Health Insurance Plans

Transcription

1 Health Insurance Plans for Individuals and families from Blue Cross of Idaho Choose coverage that fits. Form No (11-13) Policy Form Numbers: / / / / / / / / / / / / /11

2 At Blue Cross of Idaho, we understand that a good health insurance company has to focus on a variety of things that affect its members. In this guide, we ll help you understand the complex health insurance and healthcare industries so that you can find the best coverage to meet your needs. You ll learn how the Affordable Care Act will impact your wallet, your insurance, and your family. We will introduce you to our product portfolio, outline the services and resources we offer our members, and explain the Idaho Health Insurance Exchange and the financial assistance that may be available to you. We know you have options when you look for health insurance and we thank you for considering Blue Cross of Idaho. We re confident you will find we offer: Coverage to meet your lifestyle and financial needs The largest network of healthcare providers to meet your healthcare needs Exceptional customer service Tools and resources to help you navigate a complex system We look forward to serving you!

3 3 What s New? 9 How to Choose the Right Plan 13 blue cross of Idaho health Insurance Plans 25 SAVE MONEY AND PURCHASE INSURANCE 29 Additional Resources Choose coverage that fits bcidaho.com. 3

4 4 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families Visit bcidaho.com for more information about Blue Cross of Idaho, the Affordable Care Act and the Idaho Health Insurance Exchange

5 What s New? The new healthcare law, called the Affordable Care Act (ACA), has brought many changes to health insurance for people who purchase individual or family insurance. There are changes to how we purchase and pay for insurance, new plan options and even financial assistance available to those who qualify. Here s a snapshot of the major changes: ACA may provide financial assistance to help you pay for your health insurance and healthcare costs. You can t be denied coverage because of a pre-existing health condition. Insurance companies can t drop your coverage if you get sick. All health insurance plans must cover standard essential health benefits. After your premium payments, the most in a year you will pay for covered healthcare services from in-network providers is $6,350 for individuals and $12,700 for families. Parents can keep their kids on their plans until they re 26 years old. There are no annual or lifetime coverage maximums on EHBs. Preventive care, such as annual doctor visits or regular screenings, is now covered with no out-of-pocket costs through your insurance plan. All Idahoans, with few exceptions, are required to have health insurance, or pay a tax penalty. The Idaho Health Insurance Exchange is an online marketplace where individuals and families can compare and purchase plans and get financial help to pay premiums. Federal law requires dependents under age 19 to have dental insurance with their medical insurance. Blue Cross of Idaho offers dental products that provide the coverage you need and meet all ACA requirements. Choose coverage that fits bcidaho.com. 5

6 New Ways to Get a Break on Costs There are new ways to get help paying for your insurance. Based on your income and family size, you may be eligible for financial assistance with your monthly health insurance costs called a monthly premium tax credit. You might also receive costsharing subsidies that help reduce your healthcare costs, such as your deductible. This could also lower your out-of-pocket costs when you visit your doctor or go to the emergency room. See the Save Money and Purchase Insurance section of this booklet on page 29 to learn more about this new financial help. To get this financial help, you ll need to enroll in health coverage through Idaho s Health Insurance Exchange. The next section will help you understand this new way to compare and enroll in insurance plans. Idaho s Health Insurance Exchange At a Glance The Exchange is an online marketplace where insurance companies will offer their plans. Idahoans can compare and select a coverage plan that best fits their healthcare needs and budget. Open Enrollment is from October 1, 2013 through March 31, HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

7 What s new? New Ways to Compare Health Insurance Plans You and your family have new health insurance options and Idaho s Health Insurance Exchange offers people a way to compare these new plans and find out if you qualify for a monthly premium tax credit and a cost-sharing subsidy. The Exchange is particularly helpful if you: Have not been able to afford coverage Don t have enough coverage Want a different plan that better meets your needs You may be eligible for subsidies to help you pay for health insurance and healthcare services Choose coverage that fits bcidaho.com. 7

8 What is the Exchange and how does it work? Idaho s Health Insurance Exchange is a website where you can compare insurance plans, apply for financial assistance, and buy a plan that best fits the needs of you and your family. When you fill out an application on the Idaho Health Insurance Exchange, you ll learn if you qualify for financial assistance like lower monthly premiums, lower out-of-pocket costs (copayments, deductibles) or if you qualify for free or low-cost government programs like Medicaid or Medicare. The Exchange will look and operate much like an online travel website, and show insurance plans from many different providers, including plans from Blue Cross of Idaho. You can compare all plans in one place so you can find the right option based on your health insurance needs and budget. Who can enroll? Legal residents of Idaho who do not have qualified health insurance through their employer or another government program. Illegal aliens and incarcerated individuals are not eligible for the Exchange. 8 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

9 What s new? Open Enrollment Coverage Requirement Most Idahoans are required to have health insurance in 2014 or pay a penalty. October 2013 through March 2014 Idahoans can buy insurance at bcidaho.com or from the Idaho Health Insurance Exchange during Open Enrollment from October 2013 through March December 15, 2013 You will have until December 15, 2013 to apply for coverage starting on January 1, After December 15, you will still be able to apply for the monthly premium credit and buy insurance on the Exchange, however, your coverage will not begin until February 1, If you have a change in your life, such as a new baby or marriage, or change in your health insurance, you may have a special enrollment period and be eligible to buy insurance, after the Open Enrollment period. Choose coverage that fits bcidaho.com. 9

10 Did You Know? We Strive to Help You Meet Your Healthcare Needs From our nurses in our health management programs to our online health and wellness tools and more, we provide members with resources to help them take control of their health. Key terms I should know Premium The amount you pay each month for your health insurance plan. Deductible The amount you pay each year for out-ofpocket expenses before the health insurer picks up expenses. You won t have to pay any deductible for preventive care. Coinsurance Your share of the costs you pay, calculated as a percentage. (for example, you pay 20 percent, insurance pays 80 percent). Copayment A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication. Network The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members. Out-of-Pocket Expenses Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions. Out-of-Pocket Maximum After your premium payments, the most in a year you will pay for covered healthcare services from in-network providers is $6,350 for individuals and $12,700 for families. See the Glossary on page 34 for more key terms. 10 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

