Tribal 2016 Health. Blue Cross of Idaho. Choose that coverage fits. Choose coverage. that fits. Individuals from 3-074P (10-10) 3-075P (10-10)

Transcription

1 Tribal 2016 Health Insurance Silver Plans Plans for for Individuals Individuals from from Blue Cross of Idaho Choose coverage Choose that coverage fits. that fits. Form No (10-15) Policy Form Numbers: (01-16) (01-16) (01-16) (01-16) 3-073P (10-10) 3-074P (10-10) 3-075P (10-10)

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3 Blue Cross of Idaho Health Insurance Plans The Affordable Care Act offers Native Americans health insurance benefits and greater access to healthcare. The Affordable Care Act (ACA) includes specific provisions dedicated to Native Americans including financial assistance that may greatly reduce your monthly health insurance costs. We know your access to Indian Health Services, tribal programs, and other urban Indian programs are critical to you. But a private health plan with Blue Cross of Idaho does not impact your eligibility for these critical programs. In fact, a private health insurance plan provides you and your family greater access to services IHS may not provide, such as emergency room services, maternity and newborn care, annual doctors visits and medical screenings. You might even qualify for health coverage through Medicare, Medicaid, or the Children s Health Insurance Program (CHIP). Tribal health insurance plans are only available through Your Health Idaho, the state health insurance marketplace. Visit yourhealthidaho.org to learn more and to sign up for coverage. You are eligible for these new benefits and a new plan any time of year. So, you can research plans, find coverage that fits your budget and your family s medical needs and apply when you are ready. Números de Formulario de Póliza: / / / /16 CHOOSE COVERAGE /16 THAT /16 FITS bcidaho.com / / / / / / / / / /11

4 Keep your eligibility for Indian Health Services You and your family may use Indian Health Services, tribal programs, and other urban Indian health programs for your healthcare. The good news? The ACA doesn t impact your eligibility for those critical programs. In fact, a private health plan such as one from Blue Cross of Idaho offers you greater access to doctors, specialists and hospitals. A new Blue Cross of Idaho plan allows you to choose a doctor from our long list of primary care providers in Idaho, get a prescription filled at a convenient pharmacy, or go to the hospital in an emergency. A note about provider networks Blue Cross of Idaho s Choice plan offers the largest Preferred Provider Organization (PPO) network in the state and includes every acute care hospital and 96 percent of all Idaho physicians. ConnectedCare sm and CarePoint sm are managed care plans supported by exclusive networks of providers located in service areas in southwest, central, and east Idaho. The advantage of these plans over other types of health insurance is specialized, coordinated treatment and a lower monthly payment. If you enroll in a Connect or CarePoint plan, you must follow some additional requirements to get the full benefit of your coverage. First, you must visit providers and hospitals that are part of the applicable network in your service area. Second, you must choose one provider as your primary care provider (PCP). Your doctor coordinated treatment when needed. Finally, your PCP must provide referrals to specialists within your network. You can easily search for a provider at bcidaho.com/findaprovider. No matter which plan you choose, it is important that you use the hospitals, doctors and specialists in our network. This helps keep your costs down. If you visit a doctor not listed in our network, you may have to pay the difference between what the provider bills and what your contract allows for the service. If you have questions, or you are not finding a doctor in the network, please give us a call. We d love to help you find the care you need HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals

5 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Get a Break on Costs Depending on your income and family size, you may be eligible for assistance with your monthly premium costs or out-of-pocket expenses. Reduce Your Monthly Payments The monthly premium tax credit can save you money by lowering your monthly premium payments. Use the first column in the chart below to see if you may qualify. And Your Out-of-Pocket Expenses A cost-sharing reduction can lower your deductible and coinsurance. Use the second column in the chart below to see if you may qualify. If your household income Family Size is below 300 percent of the federal poverty level, you may not have to pay copayments or other cost-sharing when you choose a Tribal plan. Calculate Your Savings Visit our subsidy calculator at shoppers. bcidaho.com to get an estimate on how much money you might be able to save. Remember, this is just an estimate. To get a more detailed number, you ll need to apply for coverage at yourhealthidaho.org 2015 FEDERAL INCOME GUIDELINES Monthly Premium Tax Credit 400% of FPL If you make less than this, you may qualify for help paying your monthly premiums. Cost-Sharing Reduction 300% of FPL If you make less than this, you may qualify for help paying expenses such as deductible and coinsurance payments. 1 $47,080 $35,310 2 $63,720 $47,790 3 $80,360 $60,270 4 $97,000 $72,750 5 $113,640 $85,230 6 $130,280 $97,710 7 $146,920 $110,190 8 $163,560 $122,670 IDAHO HEALTH INSURANCE EXCHANGE You need to enroll in health coverage through Idaho s Health Insurance Exchange, yourhealthidaho.org to qualify for financial assistance. The exchange has an easy application process to determine what benefits are available to you and your family. YEAR-ROUND OPEN ENROLLMENT The ACA allows Native Americans to enroll in a QHP anytime during the year. So, you can research plans, evaluate your budget and purchase a plan that fits your needs whenever you are ready. * For families with more than eight people, add $4,160 for each additional person. CHOOSE COVERAGE THAT FITS bcidaho.com 3

