it s your health. plan. know your benefits. State of Minnesota Advantage Health Plan member resource guide

Transcription

1 it s your health. plan. know your benefits. State of Minnesota Advantage Health Plan member resource guide 2016 health benefits

2 Welcome to Blue Cross Blue Cross and Blue Shield of Minnesota is committed to making a healthy difference in people s lives. Understanding your health plan and benefits can help you better manage your care. We provide great benefits, proven support and services, and online resources that give you the information you need to be healthy and make informed decisions. Not yet a member? There are many good reasons why more people are covered by Blue Cross than any other health plan. If you re not a member yet, you can find more information about Blue Cross by visiting bluecrossmn.com/segip. You can check out the health & wellness sections for information that can help you save on health care and be healthier. Blue Cross and Blue Shield of Minnesota customer service Once you become a member, visit bluecrossmn.com/ segip to register and sign in to the mybluecross member center. MyBlueCross is where you ll find all of the tools and resources listed below. You can manage your health plan, your costs and your health all in one place. See the mybluecross section in this book for more information. You also have a specially trained customer service representative to help when you call for assistance. This Health Guide will answer your specific health or medical questions and can also guide you to helpful information and resources. (651) or toll free at TTY toll free Customer service hours Monday Friday 7 a.m. to 8 p.m. CT Resources included with your plan For information about the health services and support listed here, go to bluecrossmn.com/segip and sign in to mybluecross, select Live Healthy then Health Programs & Discounts, call customer service or call the phone numbers below. Quitting tobacco support BLUE (2583) Maternity management (651) or toll free at Employee Assistance Program (651) or toll free at Laser vision correction savings Discounted acupuncture, massage and health products mybluecross > plan details > Health Support Navitus Health Solutions (pharmacy benefit manager) StayWell Helpline (personal health assessment and Wellness Vendor) Find a provider Minnesota Advantage Health Plan Provider Network Visit bluecrossmn.com/segip and use the Find a doctor search.

3 Understanding and using your plan Welcome and how your plan works > Minnesota Advantage Health Plan... 2 > Finding a provider... 4 > How your claims are paid... 5 > Your member ID card... 5 Stretch your health care dollars > Take advantage of preventive care > Laser vision (LASIK) savings > Online marketplace for discounts > Explore your health care options Health and health plan resources on mybluecross > What s available at mybluecross... 7 > Online health and wellness resources... 7 > How to register for mybluecross... 7 Glossary > Helpful terms to know...11 Blue Cross Health Support > Online care... 8 > Navigation team... 8 > Quitting tobacco support... 8 > Maternity management... 8 > Employee Assistance Program... 8 > Chronic condition management... 9 > Case management