11 HOW TO CHOOSE the right plan How to Choose the Right Plan Choosing the right coverage depends on knowing your healthcare needs, what you want from your coverage and what your budget will allow. Let s say you don t have any health coverage, or your current coverage is simply not right for you, now is the time to evaluate your options and find the coverage that fits you and your family. Blue Cross of Idaho has options to meet your medical needs. Our networks include 96 percent of all the doctors and 100 percent of all the hospitals in Idaho, so you can choose among many different plans. Here are some of the differences among plans: 1. The type of hospital and doctor network: Blue Cross of Idaho offers plans with access to our robust PPO network, featuring 96 percent of doctors and all hospitals in the state, and our ConnectedCare sm networks which provide coordinated care through primary care and specialty physicians in select areas of the state. This gives you the freedom to choose from plans with the largest provider network in Idaho, or those with coordinated care that can lower your monthly premium. Look at the list of doctors and hospitals in each plan type to see if the healthcare providers you prefer are available in the plans you like. 2. The amount of deductible: Blue Cross of Idaho offers different deductible levels, including one plan with a $0 deductible. The difference in deductible usually changes the amount of monthly premium you pay. 3. How you pay for your care: Many of our plans include deductibles, copayments and/or coinsurance. One more option is a high deductible health plan paired with a tax free Health Savings Account (HSA) that allows you to set up a special bank account to save money to pay for your deductible and other medical expenses. When you put money in your HSA, you will keep that money forever, unless you decide to spend it on health costs. You will not pay tax on this money, and it will be in a savings account where it can earn interest. Choose coverage that fits bcidaho.com. 9

12 Did You Know? You can get services from the best doctors and hospitals all over the United States in Blue networks, from Johns Hopkins and the Cleveland Clinic to the Mayo Clinic and virtually every research and academic medical institution in the country. What are the new options? Introducing metal levels for easy comparison across plans Individual insurance plans are organized into four metal levels based on the amount of coverage provided. These levels are Bronze, Silver, Gold, and Platinum, and vary by the monthly premium cost and the percent of expected costs covered. The metal level ranking system makes it easy to compare plans in the same category or across categories. This allows you to make apples-to-apples comparisons among plans, see your expected costs more easily and get the coverage you need. It is important to know that all metal levels have the same essential health benefits, such as emergency room services, maternity and newborn care, annual doctor visits, and medical screenings. As a general rule of thumb, you can choose to pay a higher monthly premium, so that when you need medical care, you pay less. Or you can choose a lower monthly premium so that when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget. 10 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

13 HOW TO CHOOSE the right plan Blue Cross of Idaho Insurance Plans Monthly Premium In-network Deductible Range Individual/Family Out-of-Pocket Maximum Individual/Family Eligible for Monthly Premium Tax Credit Eligible for Cost Sharing Subsidy Bronze Plans $ $5,000-$6,350/ $10,000-$12,700 $6,350/$12,700 Silver Plans $$ $0-$4,000/$0-$8,000 $6,350/$12,700 Gold Plans $$$ $1,000/$2,000 $6,350/$12,700 Platinum Plan $$$$ $550/$1,100 $6,350/$12,700 Minimum Benefit Plans $ $6,350/$12,700 $6,350/$12,700 Short-Term PPO $ $500-$2,000 individual only $2,500 - $4,000 individual only Simply put: The Platinum plans have the most expensive monthly payments, but the insurance plan will cover more of the costs when you receive healthcare services. The Bronze plans have the lowest monthly payments, but you will be responsible for more of the costs when you receive healthcare services. A deductible is the amount you pay each year for out-of-pocket expenses before your insurance covers the cost. You should consider the deductible when evaluating plans. Generally speaking, the higher your monthly insurance costs, called premiums, the lower your deductible and vice versa. It s also important to note that not all services are subject to deductible. Some insurance plans pay for certain medical services (like trips to your doctor) before you meet the deductible. An out-of-pocket maximum is a fixed dollar amount $6,350 for individuals, $12,700 for families that is the most you will pay for covered services from in-network providers in an annual benefit period. Once you meet this maximum, your insurance will cover the total cost of covered services. Check out Blue Cross of Idaho s insurance products for each metal level to find the plan that s right for you. See the Blue Cross of Idaho Health Insurance Plans section of this booklet. Choose coverage that fits bcidaho.com. 11

14 Key considerations in choosing the right plan for you Please consider these questions before you choose a coverage plan to help narrow down your best options: Do I qualify for a break on costs based on my income and family size? Take a look at the Get a Break on Costs section of this booklet to learn if you may be able to get financial assistance. What sort of health services and medications might my family and I need? Think about your current and future healthcare needs. How often do you need to go to the doctor? What is your family s health history? Do you have a job or do activities through which you might get injured? Does your child play a sport in which they might get injured? Does the plan include my current doctors? Each plan may include a different set of doctors and other health service providers, which is called being in-network. Look at the list of doctors and hospitals in each plan at bcidaho.com to see if the healthcare providers you prefer are in the network of the plans you are considering. What is the best way for me to balance the deductible and premium options? In balancing your deductible and premium choices, ask yourself: Would I rather pay a higher monthly premium so that my insurance pays a greater portion of the costs if I get sick or injured, i.e. a lower deductible; OR would I rather have a lower monthly premium and pay a greater share of the cost if I get sick or injured, i.e., a higher deductible? In addition, make sure you have all the information to complete your application on the Idaho Health Insurance Exchange to see if you qualify for help in paying your monthly premiums, including: Dates of birth for all family members Social Security numbers for all family members Employer information (Employer name, address, phone number and average hours worked each week) Income information (Adjusted Gross Income from your previous year s tax return) 12 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

15 Blue Cross of Idaho Health Insurance Plans We offer a variety of health insurance plans with the coverage you need at a price you can afford. Whether you buy directly from us, or through the Idaho Health Insurance Exchange, you will find affordable coverage for you and your family from Blue Cross of Idaho. Please take a look at the individual and family metallic plans we offer below. As we discussed in the How Do I Choose the Right Plan section of this booklet, all of our plans fit into four levels based on the amount of coverage they provide. These levels, known as metal levels, are Bronze, Silver, Gold, and Platinum. In the following pages, we provide coverage details and plan information to help you find the insurance that best meets your needs. You can learn more about our products and the metal levels at bcidaho.com. Blue Cross of Idaho Metallic Plans BRONZE SILVER GOLD Platinum Bronze Choice Silver Choice Gold Choice Platinum Connect Bronze Connect Silver Connect Gold Connect Bronze HSA Saver Silver Choice no deductible Silver Connect no deductible Choose coverage that fits bcidaho.com. 13