6 Key terms There are a few parts of health insurance you should completely understand. Here s what you should get familiar with. PREMIUM The amount you pay each month for your health insurance plan. ANNUAL OUT-OF-POCKET MAXIMUM What you pay for healthcare each year, up to a maximum amount. This is in addition to whatever insurance premium you pay each month. DEDUCTIBLE This is a set dollar amount you are responsible for paying when you need most covered services. Once your deductible is met, it goes away until you renew your plan. Some plans have one deductible for medical care and a different deductible for prescription drugs. COINSURANCE This means we split the cost of your covered healthcare with you. For example, if we cover 70% of the doctor s allowed amount, you d cover the remaining 30%. COPAYMENT A set amount you pay directly to a doctor, hospital or pharmacy when you need service. Depending on your plan, you might pay a copayment to see your primary care doctor or if you use the ER but aren t admitted. NETWORK A network is a group of doctors, hospitals, pharmacies and clinics who agree to provide service and send us the bill (called in-network ). We ve negotiated prices for thousands of services you may need, which is good for your wallet. You can use providers who aren t in your group (called out-of-network ), but they can charge you more for their services. You can find a full list of providers at bcidaho.com/findaprovider. 4 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals

7 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Visit bcidaho.com/sbc for a Summary of Benefits and Coverage. BRONZE, SILVER, OR GOLD CHOICE (For incomes less than 300 percent of FPL) Benefit Details In-Network Out-of-Network Deductible Coinsurance Annual Out-of-Pocket Maximum Doctor s Office Visit & Urgent Care Emergency Room Prescriptions Diagnostic X-Ray & Lab Outpatient Rehab 2 Physician, Surgical, Medical & Inpatient Hospital Services Pregnancy Services Chiropractic Care 3 Diabetes Education Outpatient Mental Health & Substance Abuse Therapy Services Preventive Care Immunizations $0 per person or $0 per family You pay no coinsurance $0 per person or $0 per family WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM 1 for covered prescriptions. for for listed preventive care. for listed immunizations. 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 2 Includes physical, occupational and speech therapy services. You have a combined total of up to 20 in- and out-of-network visits for covered therapy services per member per year. 3 You have a combined total of 18 in- and out-of-network visits for covered chiropractic services per member per year. Important News While Blue Cross of Idaho offers Tribal plans in every metal level, if you qualify for a cost-sharing reduction, you ll get the same benefits no matter which metal level you pick. Choosing a Bronze plan will give you the best value for your monthly premium. Keep in Mind For Tribal members with a yearly < 300 income less than 300 percent of the percent federal poverty level (FPL), we pay 100 percent of covered services. If you visit an out-of-network provider, you may be responsible for the difference between what is billed and what we allow. For Tribal members with a yearly > 300 income greater than 300 percent percent of FPL, we pay 100 percent of covered services when you visit an Indian Health Services or tribal organization provider, or are referred by an IHS physician. Network benefits apply if you do not receive a referral. CHOOSE COVERAGE THAT FITS bcidaho.com 5