4 Minnesota Advantage Health Plan How does the Minnesota Advantage Health Plan work? Under this plan, you will share the cost of specific medical services you receive by paying some out-ofpocket costs (through office visit copays, deductibles, and coinsurance). The amount of your cost sharing will depend on the primary care clinic you select and the cost level assigned to that clinic. Primary care clinics All Minnesota Advantage Health Plan members choose a primary care clinic from one of the four levels when they enroll. Whether it s time for a checkup or time to see a specialist, your primary care clinic will coordinate most of your care and referrals. The primary care providers and specialists who practice at each clinic are shown at bluecrossmn.com/segip. Use the Find a doctor search, enter your location and search under view other networks to locate primary care clinic information and cost levels. You ll also find information on where you ll be admitted if you need hospital care. Obstetrician/gynecologists (ob/gyns) Women may see any of the ob/gyns in the Minnesota Advantage provider network without a primary care clinic referral. Ob/gyns can be located at bluecrossmn.com/ segip. Using the Find a doctor search, enter your location and search under view other networks, self referral and specialty providers. Network ob/gyns can only refer members to other network ob/gyn specialists. All other referrals must come from your primary care clinic. Chiropractors You can see any of the chiropractors in the Minnesota Advantage provider network without a primary care clinic referral. Chiropractors can be located at bluecrossmn.com/ segip. Using the Find a doctor search, enter your location and search under view other networks, self referral and specialty providers. Eyecare specialists See any provider for routine eye care in the Minnesota Advantage provider network each year. You don t need a referral from your primary care clinic. Eyecare specialists can be located at bluecrossmn.com/segip. Using the Find a doctor search, enter your location, under last name, specialty, product or procedure, enter eye and make a selection. Hearing aid provider section See any provider in the Minnesota Advantage provider network without a referral for hearing exams and hearing aids once every three years, and for hearing aid accessories. Hearing aid providers can be located at bluecrossmn.com/segip. Using the Find a doctor search, enter your location, under last name, specialty, product or procedure, enter hearing and make a selection. Medical suppliers When your care requires medical supplies, eligible products may be purchased from the suppliers listed at bluecrossmn.com/segip. Using the Find a doctor search, under last name, specialty, product or procedure, enter medical supplies. Select network for behavioral health and chemical dependency treatment The Minnesota Advantage Health Plan has a select network of providers who specialize in behavioral health and chemical dependency treatment. To find a provider in the special network, use the Find a doctor search. Enter your location and search under view other networks, to locate behavioral health and chemical dependency providers or call customer service at (651) or toll free at to assist you with any provider network questions. How to get care after normal office hours Doctor On Demand Online care Get real-time, online access to board-certified physicians, psychologists, psychiatrists and lactation consultants 365 days a year through Doctor On Demand. 2

5 On-demand care from board-certified physicians is available in 47 states from 7 a.m. to 11 p.m. daily; appointments are available 24 hours a day. Licensed psychologists, psychiatrists and lactation consultants are available in all 50 states by appointment from 7 a.m. to 10 p.m. daily. A typical medical visit costs $40, and depending on your health plan, all or some of the cost may be covered. Your visit will be processed like a typical medical claim so no up-front payments are required, with the exception of copays, if applicable. Doctor On Demand is available on camera-equipped smartphones, tablets or computers through DoctorOnDemand.com/bluecrossmn or the Doctor On Demand app (available on Android, Apple and Kindle). Doctor On Demand is an independent company providing telehealth services and is not available in every state. Check DoctorOnDemand.com/bluecrossmn to ensure you are located in a state that is eligible to participate. Convenience clinics You can use convenience clinics on a drop-in basis for many common illnesses. There is a $10 copay for convenience clinic visits. To find a list of them, use the Find a doctor search at bluecrossmn.com/segip. Enter your location, search and choose Urgent Care/ Convenience Clinics. Urgent care A fever, sprained ankle or stomach ache is not an emergency, but you still may need to see a doctor. This is called urgent care. Call your clinic if you need urgent care. They will help you decide what to do next. You can also search for urgent care facilities on our Find a doctor web tool available on bluecrossmn.com/segip. Enter your location, search and click on urgent care. Care outside the service area Only urgent care and emergency services for an injury or illness that needs treatment right away are covered. Blue Distinction Specialty Care Program Blue Distinction is a national program that was created to help you find the highest quality specialty care centers for spine surgery, knee and hip replacements, cardiac care, bariatric surgery, complex and rare cancers treatments and transplants. Blue Distinction has evolved to include more robust quality measures and costefficiency criteria, and now has two designations: Blue Distinction Centers and Blue Distinction Centers+ SM. To learn more about Blue Distinction Centers (BDC), visit bcbs.com/bluedistinction and look for the BDC icon. You can also call customer service at (651) or toll free at To find a BDC provider in your network, be sure to use the Find a Doctor tool at bluecrossmn.com/segip. Enter your location and under last name, specialty, product or procedure, enter hospital. Note: Blue Distinction Centers met overall quality measures for patient safety and outcomes, developed with input from the medical community. Blue Distinction Centers+ also met cost measures that address consumers need for affordable healthcare. Individual outcomes may vary. National criteria is displayed on Neither Blue Cross and Blue Shield Association nor any Blue plans are responsible for damages, losses, or non-covered charges resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers. Designation as Blue Distinction Centers means these facilities overall experience and aggregate data met objective criteria established in collaboration with expert clinicians and leading professional organizations recommendations. Designation as a Blue Distinction Total Care Provider means this provider has met the established national criteria and has been designated by the local plan. Individual outcomes may vary. To find out which services are covered under your plan at any facilities, please call the customer service number on the back of your member ID card before making an appointment, to verify the most current information on its network participation and Blue Distinction status. How we work with your doctor We work with your doctor to make sure you get the care that s best for you. It s our job to see that the services you receive are effective, appropriate and efficient. Here are examples: Review services to verify they are medically necessary and that the treatment provided is the proper level of care. Prior authorization is recommended before you receive selected services (see your Summary of Benefits). That way, both you and your doctor know what s covered ahead of time. If your care is directed by an out-of-network doctor, it s your responsibility to get advance approval. Plan care for special medical needs our case managers are nurses who work with patients, family members, doctors and employers to arrange care and services for members with ongoing, long-term needs (like head injuries, AIDS and spinal disorders). They coordinate care from many different sources. 3