16 Individual and Family Medical Plans Now let s dive into the health insurance plans you can choose from. Following these plan descriptions, you ll also find a summary chart outlining the key cost information for each plan. Please note: At this time the Connect plans in Bronze, Silver, Gold and Platinum are only available through the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Provider Network in eastern Idaho. Bronze HSA Saver: A health plan that you can pair with a Health Savings Account (HSA) you set up at your financial institution, like a bank. You can use the tax-free money you deposit into your HSA to cover a wide range of medical costs like your deductible and any other medical costs. If you don t use the money, you can keep it in your account to earn interest and use when you need it at any time in the future. Bronze Medical Plans Our Bronze plans offer our lowest monthly payment options for slightly higher deductible amounts. If you want robust coverage for your routine, preventive care at lower monthly prices, our Bronze plans may be for you. Bronze Choice: Combining the low cost and robust benefits of our Bronze plans with our PPO provider network, featuring all of the hospitals in Idaho and 96 percent of doctors and physicians. Bronze Connect: Our lowest cost plan brings the benefit package of other Bronze plans together with our ConnectedCare networks in southwestern and southeastern Idaho to meet your coverage and cost needs. Remember if you purchase insurance through the Idaho Health Insurance Exchange, you may be eligible for financial help to cover your monthly insurance costs (your premium) and your additional healthcare costs. Check out the Get a Break on Costs section of this booklet to learn more. 14 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

17 Blue cross of Idaho Health Insurance Plans Silver Medical Plans Our Silver plans provide a variety of coverage options and pricing structures to meet your health insurance needs. You can choose from a $0 deductible option to a higher deductible with low copayment and rich pharmaceutical benefits. Your monthly insurance costs, or premiums, will be slightly higher than those of the Bronze plans but your coverage will pay more of the costs of the services you receive. Silver Choice: Low out-of-pocket costs for trips to the doctor and prescription drugs combine with the variety and strength of our PPO provider network. Silver Choice No Deductible: A $0 deductible allows you to avoid having to meet a deductible before your insurance kicks in, while providing the strength of our PPO network. Silver Connect: Low out-of-pocket costs for trips to the doctor and prescription drugs meets the value of a primary care physician of your choice coordinating your care through the ConnectedCare network. Silver Connect No Deductible: Coordinated medical care without a deductible ensures you get the care you need without huge out-of-pocket costs after your monthly premiums. Did You Know? Silver Plans offer reductions in deductible, copayment and monthly premium payments for people who qualify. Check out the Save Money and Purchase Insurance tab on page 29 of this book to learn more. Choose coverage that fits bcidaho.com. 15

18 Gold Medical Plans We offer Gold plans on our PPO and ConnectedCare networks. With low deductible and copayment amounts, our Gold plans combine some of our richest benefit packages with affordability to give you and your family peace of mind in your health insurance. Gold Choice: Low out-of-pocket costs for trips to the doctor and prescription drugs and a $1,000 deductible make this an easy Choice. The variety and strength of our PPO network is icing on the cake. Gold Connect: This connects low costs and deductible with coordinated care offering proactive, quality care to meet your needs and budget through our ConnectedCare networks in southwest or eastern Idaho. 16 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

19 Blue cross of Idaho Health Insurance Plans Platinum Medical Plans Our Platinum plan is available on our ConnectedCare network in southwestern Idaho. Platinum Connect is a low deductible plan with the highest level of coverage. This plan brings you, your medical providers and health insurance together to offer proactive, quality care at an affordable price. Among all the metal levels, Platinum plans will have the highest predictable monthly premiums, but you ll have the lowest out-of-pocket costs when you get medical care. Platinum Connect: Our most comprehensive coverage plan combines a low deductible with our most robust benefit structure. This plan offers the value of having your primary care doctor from the Saint Alphonsus Health Alliance Network in southwest Idaho coordinate your care with other healthcare providers, such as specialists. Covered Connect: The same benefit design as our Covered Choice plan at a slightly lowered price. Available only to buyers in southwestern and eastern Idaho, through our ConnectedCare networks in those areas of the state. Short-term PPO Plan Do you need coverage for a short period of time? Blue Cross of Idaho s Short Term PPO offers a limited benefit program for temporary coverage. You can protect yourself and eligible dependents during those times between coverage and choose from non-renewable coverage for one to 10 months. Our short-term plans are only available directly from Blue Cross of Idaho and are not subject to the rules set forth by the ACA, including the pre-existing condition coverage requirement. Dental insurance must be included in your coverage if you or a dependent are under the age of 19. Minimum benefit plans We also offer a pair of high-deductible, low payment plans available to people under the age of 30, and for people who qualify through the Exchange on a hardship exemption. These catastrophic plans provide coverage for the essential health benefits but only after a member has met the deductible levels in out-ofpocket expenses. If you are under the age of 30, or if you meet certain criteria through the Exchange, these plans may be a good choice for you. Members on the catastrophic plans are not eligible for the monthly premium tax credit or cost sharing subsidy available through the Idaho Health Insurance Exchange. Covered Choice: Combines our largest provider network with a high-deductible, lower-premium plan design. Choose coverage that fits bcidaho.com. 17

20 The size of our provider networks allows us to negotiate pricing to help keep your costs low. Our Provider Networks You ll get the best choice of doctors and hospitals with Blue Cross of Idaho. As you read the descriptions of each of the plans, you ll notice that Choice plans use our PPO network, whereas the Connect plans use our new ConnectedCare network. As you consider which plan is right for you, check to make sure the healthcare providers and facilities, such as hospitals, you like are in the plan s provider network. You can look for specific doctors and hospitals through our Find a Provider link on our homepage at bcidaho.com. Preferred Provider Organization (PPO) Network: If you choose a plan with the PPO network, you ll get access to 96 percent of all physicians in the state. Additionally, you can visit any acute care hospital in Idaho, i.e., those hospitals that provide services for short-term illnesses or injuries. With this vast group of in-network providers, you can be sure to find a provider you want, pay the in-network costs and avoid the higher costs that come when you use a provider or health services facility that is out-of-network. Plus, you won t need referrals to visit specialists or other care providers. It s your choice who you see. ConnectedCare Network: Our ConnectedCare products are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Health Network in eastern Idaho. When you choose managed care through ConnectedCare networks, you ll receive high quality care, close to home from highly skilled healthcare providers dedicated to delivering effective, efficient care. Our Connect plans, in combination with ConnectedCare networks in southwestern and eastern Idaho, are designed to improve the quality of care and control costs by coordinating your services through a primary care physician (PCP). You ll need to select a PCP to serve as your care coordinator. What does that mean? Your PCP will act as a central point for your care, coordinating your treatment by providing your care when it is appropriate or referring you to other in-network specialists for other healthcare services as needed. With more coordinated care, we believe your receive higher quality care for your overall wellbeing. Please note: at this time the ConnectedCare network is only available in southwestern and eastern Idaho. 18 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

