowed Benefit after $75 facility copay and $75 physician copay. OUTPATIENT HOSPITAL/FACILITY SERVICES Cardiac Rehabilitation (Outpatient Freestanding Clinic or Outpatient Hospital only, 36 sessions in 12-week period with physician supervision and in medical facility; medical necessity with physician authorization and history of heart attack in past 12 months, CABG surgery, angioplasty, heart valve surgery, heart transplant, stable angina pectoris, compensated heart failure.) 90% of Allowed Benefit 70% of Allowed Benefit; after deductible 100% of Allowed Benefit Home Health Care (120 days per plan year) Minor/All Surgery (includes hospital based and freestanding surgical centers) Preadmission Testing Diagnostic Tests (includes X-rays, machine tests, pathology, CAT scans, MRIs, and Holter Monitors) Laboratory Testing related to Diabetes, Hypertension, Coronary Artery Disease, Asthma, COPD (including test strips for Diabetes) Diagnostic Mammogram (no age limit) OUTPATIENT/OFFICE PROFESSIONAL SERVICES Physician Office Visit Primary Care $15 copay 70% of Allowed Benefit after deductible $15 copay Physician Office Visit Specialist $30 copay 70% of Allowed Benefit after deductible $30 copay Urgent Care Centers $30 copay 70% of Allowed Benefit after deductible $30 copay Minor/All Surgery Anesthesia Allergy testing, injection and serum (copay applies to testing and serum) $15 copay (PCP); $30 copay (Specialist) 70% of Allowed Benefit after deductible $15 copay (PCP); $30 copay (Specialist) X-rays, machine tests and pathology, CAT SCANS, MRIs, and Holter Monitors (physician interpretation of results) Physical Therapy, Occupational Therapy and Speech Therapy Note: Contact health plan if Speech Therapy provided due to catastrophic illness for consideration of additional visits. Hearing Exams and Hearing Aids (Includes Hearing Aid Mandate for minor children) $30 copay; up to 50 days per plan year combined for Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. Exam: $15 copay (PCP), $30 (Specialist); 100% of the plan allowance for the basic standard device, per ear, every 36 months. 70% of Allowed Benefit after deductible; up to 50 days per plan year combined for Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. $30 copay; up to 50 days per plan year combined for Occupational, Physical and Speech Therapy. Based on medical necessity. Occupational and Physical Therapy requires precertification after 6th visit. Speech precertification after 1st visit. 70% of Allowed Benefit after deductible Exam: $15 copay (PCP), $30 (Specialist); 100% of the plan allowance for the basic standard device, per ear, every 36 months. Chiropractic and Acupuncture Pain Management $30 copay 70% of Allowed Benefit after deductible $30 copay In Vitro Fertilization (IVF) and Artificial Insemination (AI) (preauthorization required) IVF and AI benefits are available for a legally married couple if: There is a history of infertility throughout the most recent two years of marriage; or Female infertility is due to endometriosis exposure in womb to diethylstilbestrol (DES) or blockage of or surgical removal of one of more fallopian tubes; or Male infertility is the documented diagnosis. The patient s oocytes must be fertilized with her spouse s sperm. Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime. The AI attempts must be taken before IVF attempts will be covered. BEHAVIORAL HEALTH 90% of Allowed Benefit 70% of Allowed Benefit 100% of Allowed Benefit Inpatient Hospital Care Partial Hospitalization Services Outpatient Services (Includes Intensive outpatient services) $15 copay 70% of Allowed Benefit after deductible $15 copay Residential Crisis PRESCRIPTION DRUGS ROUTINE DENTAL ROUTINE ADULT VISION Not covered under Medical Plan. Refer to your 2015 Guide to Your Health Benefits booklet provided by Employee Benefits Division which can be found at Not covered under Medical Plan. Refer to your 2015 Guide to Your Health Benefits booklet provided by Employee Benefits Division which can be found at Vision Exam $45 Allowed Benefit 70% of Allowed Benefit after deductible $45 Allowed Benefit Prescription Lenses Single Vision Lenses: $52 Allowed Benefit; Bifocal Lenses: $82 Allowed Benefit; Trifocal Lenses: $101 Allowed Benefit; Lenticular Lenses: $181 Allowed Benefit Frames (in lieu of contact lenses) $45 Allowed Benefit $45 Allowed Benefit Contact Lenses (in lieu of frames & lenses) ROUTINE PEDIATRIC VISION (for members through age 18) Contact Lenses: $97 Allowed Benefit; Medically Necessary Contact Lenses: $285 Allowed Benefit Vision Exam 100% of Allowed Benefit 70 % of Allowed Benefit after deductible 100% of Allowed Benefit Single Vision Lenses: $52 Allowed Benefit; Bifocal Lenses: $82 Allowed Benefit; Trifocal Lenses: $101 Allowed Benefit; Lenticular Lenses: $181 Allowed Benefit Contact Lenses: $97 Allowed Benefit; Medically Necessary Contact Lenses: $285 Allowed Benefit Prescription Lenses (basic lenses which means spectacle lenses with no addons such as glare resistant treatment, ultraviolet coating, progressive lenses, transitional lenses, etc.) Single Vision Lenses: $40 Allowed Benefit; Bifocal Lenses: $60 Allowed Benefit; Trifocal Lenses: $80 Allowed Benefit; Lenticular Lenses $100 Allowed Benefit Single Vision Lenses: $40 Allowed Benefit; Bifocal Lenses: $60 Allowed Benefit; Trifocal Lenses: $80 Allowed Benefit; Lenticular Lenses $100 Allowed Benefit Frames (in lieu of contact lenses) $70 Allowed Benefit $70 Allowed Benefit Contact Lenses (in lieu of frames & lenses) Contact Lenses: $105 Allowed Benefit; Medically Necessary Contact Lenses: $225 Allowed Benefit Contact Lenses: $105 Allowed Benefit; Medically Necessary Contact Lenses: $225 Allowed Benefit AB (Allowed Benefit): The maximum dollar amount allowed for services covered, regardless of the provider s actual charge. This chart is a general summary of benefits and does not guarantee coverage. Please contact Customer Service or refer to after the Open Enrollment for on-line PPO and EPO group benefit booklets or Evidence of Coverage with plan details.