6 No paperwork or claims to file Network providers file claims for you. Your Explanation of Health Care Benefits (EOB) form confirms your claim was processed. You will only receive an EOB in the mail when, after Blue Cross processes your claim, you have a payment responsibility. How cost sharing is calculated Copays are flat fees you pay at the time you receive a service. Coinsurance is the percentage of charges you pay for a service. It s based on the allowed amount. Deductible is the portion of the allowed amount you must pay for certain covered services each year before Blue Cross begins to pay benefits. Allowed amount is the negotiated amount that network providers have agreed to accept as full payment at the time your claim is processed. If you see a provider who doesn t participate with Blue Cross, the allowed amount is either the billed charge or a percentage of the network allowed amount, whichever is less. Summary of Benefits Please see page 6 for highlights of what s covered by your Minnesota Advantage Health Plan. More information about your benefits is detailed in the Summary of Benefits which is available in the Employee Information section of the SEGIP website, mn.gov/mmb/segip, under medical-dental/current employees/understand benefits or at bluecrossmn.com/segip. A copy of the Summary of Benefits will not be mailed to you. If you do not have access to the Internet, please contact your agency s HR office. Finding a provider To find a doctor, clinic or hospital in the Minnesota Advantage network, use one of these resources: Visit bluecrossmn.com/segip and use the Find a doctor search. You can find a provider in your area and even create a customized provider directory. Search for a doctor by name, location, specialty, gender or language spoken. You ll also find information about provider quality. Call customer service at (651) or toll free at If you live outside of Minnesota or need Emergency Care while traveling you may use: In Minnesota or nationwide BlueCard national provider network Visit bluecrossmn.com/segip and use the Find a doctor search. Enter a location, then select view other networks and National BlueCard. You can also call BLUE (2583). In the BlueCard Worldwide network BlueCard international provider network Visit bluecrossmn.com/segip and use the Find a doctor search. Enter a location, click search, then select looking for an international doctor? at the bottom of the page. You can also call BLUE (2583) or call collect (804) Customer service/health Guides: (651) or toll free at TTY toll free Monday Friday, 7 a.m. to 8 p.m. CT bluecrossmn.com/segip 4