21 Blue cross of Idaho Health Insurance Plans Did You Know? We Offer Wide, Quality Provider Networks 96% of Idaho doctors and 100% of Idaho hospitals are in our network. Plus, thousands of doctors and hospitals all over the United States are in the BlueCard network. Outside of the United States, members have access to doctors and hospitals in more than 200 countries and territories around the world. Choose coverage that fits bcidaho.com. 19

22 Benefit grid outlines coverage for in-network and out-of-network services. Not a comprehensive list of benefits. Metal level Catastrophic Plans (Minimum Benefit) Bronze Plans Covered Choice AND Covered Connect In-Network Out-of-Network Deductible Individual $6,350 Family $12,700 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Services Individual $6,350 Family $12,700 You pay nothing. (Services may be subject to deductible.) preventive care services. Individual $6,350 Family $12,700 Covered Choice $8,350 / $16,700 Covered Connect $10,000 / $20,000 You pay 30%. (Services may be subject to deductible.) In-Network Individual $5,000 Family $10,000 Individual $6,350 Family $12,700 You pay nothing. (Services may be subject to deductible.) Bronze HSA Saver Out-of-Network Individual $5,000 Family $10,000 Individual $8,350 Family $16,700 What You ll Pay up to your annual out-of-pocket maximum preventive care services. You pay 30% (Services may be subject to deductible.) Doctor s Office Visit Immunizations Inpatient Hospital Services Emergency Room Visit Prescription Drugs Pregnancy Outpatient Mental Health Services Covered Choice : You pay $30 each for first 3 office visits, then costs up to your deductible. Covered Connect : You pay $10 copayment (each for first 3 PCP office visits, then costs up to your deductible.) You pay costs up to your deductible for non- PCP visits with referral. immunizations. deductible. deductible. deductible. deductible. You pay costs up to your deductible and then nothing. immunizations. * deductible and then you pay nothing. immunizations. deductible and then nothing. deductible and $150 copayment. immunizations. deductible, 30% and $150 copayment.* generic and brand-name preventive drugs. deductible and $10 copayment for non-preventive generic drugs, and 50% for non-preventive brand-name drugs. deductible and then nothing. deductible and then nothing. Physician, Surgical & Medical Services Diabetes Education Services Chiropractic Care Outpatient Rehabilitation Services Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Services deductible. deductible. deductible. Up to a combined in and out-of-network total of 18 visits per member, per benefit period. deductible. PT, ST, OT limited to a combined total of 20 visits per member, per benefit period deductible. deductible and then nothing. deductible and then $30 copayment. deductible and then nothing. deductible and then nothing. deductible, then nothing. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. * For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 20 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

23 Blue cross of Idaho Health Insurance Plans Visit bcidaho.com for a Summary of Benefits and Coverage. Metal level Plans In-Network Bronze Choice Out-of-Network Bronze In-Network Bronze Connect Out-of-Network Deductible Individual $6,350 Family $12,700 Annual Out-of-Pocket Maximum Costs Individual $6,350 Family $12,700 Individual $6,350 Family $12,700 Individual $8,350 Family $16,700 Individual $6,350 Family $12,700 Individual $6,350 Family $12,700 Individual $6,350 Family $12,700 Individual $10,000 Family $20,000 Coinsurance Preventive Care Services You pay nothing. (Services may be subject to deductible.) preventive care services. You pay 30% (Services may be subject to deductible.) You pay nothing. (Services may be subject to deductible.) What You ll Pay up to your annual out-of-pocket maximum preventive care services. You pay 30% (Services may be subject to deductible.) Doctor s Office Visit You pay $30 copayment (up to 4 non-preventive office visits, then you pay costs up to your deductible.) You pay $30 copayment (up to 5 PCP office visits, then you pay costs up to your deductible.) You pay costs up to your deductible for non-pcp visits with referral. Immunizations Inpatient Hospital Services Emergency Room Visit immunizations. deductible and then nothing. deductible and then nothing. immunizations. * immunizations. deductible and then nothing. deductible and then nothing. immunizations. * Prescription Drugs Pregnancy Outpatient Mental Health Services Physician, Surgical & Medical Services Diabetes Education Services deductible and then nothing. You pay $30 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible. deductible and then nothing. You pay $30 copayment. You pay costs up to your deductible and then nothing. deductible and then nothing. You pay $30 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible. deductible and then nothing. You pay $30 copayment. You pay costs up to your deductible and then nothing. Chiropractic Care Outpatient Rehabilitation Services Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Services deductible and then nothing. deductible and then nothing. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. deductible and then nothing. deductible and then nothing. deductible and then nothing. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. deductible and then nothing. * For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. Choose coverage that fits bcidaho.com. 21

24 Benefit grid outlines coverage for in-network and out-of-network services. Not a comprehensive list of benefits. Metal level Plans In-Network Silver Choice Out-of-Network Silver In-Network Silver Connect Out-of-Network Deductible Individual $4,000 Family $8,000 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Services Individual $6,350 Family $12,700 You pay 30% of the cost of your care. (Services may be subject to your deductible.) preventive care services. Individual $4,000 Family $8,000 Individual $8,350 Family $16,700 You pay 50% of the cost of your care. (Services may be subject to your deductible.) Individual $4,000 Family $8,000 Individual $6,350 Family $12,700 You pay 30% of the cost of your care. (Services may be subject to your deductible.) Individual $4,000 Family $8,000 Individual $10,000 Family $20,000 What You ll Pay up to your annual out-of-pocket maximum preventive care services. You pay 50% of the cost of your care. (Services may be subject to your deductible.) Doctor s Office Visit Immunizations Inpatient Hospital Services Emergency Room Visit Prescription Drugs Pregnancy Outpatient Mental Health Services Physician, Surgical & Medical Services Diabetes Education Services Chiropractic Care Outpatient Rehab Services Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Services You pay $10 copayment (up to 4 non-preventive office visits, then you pay costs up to your deductible and 30%.) immunizations. deductible, 30% and $150 copayment. You pay $10 copayment for generic drugs. immunizations. deductible, 50% and $150 copayment.* You pay costs up to a separate $2,350 deductible for brand-name and specialty drugs and then: $30 for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs. You pay $10 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible and 30%. You pay $10 copayment per visit. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. You pay $10 copayment (up to 5 PCP office visits, then you pay costs up to your deductible and 30%.) You pay costs up to your deductible and 30% for non-pcp visits with referral. immunizations. deductible, 30% and $150 copayment. You pay $10 copayment for generic drugs. immunizations. deductible, 50% and $150 copayment.* You pay costs up to a separate $2,350 deductible for brand-name and specialty drugs and then: $30 for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs. You pay $10 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible and 30%. You pay $10 copayment per visit. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. * For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 22 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