8 * Our Connect plans and CarePoint plans are supported by select provider networks in southwestern, eastern, and central Idaho. When you choose managed care through a Coordinated Care network, you must choose a primary care physician (PCP) from these networks to serve as your care coordinator. You must obtain a referral from your PCP to see a specialist. BRONZE, SILVER, OR GOLD CONNECT* (For incomes less than 300 percent of FPL) SILVER CAREPOINT* (For incomes less than 300 percent of FPL) Benefit Details In-Network Out-of-Network In-Network Out-of-Network Deductible $0 per person or $0 per family $0 per person or $0 per family Coinsurance You pay no coinsurance You pay no coinsurance Annual Out-of-Pocket Maximum Doctor s Office Visit & Urgent Care Emergency Room $0 per person or $0 per family $0 per person or $0 per family WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM 1 1 Prescriptions for covered prescriptions. for covered prescriptions. Diagnostic X-Ray & Lab Outpatient Rehab 2 Physician, Surgical, Medical & Inpatient Hospital Services 1 Pregnancy Services Chiropractic Care 3 Diabetes Education Outpatient Mental Health & Substance Abuse Therapy Services Preventive Care for listed preventive care. for listed preventive care. Immunizations for listed immunizations. for listed immunizations. 1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 2 Includes physical, occupational, and speech therapy services. You have a combined total of up to 20 in- and out-of-network visits for covered therapy services per member per year. 3 You have a combined total of 18 in- and out-of-network visits for covered chiropractic services per member per year. 6 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals

9 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Dental Plans Good oral health is an important part of overall health. Our flexible and affordable dental plans include varying degrees of coverage so you can select a dental plan that best fits your health and financial needs. Our Dental Choice sm and Dental Choice Plus sm plans offer low deductibles and out-of-pocket maximums and meet all of the Affordable Care Act (ACA) requirements. We also offer flexible, affordable dental coverage in three benefit levels with our Healthy Smiles sm Preventive, Plus, and Preferred plans.** You can choose a plan directly from Blue Cross of Idaho or through the Idaho health insurance exchange at yourhealthidaho.org. The cost-sharing reduction for members of federally recognized tribes with qualifying incomes does not apply to dental coverage. You can still receive dental services through your Indian healthcare provider. Benefit Details DENTAL CHOICE (Under Age 19) DENTAL CHOICE (Age 19 and Older) In-Network Out-of-Network In-Network Out-of-Network Individual Deductible $50 per member, $100 per member, $50 per member, $100 per member, Annual Out-of- Pocket Maximum $350 Individual/ $700 Two or more $10,000 None None Benefit Period Maximum None None $1,000 Preventive Dental Services (No waiting period; Includes exams, x-rays and fluoride) You pay $50 copayment per visit. You pay $25 copayment per visit. Basic Dental Services (Includes sealants, fillings, extractions, and periodontal maintenance) 6-month waiting period for members age 19 and older Major Dental Services (Root canals, periodontics, crowns, bridges, dentures, and dental implants) 12-month waiting period for members age 19 and older Orthodontics 24-month waiting period for members under age 19; medically-necessary, non-cosmetic treatment. Prior authorization required. deductible, you pay 80% No Benefit No Benefit **Our Healthy Smiles plans are not ACA-qualified plans and do not meet coverage requirements for people under age 19. CHOOSE COVERAGE THAT FITS bcidaho.com 7

10 Benefit Details DENTAL CHOICE PLUS (Under Age 19) DENTAL CHOICE PLUS (Age 19 and Older) In-Network Out-of-Network In-Network Out-of-Network Individual Deductible $50 per member, $100 per member, $50 per member, $100 per member, Annual Out-of- Pocket Maximum $350 Individual/ $700 Two or more $10,000 None None Benefit Period Maximum Preventive Dental Services (No waiting period; Includes exams, x-rays and fluoride) Basic Dental Services (Includes sealants, fillings, extractions, and periodontal maintenance) Major Dental Services (Root canals, periodontics, crowns, bridges, dentures, and dental implants) Orthodontics Benefit Details None None $1,000 You pay $40 copayment per visit. deductible, you pay 20% of the allowed of the allowed of the allowed 24-month waiting period for members under age 19; medicallynecessary, non-cosmetic treatment. Prior authorization required. You pay $10 copayment per visit. deductible, you pay 20% 6-month waiting period for members age 19 and over of the allowed of the allowed 12-month waiting period for members age 19 and older deductible, you pay 80% of the allowed No Benefit No Benefit HEALTHY SMILES PREVENTIVE* HEALTHY SMILES PLUS* HEALTHY SMILES PREFERRED* In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Individual Deductible Benefit Period Maximum Preventive Dental Services (No waiting period; Includes exams, x-rays and fluoride) Basic Dental Services (Includes sealants, fillings, extractions, and periodontal maintenance) Major Dental Services (Root canals, periodontics, crowns, bridges, dentures, and dental implants) Dental Maximum Carryover $0 You pay $20 copayment per visit. $50 per member, $50 per member, $50 per member, None $1,000 per member, $1,000 per member, Not Covered and then 50% Not Covered Not Included You pay $20 copayment per visit. and then 20% 6-month waiting period and then 50% and then 50% You pay $20 copayment per visit. and then 20% and then 50% 6-month waiting period and then 50% and then 50% and then 50% 12-month waiting period $250 per member, (up to a maximum of $1,000, per insured) *Our Healthy Smiles plans are not ACA-qualified plans and do not meet coverage requirements for people under age HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals

11 EXCLUSIONS AND LIMITATIONS Exclusions & Limitations In addition to the exclusions and limitations listed elsewhere in this booklet, the following exclusions and limitations apply to the medical policies, unless otherwise specified. PREEXISTING CONDITION WAITING PERIODS There is no preexisting condition waiting period for benefits available under this Policy. GENERAL EXCLUSIONS AND LIMITATIONS 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 Member. However, the Member 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 Member has a non dental, life endangering condition which makes hospitalization necessary to safeguard the Member 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 Member 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 Member 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 Contract 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 Contract. 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 Member by blood or marriage and who ordinarily dwells in the Member 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 a Member who is a dependent child. Benefits for reconstructive Surgery to correct an Accidental Injury are available even though the accident occurred while the Member was covered under a prior insurer s coverage. Rendered prior to the Member 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, except as specified as a Covered Service in this Contract. For failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses unless specified as a Covered Service in this Contract, or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider. For Inpatient admissions that are primarily for Diagnostic Services or Therapy Services; or for Inpatient admissions when the Member is ambulatory and/or confined primarily for bed rest, special diet, 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 Contract. 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 Contract. Blue Cross of Idaho does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan including enrollment and benefit determinations. CHOOSE COVERAGE THAT FITS bcidaho.com 9

12 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 Member 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 Contract; 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 Contract; 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 Contract. 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 a Member s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures. Any expenses, procedures or services related to Surrogate pregnancy, delivery or donor eggs. For Transplant services and Artificial Organs, except as specified as a Covered Service under this Contract. 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 Contract, if any. Additionally, reversals, revisions, and/or complications of such surgical procedures are excluded, except when required to correct an immediately life endangering condition. For Hospice, except as specified as a Covered Service in this Contract. 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 Member in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Member to Covered Services under this Contract, if and to the extent those benefits are payable to or due the Member 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 Member, and the Member s heirs and personal representative against all insurers, underwriters, self insurers or other such obligors contractually liable or obliged to the Member, 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 a Member would have no legal obligation to pay in the absence of coverage under this Contract 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 Contract. For immunizations, except as specified as a Covered Service in this Contract. 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 a Member. 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 Contract. 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 Contract. 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 Contract. For arch supports, orthopedic shoes, and other foot devices. Benefits for contraceptives, unless specified as a Covered Service in this Contract. 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. GENERAL EXCLUSIONS AND LIMITATIONS FOR DENTAL CHOICE AND DENTAL CHOICE PLUS PLANS There are no benefits for services, supplies, drugs or other charges that are: Procedures that are not included in the Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an Insured s covered dental condition; or that do not have uniform professional endorsement. Charges for services that were started prior to the Insured s Effective Date. The following guidelines will be used to determine the date when a service is deemed to have been started: 10 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals

13 EXCLUSIONS AND LIMITATIONS For full dentures or partial dentures: on the date the final impression is taken. For fixed bridges, crowns, inlays or onlays: on the date the teeth are first prepared. For root canal therapy: on the later of the date the pulp chamber is opened or the date canals are explored to the apex. For periodontal Surgery: on the date the Surgery is actually performed. For all other services: on the date the service is performed. For orthodontic services, if benefits are available under this Policy: on the date any bands or other appliances are first inserted. Cast restorations (crowns, inlays or onlays) for teeth that are restorable by other means (i.e., by amalgam or composite fillings). Replacement of an existing crown, inlay or onlay that was installed within the preceding five (5) years or replacement of an existing crown, inlay or onlay that can be repaired. Appliances, restorations or other services provided or performed solely to change, maintain or restore vertical dimension or occlusion. A service for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho. In excess of the Maximum Allowance. A partial or full removable denture for fixed bridgework, or the addition of teeth thereto, if involving a replacement or modification of a denture or bridgework that was installed during the preceding five (5) years. Orthodontic services and supplies unless otherwise specifically listed in the Closed List of Dental Covered Services. Replacement of lost or stolen appliances. Ridge augmentation procedures. Any procedure, service or supply other than vestibuloplasty, alveoloplasty or alveolectomy required to prepare the alveolus, maxilla or mandible for a prosthetic appliance. Excluded services include, but are not limited to stomatoplasty and synthetic bone grafts to the alveolars, maxilla or mandible. Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome. Orthognathic Surgery, including, but not limited to, osteotomy, ostectomy and other services or supplies to augment or reduce the upper or lower jaw. Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable. Any service, procedure or supply for which the prognosis for success is not reasonably favorable as determined by BCI. Myofunctional therapy and biofeedback procedures. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures. Occlusal adjustments. Not prescribed by or upon the direction of a Provider. 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 therefor 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 personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs. For telephone consultations; 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 Dentist or other Provider. For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child. 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 Services 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 for any reason makes payment for or otherwise provides benefits excluded by this provision, 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, self insurers 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 Blue Cross of Idaho 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. Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in eligibility status which occurs during the Policy term. Provided outside the United States, which if had been provided in the United States, would not be Covered Services under this Policy. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. For acupuncture or hypnosis. Repair, removal, cleansing or reinsertion of Implants. Precision or semi-precision attachments (including Implants placed to support a fixed or removable denture) Denture duplication. Oral hygiene instruction. Treatment of jaw fractures. Charges for acid etching. Charges for oral cancer screening which are included in a regular oral examination. No benefits are available for replacement and/ or repair of orthodontic appliances. This includes removable and/or fixed retainers. II. CONDITIONS RIGHT TO REVIEW DENTAL WORK Before providing benefits for Covered Services, Blue Cross of Idaho has the right to refer the Insured to a Dentist of its choice and at its expense to verify the need, quantity and quality of dental work claimed as a benefit under this section. B. Care Rendered by More Than One Dentist If an Insured transfers from the care of one Dentist to another Dentist during a Dental Treatment Plan, or if more than one Dentist renders services for one dental procedure, Blue Cross of Idaho will pay no more than the amount that it would have paid had but one Dentist rendered the service. C. Alternate Treatment Plan If a Dentist and an Insured select a Dental Treatment Plan other than that which is customarily provided by the dental profession, payments of benefits available under this section shall be limited to the Dental Treatment Plan that is the standard and most economical, according to generally accepted dental practices. CHOOSE COVERAGE THAT FITS bcidaho.com 11

14 GENERAL EXCLUSIONS AND LIMITATIONS FOR HEALTHY SMILES PLANS There are no benefits for services, supplies, or other charges that are procedures that are not included in the Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an Insured s covered dental condition; or that do not have uniform professional endorsement. Charges incurred for services that were started prior to the Insured s Effective Date. The following guidelines will be used to determine the date on which a service shall be deemed to have been started: For full dentures or partial dentures on the date the final impression is taken. For fixed bridges, crowns, inlays or onlays on the date the teeth are first prepared. For root canal therapy on the later of the date the pulp chamber is opened or the date canals are explored to the apex. For periodontal surgery on the date the surgery is actually performed. For all other services on the date the service is performed. A service furnished to an Insured for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho. In excess of the Maximum Allowance. Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome. Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable. Any service, procedure or supply for which the prognosis for success is not reasonably favorable. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures. Not prescribed by or upon the direction of a Provider. Investigational in nature. Provided for any condition, Disease, Illness or Accidental Injury to the extentthat the Insured is entitled to benefits under occupational coverage, obtained or provided by or through an 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 therefor would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Part B. 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 personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs. For telephone consultations; 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 Dentist or other Provider. For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child. 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. 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. Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in Eligibility status which occurs during the Policy term. Provided outside the United States, which if had been provided in the United States, would not be Covered Services under this Policy. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. 12 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals

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16 P.O. Box 7408 Boise, ID GO CROSS ( ) bcidaho.com Meridian STREET ADDRESS 3000 E. Pine Avenue Meridian, ID MAILING ADDRESS P.O. Box 7408 Boise, ID CLAIMS INQUIRIES Coeur d Alene Idaho Falls Lewiston Pocatello Twin Falls 1450 NW Blvd., Suite 106 Coeur d Alene, ID Channing Way Idaho Falls, ID S. 5th Ave., Suite 150 Pocatello, ID Blue Lakes Blvd. N. Twin Falls, ID by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association