7 How your claims are paid Your visit. Depending on your provider, you may be required to pay an office copay at the time of service. Your provider will know this because your member ID card will indicate the amount in the office copay field. Your in-network provider submits your claim to Blue Cross. Blue Cross typically processes your claim within two weeks of receiving all the necessary paperwork from your provider. You receive an Explanation of Health care benefits. If you owe something to your provider, you will receive an Explanation of Health Care Benefits (EOB) in the mail. The EOB is not a bill. Your provider will send you a bill and the amount owed should match what is explained on the EOB. Note: Each covered family member can see their own EOBs on their home page after they register and sign in at bluecrossmn.com/segip. You can view your own EOBs and those for covered dependents who are 12 and under. Providers bills typically arrive within two weeks after you receive your EOB. Compare your EOB to your provider bill. Make sure the amount on the bill matches what is listed on your EOB. If not, contact Blue Cross customer service. pay your provider. Your member ID card Your member ID card is very important and should be carried with you. It tells providers that you have coverage and gives them information they need to submit your claims to Blue Cross. You should also have your member ID card handy when you call customer service. Each member ID card can be used only for the person whose name appears on the card. If you need to replace your card, sign in at bluecrossmn.com/segip and see My ID cards or call customer service. You can also print, or fax a copy of your member ID card. And don t forget, if you download the BlueCrossMN mobile app, you can have a digital version of your member ID card on your smart phone. The sample below is a guide only. The information and the format of your card may vary. Name Group Number XXXXX-XX ELIZABETH SAMPLENAME CONTRACT YEAR Identification # Member # Customer Service: (651) Member: See your Schedule 00 of Benefits for covered services or other important Provider Service: Service Type information. Possession Medical of this card Care does Type24-Hour Tiered Nurse Health Advice: Plan Office Copay not guarantee Level 3 eligibility for benefits. $ PCP EAP: Provider Name (651) Convenience Clinic Copay $ Providers: Claim filing and inquiries to local Blue Cross and/or Blue Shield plan. For all other inquiries, notifications or authorizations, call Provider Service. The medical plan is that of the employer. Blue Cross and Blue Shield of Minnesota, a nonprofit independent licensee of the Blue Cross and Blue Shield Association, is serving only as the claims administrator and does not assume financial risk for claims. This is your Blue Cross member ID number. Your calls to customer service will be faster if you have this number handy. Use the resources on the back of your card when you have questions. This symbol indicates you can receive benefits while traveling when you see any BlueCard traditional network provider nationwide or overseas. 5

8 Minnesota Advantage Health Plan benefits schedule Benefit Provision Cost Level 1 You Pay A. Preventive care services Routine medical exams, cancer screening Child health preventive services, routine immunizations Prenatal and postnatal care and exams Adult immunizations Routine eye and hearing exams B. Annual first dollar deductible (single/family) C. Office visits for illness/injury, for outpatient physical, occupational or speech therapy, and urgent care Outpatient visits in a physician s office Chiropractic services Outpatient mental health and chemical dependency Urgent care clinic visits (in and out of network) D. in-network convenience clinics and online care (deductible waived) E. Emergency care (in or out of network) Emergency care received in a hospital emergency room F. Inpatient hospital copay (waived for admission to Center of Excellence) Cost Level 2 You Pay 6 Cost Level 3 You Pay Nothing Nothing Nothing Nothing Cost Level 4 You Pay $150/$300 $250/$500 $550/$1,100 $1,250/$2,500 $25/$30* copay per visit; annual $30/$35* copay per visit; annual $60/$65* copay per visit; annual $10 copay $10 copay $10 copay $10 copay $100 copay; annual $100 copay; annual G. Outpatient surgery copay $60 copay; annual $100 copay; annual $200 copay; annual $120 copay; annual $100 copay; annual $500 copay; annual $250 copay; annual H. Hospice and skilled nursing facility Nothing Nothing Nothing Nothing I. Prosthetics, durable medical equipment J. Lab (including allergy shots), pathology and X-ray (not included as part of preventive care and not subject to office visit or facility copayments) $80/$85* copay per visit; annual 25% coinsurance; annual 25% coinsurance; annual 25% coinsurance; annual 20% coinsurance 20% coinsurance 20% coinsurance 25% coinsurance; annual 5% coinsurance; annual K. MRI/CT scans 5% coinsurance; annual L. Other expenses not covered in A-K above, including but not limited to: Ambulance Home health care Outpatient hospital services (non-surgical) - Radiation/chemotherapy - Dialysis - Day treatment for mental health and chemical dependency - Other diagnostic or treatment related outpatient services M. Prescription drugs 30-day supply of Tier 1, Tier 2 or Tier 3 prescription drugs, including insulin, or a 3-cycle supply of oral contraceptives Note: All Tier 1 generic and select branded oral contraceptives are covered at no cost. N. Plan maximum out-of-pocket expense for prescription drugs (excludes PKU, infertility, growth hormones) (single/family) O. Plan maximum out-of-pocket expense (excluding prescription drugs) (single/family) 5% coinsurance; annual 5% coinsurance; annual 10% coinsurance; annual 5% coinsurance; annual 20% coinsurance; annual 20% coinsurance; annual 20% coinsurance; annual 25% coinsurance; annual 25% coinsurance; annual 25% coinsurance; annual $14/$25/$50 $14/$25/$50 $14/$25/$50 $14/$25/$50 $800/$1,600 $800/$1,600 $800/$1,600 $800/$1,600 $1,200/$2,400 $1,200/$2,400 $1,600/$3,200 $2,600/$5,200