25 Blue cross of Idaho Health Insurance Plans Visit bcidaho.com for a Summary of Benefits and Coverage. Metal level Plans Silver Choice No Deductible In-Network Out-of-Network Silver Silver Connect No Deductible In-Network Out-of-Network Deductible Individual $0 Family $0 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Services Individual $6,350 Family $12,700 You pay 50% of the cost of your care. preventive care services. Individual $1,000 Family $2,000 Individual $8,350 Family $16,700 You pay 75% of the cost of your care. (Services may be subject to your deductible.) Individual $0 Family $0 Individual $6,350 Family $12,700 You pay 50% of the cost of your care. Individual $1,000 Family $2,000 Individual $10,000 Family $20,000 What You ll Pay up to your annual out-of-pocket maximum deductible and then 75%. preventive care services. You pay 75% of the cost of your care. (Services may be subject to your deductible.) deductible and then 75%. Doctor s Office Visit You pay 50%. deductible and then 75%. You pay 50%. deductible and then 75%. Immunizations Inpatient Hospital Services Emergency Room Visit Prescription Drugs immunizations. You pay 50%. You pay $150 copayment and then 50%. immunizations. deductible and then 75%. deductible, 75% and $150 copayment.* You pay 50% of the cost of your prescription. immunizations. You pay 50%. You pay $150 copayment and then 50%. immunizations. deductible and then 75%. deductible, 75% and $150 copayment.* You pay 50% of the cost of your prescription. Pregnancy You pay 50%. deductible and then 75%. Outpatient Mental Health Services You pay 50%. deductible and then 75%. You pay 50%. You pay 50%. deductible and then 75%. deductible and then 75%. Physician, Surgical & Medical Services You pay 50%. deductible and then 75%. Diabetes You pay 50%. Education Services deductible and then 75%. Chiropractic Care You pay 50%. deductible and then 75%. Outpatient Rehab Services Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Services You pay 50%. You pay 50%. Up to a combined total of 18 visits per member, per benefit period. deductible and then 75%. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. deductible and then 75%. You pay 50%. You pay 50%. You pay 50%. You pay 50%. You pay 50%. deductible and then 75%. deductible and then 75%. deductible and then 75%. Up to a combined total of 18 visits per member, per benefit period. deductible and then 75%. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. deductible and then 75%. * For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. Choose coverage that fits bcidaho.com. 23

26 Benefit grid outlines coverage for in-network and out-of-network services. Not a comprehensive list of benefits. Metal level Plans In-Network Gold Choice Out-of-Network Gold In-Network Gold Connect Out-of-Network Deductible Individual $1,000 Family $2,000 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Services Individual $6,350 Family $12,700 You pay 15% of the cost of your care. (Services may be subject to deductible.) preventive care visits. Individual $1,000 Family $2,000 Individual $8,350 Family $16,700 You pay 50% of the cost of your care. (Services may be subject to deductible.) Individual $1,000 Family $2,000 Individual $6,350 Family $12,700 You pay 15% of the cost of your care. (Services may be subject to deductible.) What You ll Pay up to your annual out-of-pocket maximum preventive care visits. Individual $1,000 Family $2,000 Individual $10,000 Family $20,000 You pay 50% of the cost of your care. (Services may be subject to deductible.) Doctor s Office Visit Immunizations Inpatient Hospital Services Emergency Room Visit Prescription Drugs Pregnancy You pay $10 copayment (up to 4 office visits, then you pay costs up to your deductible and coinsurance.) immunizations. deductible and then 15%. deductible, 15% and $150 copayment. immunizations. deductible, 50% and $150 copayment.* You pay $10 copayment for generic prescription drugs. deductible for brand-name and specialty drugs and then: $30 for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs. deductible and then 15%. You pay $10 PCP copayment and $40 non-pcp copayment (up to 5 office visits, then you pay costs up to your deductible and coinsurance.) You pay costs up to your deductible and 15% for non-pcp visits with referral. immunizations. deductible and then 15%. deductible, 15% and $150 copayment. immunizations. deductible, 50% and $150 copayment.* You pay $10 copayment for generic prescription drugs. deductible for brand-name and specialty drugs and then: $30 for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs. deductible and then 15%. Outpatient Mental Health Services Physician, Surgical & Medical Services Diabetes Education Services Chiropractic Care Outpatient Rehab Services Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Services You pay $10 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible. deductible and then 15%. You pay $10 copayment per visit. deductible and then 15%. deductible and then 15%. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period deductible and then 15%. You pay $10 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible. deductible and then 15%. You pay $10 copayment per visit. deductible and then 15%. deductible and then 15%. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period deductible and then 15%. * For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 24 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

27 Blue cross of Idaho Health Insurance Plans Visit bcidaho.com for a Summary of Benefits and Coverage. Metal level Plans In-Network Deductible Individual $550 Family $1,100 Annual Out-of-Pocket Maximum Costs Coinsurance Preventive Care Services Doctor s Office Visit Immunizations Inpatient Hospital Services Emergency Room Visit Prescription Drugs Pregnancy Outpatient Mental Health Services Physician, Surgical & Medical Services Diabetes Education Services Chiropractic Care Outpatient Rehab Services Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST) Diagnostic X-Ray and Lab Services Individual $6,350 Family $12,700 Platinum Platinum Connect Out-of-Network Individual $550 Family $1,100 Individual $10,000 Family $20,000 You pay nothing. (Services may You pay 50% of the cost of your be subject to deductible.) care. (Services may be subject to deductible.) What You ll Pay up to your annual out-of-pocket maximum preventive care visits. You pay $10 PCP copayment and $40 non-pcp copayment (up to 5 office visits, then costs up to your deductible.) You pay costs up to your deductible for non-pcp visits with referral. immunizations. deductible and then nothing. You pay $150 copayment (Not subject to deductible.) You pay $10 copayment for generic prescription drugs. immunizations. You pay $150 copayment and then 50% (Not subject to deductible.)* You pay $10 copayment for generic prescription drugs. You pay $30 copayment for preferred brand-name, $50 copayment for non-preferred brand-name, $100 copayment for specialty drugs. You pay $200 copayment for facility services and costs up to your deductible for physician s care. You pay $10 copayment for outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible. deductible. You pay $10 copayment per visit. deductible. deductible. deductible. Up to a combined total of 18 visits per member, per benefit period. PT,OT,ST limited to a combined total of 20 visits per member, per benefit period. * For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. Key terms I should know Premium The amount you pay each month for your health insurance plan. Deductible The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won t have to pay any deductible for preventive care. Coinsurance Your share of the costs you pay, calculated as a percentage. (for example, you pay 20 percent, insurance pays 80 percent). Copayment A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication. Network The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members. Out-of-Pocket Expenses Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions. Out-of-Pocket Maximum After your premium payments, the most in a year you will pay for covered healthcare services from in-network providers is $6,350 for individuals and $12,700 for families. The cost of your care When you use in-network providers, your cost of care is lower because even when you are paying your deductible, you only pay Blue Cross of Idaho s discounted fee. Choose coverage that fits bcidaho.com. 25

28 Why Blue Cross of Idaho? From our beginnings at a meeting in Boise in 1945, through the current evolving health insurance landscape and beyond, Blue Cross of Idaho has remained committed to a healthier Idaho. Today, Blue Cross of Idaho Health Service, Inc. is a tax-paying, not-for-profit mutual insurance company with more than 700,000 members enrolled in our medical and dental insurance programs. We employ nearly 900 employees at our headquarters in Meridian, Idaho, with additional staff in offices in Coeur d Alene, Lewiston, Twin Falls, Pocatello and Idaho Falls. Best Value Our mission is to provide our members the best value in health insurance and the tools for maintaining, and improving, their health. By providing the best value in health insurance, we meet our member needs. We do this by offering members a variety of insurance options, extensive provider networks that let you get care from the doctors you want, award winning customer service and by giving you access to the healthcare programs you need to achieve your best health. And even as healthcare costs continue to rise, we work to minimize the administrative costs, so that we can keep your premiums as low as possible. Strong Provider Networks No insurance company has a more complete network of doctors and hospitals in the state than Blue Cross of Idaho. We contract with every hospital in Idaho and 96 percent of all Idaho physicians and healthcare providers. If you re traveling outside of Idaho, doctors and hospitals all over the United States are in our BlueCard network, from Johns Hopkins and the Cleveland Clinic to the Mayo Clinic and virtually every research and academic medical institution in the country. Outside of the United States, you ll have access to doctors and hospitals in more than 200 countries and territories around the world through the BlueCard Worldwide Program. Excellent Customer Service Blue Cross of Idaho takes pride in providing exceptional service to all our members in an experienced, consistent and accountable manner. At Blue Cross of Idaho, we go to great lengths to make sure important information is always at your fingertips by providing support through our website at bcidaho.com and over the phone. Whether you prefer researching your question on our website or contacting one of our specially trained customer advocates on the phone, we re here for you. 26 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

29 Blue cross of Idaho Health Insurance Plans Here when you need us Members can connect with one of our many experienced customer advocates specifically trained to handle your needs. Our Customer Advocates are available from 8 a.m. to 6 p.m. MT Monday through Friday. Blue Cross of Idaho also provides services to our members 24 hours a day online or through our automatic phone system that offers self-service options such as claims history, eligibility or deductible information. Health Management Programs We help our members succeed in creating and sustaining healthy behaviors. By crafting programs that focus on supporting our members goals, they have access to the critical information and tools to help them live healthier, happier lives. You can too! If you participate in one of our Health Management Programs, our nurse health coaches will work with you one-on-one over the phone, helping you learn how to take the best care of yourself, realize your goals, and take confident steps toward better health. Behavioral Health Management Integration Behavioral health focuses on improving the quality of life for people with mental illness or substance abuse because mental health is a key aspect of overall health and wellbeing. Having a department dedicated to behavioral health allows us to help coordinate overall member care, and provide an integrated approach to your entire physical and mental health picture. Helpful Online Tools At bcidaho.com/members as a member you can get information on your coverage, claims, and the cost of services, take an online health risk assessment and find a doctor or hospital all available 24 x 7 on our website. Here are some of the details of what you can find on our easy-to-use site: Health plan specifics Claims history, coverage descriptions and the explanation of benefits for all claims Individual and family deductible information Searchable benefit information for your specific plan Hospital admissions and prior authorization history Provider and hospital finders Pharmacy benefits information and a prescription drug formulary Medical forms Blue Cross of Idaho has programs for asthma, congestive heart failure, depression, diabetes, and chronic obstructive pulmonary disease, among others. Choose coverage that fits bcidaho.com. 27

30 We are dedicated to providing the highest quality member service, whether through our website at bcidaho.com, over the phone, in person at our district offices and through . Additionally, members who complete a personal health assessment have access to online health coaching programs that give them personalized action plans, tools and resources to help them meet their health goals. These programs include: RELAX stress management MOVE fitness/physical activity NOURISH nutrition BREATHE smoking cessation BALANCE weight management Members can also visit our online health library to access tools and information like: Interactive tools and quizzes Symptom checker A variety of health topics Information on medical tests and medications Personal health coaching is a value added program and is not health insurance. Blue Extras! Blue Extras is a value added program and not health insurance. We know that maintaining good health is important to our members and that there are many different approaches to achieving good health. Whether you follow a formal workout routine or rely on evening walks in the neighborhood take a daily multi-vitamin or follow a strict naturopathic medicine, acupuncture and massage therapy program, our Blue Extras! program can help you succeed. Blue Extras! offers a variety of value-add services, programs and products to help our members achieve their personal health, wellness and fitness goals. The Blue Extras! program offers discounted rates to members for the following services: Baby health and safety Complementary and alternative health Fitness clubs Hearing services Medical alert services Orthodontia services Vision services Blue Extras! is available to most Blue Cross of Idaho members and is not dependent on your specific benefit plan. However, if your plan includes coverage for a service included in the Blue Extras! valueadded program, the service provider will apply the discount before submitting the claim for payment under your benefit plan. For more information about Blue Extras! and for a list of specific clubs and services providers, visit bcidaho.com. 28 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