9 *The level of the office visit copayment for the employee and his or her family is dependent upon whether the employee has completed the Health Assessment in each Open Enrollment period, and agreed to accept a health coach call. Employees who have completed the Health Assessment and agreed to accept a health coach call are entitled to the lower copayment. Employees hired after the close of Open Enrollment will be entitled to the lower copayment. This chart applies only to in-network coverage. Point of service (POS) coverage is available only for members whose permanent residence is outside the State of Minnesota and outside the service areas of the health plans participating in Advantage. This category includes employees temporarily residing outside Minnesota on temporary assignment or paid leave [including sabbatical] and college students. It is also available to dependent children and spouses permanently residing outside the service area. These members pay a $350 single or $700 family deductible and 30% coinsurance to the out-of-pocket maximum described in Section O above. Members pay the drug copayment described at Section M above to the out-of-pocket maximum described at Section N. A standard set of benefits is offered in all SEGIP Advantage Plans. There are still some differences from plan to plan in the way that benefits, including the transplant benefit, are administered, in the referral and diagnosis coding patterns of primary care clinics, and in the definition of Allowed Amount. This is only a summary. Read your Summary of Benefits for more information about what is and isn t covered. Your online resource: mybluecross As a Blue Cross member, you have access to mybluecross your secure, online member center. All you need to do is sign up. When you want onestop convenience for all your health plan information, mybluecross is your best resource. It s simple, easy to use and full of information. Register today Registration is secure and fast. With your member ID card handy, go to bluecrossmn.com/segip and register for mybluecross. Be sure to enter your address so Blue Cross can send you information more quickly. After you register, you ll have immediate access to your personal information. Covered family members can also register to see their claims. View claims, account status and plan information Order a replacement member ID card Send a secure message to customer service Provide your address to tell us how you would like to receive health support communications print or electronic Go mobile with the Blue Cross app With the BlueCrossMN mobile app, you can access your personal health plan information wherever you go. Have your member ID card always handy See your claims information Find doctors, clinics or hospitals To use the app, you have to be registered on bluecrossmn.com/segip. Once registered, you can then download the app to your smart phone. 7 Online health and wellness resources Making the right choices for your health is important and this is a great place to start. Visit bluecrossmn.com/ segip and you ll find: Prescription drug information, including drug uses, possible side effects, proper dosage and more Information and resources on topics such as fitness, nutrition, and stress management and sections dedicated to women s health, men s health, children s health and more Personalized support, online health coaching and a customized dashboard with easy access to the topics of most interest to you Interactive calculators to tell you how many calories you burn, your target heart rate and more Online resources for people with illnesses like diabetes, heart disease and asthma Protecting your privacy is very important to us We re telling you about Blue Cross and Blue Shield of Minnesota s privacy policy so you know what information we collect, why we collect it and what we do with it. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule affords members the right to receive a notice that describes how health information may be used and disclosed and how to get access to this information. This notice is posted online at bluecrossmn.com and can also be mailed to you by calling customer service and requesting a copy of the Notice of Privacy Practices. To access the notice online, go to bluecrossmn.com and type privacy in the site search box.