31 Save money and purchase insurance Get a break on costs Worried that health insurance is too expensive? Well, it may now be within reach. Not only does Blue Cross of Idaho offer plans to meet your budget and coverage needs, but depending on your income and family size, you may qualify for help paying your health insurance and healthcare costs. You may even be eligible for a low cost or $0 insurance plan. Remember, you ll need to apply for financial assistance on the Exchange. Monthly Premium tax Credits Starting in 2014, there is a new credit you may be able to use right away to lower your monthly insurance premium costs. The Federal Government will send that money directly to your insurance company. You will be able to calculate if you are eligible for a credit before you enroll in a plan. Financial assistance depends on your income and family size. For example: Individuals: A single person earning between $11,490 and $45,960 will qualify. Families: The amount of income you can have and still qualify varies according to the size of your family. As an example, a family of four with household income between $23,550 and $94,200 will qualify. You may be eligible for financial assistance that will help you right away. Family Size Income Range Eligible for Monthly Premium tax Credit Individual $11,490 $45,960 Yes Family of 4 $23,550 $94,200 Yes Visit our subsidy calculator at bcidaho.com to get an estimate on how much money you might be able to save. Choose coverage that fits bcidaho.com. 29

32 Lower your out-of-pocket costs If your household income is in a certain range between 100 percent and 250 percent of the federal poverty level you may be able to get extra help paying out-of-pocket costs, such as deductibles and coinsurance. This assistance is known as cost sharing reduction or subsidies, and is only available if you choose the silver plan. To learn more about what determines health insurance costs, go to bcidaho.com Family Size Income Range Eligible for Cost Sharing Reduction Individual $11,490 $28,725 Yes Family of 4 $23,550 $58,875 Yes Options for families There is also help for working families through already existing programs like the Children s Health Insurance Program (CHIP) and Medicaid. CHIP provides coverage for children so that they will be able to get routine checkups, dental care, and immunizations to keep them healthy. They will also get physician visits, prescription. For more information, visit: insurekidsnow.gov/state/idaho Medicaid offers $0 or low cost coverage for your healthcare needs based on income level and family size. For more information, visit: healthandwelfare.idaho.gov 30 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

33 Save money and purchase insurance How can I purchase insurance? You can purchase insurance directly from Blue Cross of Idaho, through your insurance agent, or from the Idaho Health Insurance Exchange. Purchasing insurance through Blue Cross of Idaho If you d like to purchase Blue Cross of Idaho health insurance, you can: Visit the Blue Cross of Idaho website bcidaho.com. Contact Blue Cross of Idaho Sales at GO CROSS ( ) to help choose a plan that is right for you. Visit a district office You can find locations on the back of this booklet or on our website at shoppers.bcidaho. com under the Contact Us tab. Insurance brokers An insurance broker can help you understand, compare and evaluate plans, including those from Blue Cross of Idaho, based on your specific needs. Check out our broker locator at shoppers.bcidaho.com under the Tools and Resources tab. The Idaho Health Insurance Exchange The Exchange at YourHealthIdaho.org allows you to apply for the new financial help and make side-by-side comparisons of the insurance plans available from a variety of insurance providers, including Blue Cross of Idaho. You must purchase insurance through the Exchange to qualify for the new monthly premium credit. Choose coverage that fits bcidaho.com. 31

34 Did You Know? Our website, bcidaho.com, provides our members access to a variety of information about their health plan and health history, from health plan specifics to medical forms. 32 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

35 Additional Resources To learn more about the changes to health insurance following healthcare reform and learn more about Blue Cross of Idaho products, visit: BCIdaho.com Check out Blue Cross of Idaho plans that are available to you. Blue Cross of Idaho sales GO CROSS ( ) GetCoveredIdaho.com This educational website will help Idahoans understand the changes coming to health insurance in 2014, including information on the Idaho Health Insurance Exchange, the financial assistance that may be available to you, as well as a calculator to estimate if you are eligible for those cost breaks. YourHealthIdaho.org allows you to apply for the new financial help and make side-by-side comparisons of the insurance plans available from a variety of insurance providers. Healthcare.gov This website was created by the Federal Government to help you understand more about healthcare reform and the new state health insurance exchanges that will be offering new insurance options across the country. Health insurance brokers Visit our broker locator at shoppers. bcidaho.com under the Tools and Resources tab. Choose coverage that fits bcidaho.com. 33

36 Glossary Here are simple and straightforward explanations of common terms you re bound to come across as you scan plan options. Knowing these definitions can help you find the best options are for you and your family. Premium: The amount you pay each month for your health insurance plan. Deductible: The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won t have to pay any deductible for preventive care. Coinsurance: Your share of the costs you pay, calculated as a percentage. (for example, you pay 20 percent, insurance pays 80 percent) Copayment: A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication. Network: The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members. Out-of-Pocket Expenses: Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions. Maximum Out-of-Pocket: A fixed dollar amount that is the most you will pay for covered services in a benefit period. Once you meet the out-of-pocket maximum, covered services are paid at 100 percent of the allowed amount. Monthly Premium Credits (also: Advance Premium Tax Credit): When enrollment through the Health Insurance Exchange starts in October 2013, individuals and families may be eligible for a new kind of monthly premium credit to lower what they pay for their monthly health plan premiums. The government will pay your premium credit in advance to your insurance company to help cover the cost of premiums, helping make insurance more affordable. You ll be able to buy insurance through Idaho s Health Insurance Exchange or from an insurance company, but the credits to help pay for insurance will be available only if you purchase the Idaho Health Insurance Exchange. Amount Charged / Amount Allowed: A provider can charge you any amount for a service, but a health insurer may establish the maximum it will pay for a given covered service. This amount will often be less than the charged amount. Contracting or in-network providers agree to accept the allowed amount (called the maximum allowance in your policy) as payment in full for a covered service and, as part of their contract, agree not to bill you the difference between the allowed amount and charged amount. 34 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