10 Blue Cross Health Support Visit bluecrossmn.com/segip and select Health support for information on all of your available health services and support. Online care Get real-time, online access to board-certified physicians, psychologists, psychiatrists and lactation consultants with Doctor On Demand. Quick, convenient care is available on demand or by appointment through a camera-equipped smartphone, tablet or computer. Please check DoctorOnDemand.com/bluecrossmn to ensure you are located in a state that is eligible to participate. Navigation team When you have questions about your benefits, a treatment plan, a health procedure or more, just call customer service. You ll be connected with a nurse guide who will listen carefully to your concerns and answer any health and medical questions. Call customer service at (651) or toll free at Quitting tobacco support Enhanced quitting tobacco support has helped thousands of people. It provides one-on-one phone counseling, optional text messaging and tools and strategies to help you quit in your own way, at your pace. The program includes five 10-minute calls with a Quit Coach, access to a Weight Coach, the interactive website and nicotine replacement therapy.* Call toll free at BLUE (2583) to get started. * Options include the patch, gum or lozenge mailed directly to participants in the program whose medical history does not preclude them from safely using these medications. Maternity management Maternity management support provides education and support to pregnant women so they can achieve the healthiest pregnancies possible. Pregnant women who are at high risk for complications are connected with a dedicated registered nurse to support them during their pregnancy. All pregnant women have access to online tools and resources. To request further information or to enroll, call (651) or toll free at Employee Assistance Program Personal problems like stress, marital issues and substance abuse can make it difficult to cope. The Employee Assistance Program* (EAP) is a great place to start when you re facing a difficult situation. When you call the EAP line, a professional counselor will listen to your concerns, assess the situation and then help you take the next step. Some problems may be resolved over the phone, or you may be referred to other community services. You or your family members can get help with: Marriage and relationship concerns Mental health and stress issues Family problems Legal referrals Childcare and elder care Financial matters Substance abuse Grief Work-related issues There s no cost to you to use the EAP service. Just call anytime, 24 hours a day, toll free at (651) or toll free at or visit the LifeMatters website at (password: stmn1). The EAP staff member can refer you to resources or professionals outside the EAP, but you may be responsible for the cost. * EAP is a service provided to all SEGIP participants through LifeMatters. LifeMatters is an independent company that does not provide Blue Cross and Blue Shield products or services and is solely responsible for the administration of their EAP program. 8

11 Chronic condition management If you or a family member have an ongoing health condition such as diabetes, cancer or asthma, you may be eligible to receive telephone support from a health coach through our Chronic Condition Management program. This voluntary program gives you access to a confidential trusted expert who can provide valuable information and guidance that is specific to your condition. Your health coach (registered nurse or behavioral health specialist) will get to know you and support your health the way you want it. To learn more, call the number on the back of your member ID card. Case management When you or a family member experience a major health event or illness, we can help you get through it. Our health coaches are nurses, social workers and behavioral health specialists who can provide support, help you coordinate care and identify resources and helpful information. They will work with you, your doctor and care team, and family members to ensure you are receiving the care you need. To get connected with a health coach, call the number on the back of your member ID card. Customer service/health Guides: (651) or toll free at TTY toll free Monday Friday, 7 a.m. to 8 p.m. CT bluecrossmn.com/segip 9

12 How to stretch your health care dollars Here are some ways to use your health care dollars wisely to help hold the line on costs. Take advantage of preventive care Get healthy, stay healthy. The State of Minnesota and Blue Cross are committed to your good health for the long term. Taking care of yourself includes seeing your provider for regular checkups and preventive screenings. Visit bluecrossmn.com/segip and see Preventive care services to view a comprehensive list of preventive care recommendations for children, adolescents and adults. Remember, you are covered 100 percent for preventive care if you use your primary care provider. Be sure to check which exams and screenings your doctor recommends based on your health, what your plan covers and how often they are covered. Refer to your Summary of Benefits or call customer service for more information. Laser vision (LASIK) savings Save 40 to 50 percent off the national average cost of LASIK. Offered through QualSight, the laser vision correction services include a comprehensive eye exam and pre- and post-operative care. For more information call Online marketplace for discounts ChooseHealthy provides wellness products and services that aren t typically covered by insurance. With a national network of more than 22,000 participating merchants, you ll enjoy discounts on products and services that support your health goals including fitness centers. For more information on these and any other discounts, sign in to mybluecross at bluecrossmn.com/segip. * The fitness center discount is not the same as Blue Cross Fitness Discounts. Note: Complementary care is a separate discount program, and not a service covered under your health plan benefits. Therefore, any out-of-pocket costs do not count toward your plan s out-of-pocket maximums. ChooseHealthy is a product of American Specialty Health Systems, Inc. (ASH Systems), a subsidiary of American Specialty Health Incorporated (ASH). ASH Systems is an independent entity providing complementary health and wellness products and services. Discounted medical supplies Disposable medical supplies up to a 20 percent discount from Edgepark Medical Supplies. Free home delivery. Explore your health care options Knowing your options can save you time and money. Doctor On Demand ($) Online access to doctors who can answer questions and provide a diagnosis for common health concerns. Retail health clinic ($) Quick, convenient and affordable treatment for many common illnesses. Physician s office ($$) For a wide variety of services from routine checkups to immunizations during normal business hours. Urgent care center ($$$) Handles the same problems treated in a provider s office after normal business hours. Emergency room ($$$$) For the most serious or life-threatening conditions. Members are eligible for a minimum of 10 percent discount off enrollment and/or monthly dues at more than 12,000 fitness clubs and exercise centers, as well as access to trial memberships or introductory sessions.* In addition, you ll have access to an online library filled with articles and tips to help you maintain a healthy lifestyle. 10

13 Glossary Helpful terms to know Your health plan will make more sense if you understand a few important terms. Allowed amount The maximum dollar amount that Blue Cross will consider for payment for a covered medical service. Network providers have agreed to accept a discounted amount as full payment. Coinsurance For some services, once a deductible has been paid, coinsurance is required. Coinsurance is a set percentage of the provider s fee that you pay according to your plan. For example: Provider charges: $100 (after Blue Cross discount) Plan pays: -$80 (80 percent) mybluecross A secure account designed specifically for you and covered family members. It s an easy-to-use place to manage your health, your health plan and costs, including your personal information. Out-of-pocket maximum The maximum amount of cost-sharing you must pay for covered services. The outof-pocket maximum protects you from high expenses when your share of covered costs exceeds the out-ofpocket maximum amount within the plan year. The plan will pay 100 percent of your eligible services once you have reached the out-of-pocket maximum. Provider The term provider includes doctors, nurse practitioners, specialists, clinics and hospitals. It also includes care facilities or professionals, such as physician assistants, chiropractors, psychologists and many others. You pay: $20 (your 20 percent coinsurance) Convenience clinic A health clinic located within or near a pharmacy or in a major retail store that provides treatment for common illnesses. Copay For certain services, you pay a set dollar amount or copay (for example $15). In most cases, copays are paid to the doctor or facility at the time you receive service and can vary by the type of service covered. Deductible The amount you must pay toward eligible health care services each year before your health plan pays on your behalf. For example, if your deductible is $1,000, your plan won t pay anything until you ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Eligible services Health care services that are eligible to be considered for coverage according to the health plan contract. Explanation of Health Care Benefits (EOB) A notice sent from Blue Cross describing a claim and how it was processed by the plan. It tells you the services provided, the amount billed, payment made and any costs that are the member s responsibility. 11

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16 bluecrossmn.com/segip As Minnesota s health care leader, we live fearless. We believe good health is for everyone not just our members. It s a big vision. And that s why we re investing in the communities we serve and empowering individuals to make smart choices about their health. Live fearless with the peace of mind that comes from knowing you re protected by the strength and stability of Blue Cross. We invite you to join us. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. F6788R19 (10/15)