37 Additional resources Essential Health Benefits (EHBs): Basic health benefits that most health insurance plans will have to cover starting in 2014 with no coverage limit. They include: office visits, emergency services, hospitalization, rehab care, mental health and substance abuse treatment, prescriptions, lab tests, prevention, maternal and newborn care, and pediatric care. Explanation of Benefits (EOB): An explanation of benefits (EOB) form lists the services for which you or your providers have sent claims for coverage. These forms are not bills. Federal Poverty Level (FPL): The Federal Poverty Level is a measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits. Incomes between 100 and 400 percent of the FPL ($11,490 $45,960 for an individual) are eligible for the monthly premium tax credit and those with incomes from 100 through 250 percent of FPL may be eligible for cost sharing subsidies. Idaho s Health Insurance Exchange: The Idaho Health Insurance Exchange is designed to make buying health coverage easier and more affordable. Idaho s new Health Insurance Exchange is an online portal where a variety of insurance providers will offer their products for you to consider and select a coverage plan that best fits your healthcare needs and your budget. Starting in 2014, the Exchange will allow individuals to compare health plans, get answers to questions, find out if they are eligible for credits, and enroll in a health plan that meets their needs. Insurance Providers: The private companies selling health insurance plans. Individual Mandate (Also Tax Penalty): Starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren t, you may be required to pay a tax penalty. This penalty will be either 1 percent of your taxable income OR a flat dollar amount whichever amount is greater. The flat dollar amount will increase every year you are without health insurance. It starts at $95 in 2014, $325 in 2015 and $695 in You won t have to pay a penalty if you have very low income and coverage is unaffordable to you or for other reasons, including your religious beliefs. You will also be able to apply for a waiver asking not to pay an assessment if you don t qualify automatically. Metal Levels: There are four levels of individual coverage available through Exchange plans, called bronze, silver, gold and platinum. All plans will cover the essential benefits. Bronze plans feature the lowest monthly premiums, but cover only 60 percent of average costs. Platinum plans cover 90 percent of expected costs, but have the highest premiums. Non-Covered Service: A service or type of service that is specifically excluded from coverage in your policy. Read your policy for a full list, but non-covered services often include those considered experimental or convenience items. Note: These definitions are general descriptions. Please refer to your policy for specific definitions related to your benefits. Choose coverage that fits bcidaho.com. 35

38 PREEXISTING CONDITION WAITING PERIODS There is no preexisting condition waiting period for benefits. Exclusions & Limitations In addition to the exclusions and limitations listed elsewhere in this booklet, the following exclusions and limitations apply to the entire Policy, unless otherwise specified: There are no benefits for services, supplies, drugs, or other charges that are: not Medically Necessary. If services requiring Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Insured. However, the Insured could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider. In excess of the Maximum Allowance. For Hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Insured has a non-dental, life-endangering condition that makes hospitalization necessary to safeguard the Insured s health and life. not prescribed by or upon the direction of a Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed General Hospitals, Physicians, and other Providers. Investigational in nature. provided for any condition, Disease, Illness, or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related Injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party. provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefore would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Medicare Part B or would have been made if an Insured had applied for such payment except when payment under this Policy is expressly required by federal law. provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured s household. received from a dental, vision, or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group. For Surgery intended mainly to improve appearance or for complications arising from Surgery intended mainly to improve appearance, except for: 36 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

39 Additional resources reconstructive Surgery necessary to treat an Accidental Injury, infection, or other Disease of the involved part; or reconstructive Surgery to correct Congenital Anomalies in an Insured who is a dependent child. rendered prior to the Insured s Effective Date. For personal hygiene, comfort, beautification (including non-surgical services, drugs, and supplies intended to enhance the appearance), or convenience items, even if prescribed by a Physician, including, but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, massage therapy, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, homeopathic or naturopathic, massage, or music. For telephone consultations, and all computer or Internet communications; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider. For Inpatient admissions that are primarily for Diagnostic Services, Therapy Services, or Physical Rehabilitation, except as specifically provided in this Policy; or for Inpatient admissions when the Insured is ambulatory and/or confined primarily for bed rest, special diet, behavioral problems, environmental change or for treatment not requiring continuous bed care. For Inpatient or Outpatient Custodial Care; or for Inpatient or Outpatient services consisting mainly of educational therapy, behavioral modification, self care or self help training, except as specified as a Covered Service in this Policy. For any cosmetic foot care, including but not limited to, treatment of corns, calluses and toenails (except for surgical care of ingrown or Diseased toenails). For any of the following: For appliances, splints or restorations necessary to increase vertical tooth dimensions or restore the occlusion, except as specified as a Covered Service in this Policy; For orthognathic Surgery, including services and supplies to augment or reduce the upper or lower jaw; For implants in the jaw; for pain, treatment, or diagnostic testing or evaluation related to the misalignment or discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies; For alveolectomy or alveoloplasty when related to tooth extraction. For hearing aids or examinations for the prescription or fitting of hearing aids. For orthoptics, eyeglasses or contact lenses or the vision examination for prescribing or fitting eyeglasses or contact lenses, unless specifically provided as a Covered Service in this Policy. For any treatment of either gender leading to or in connection with transsexual Surgery, gender transformation, sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition. Made by a Licensed General Hospital for the Insured s failure to vacate a room on or before the Licensed General Hospital s established discharge hour. Choose coverage that fits bcidaho.com. 37

40 not related directly to the care and treatment of an actual condition, Illness, Disease, or Accidental Injury. Furnished by a facility which is primarily a place for treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home. For Acute Care, rehabilitative care, diagnostic testing, except as specified as a Covered Service in this Policy; for Mental or Nervous Conditions and Substance Abuse or Addiction services not recognized by the American Psychiatric and American Psychological Association. For weight control or treatment of obesity or morbid obesity, including but not limited to Surgery for obesity, except when Surgery for obesity is Medically Necessary to control other medical conditions that are eligible for Covered Services under the Policy, and nonsurgical methods have been unsuccessful in treating the obesity. For reversals or revisions of Surgery for obesity, except when required to correct an immediately life-endangering condition. For an elective abortion, unless it is the recommendation of one consulting Physician that an abortion is necessary to save the life of the mother, or if the pregnancy is a result of rape as defined by Idaho law, or incest as determined by the court. For use of operating, cast, examination, or treatment rooms, or for equipment located in a Contracting or Noncontracting Provider s office or facility, except for emergency room facility charges in a Licensed General Hospital, unless specified as a Covered Service in this Policy. For the reversal of sterilization procedures, including, but not limited to, vasovasostomies or salpingoplasties. Treatment for infertility and fertilization procedures, including, but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance an Insured s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures. For Transplant services and Artificial Organs, except as specified as a Covered Service under this Policy. For acupuncture. 38 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO Individuals and Families

41 Additional resources 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. Additionally, reversals, revisions and/or complications of such surgical procedures are excluded, except when required to correct an immediately lifeendangering condition. For Hospice, except as specified as a Covered Service in this Policy. For pastoral, spiritual, bereavement or marriage counseling. For homemaker and housekeeping services or home-delivered meals. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence. Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party. For a routine or periodic 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 physical; or a screening examination including routine hearing examinations, except as specified as a Covered Service under this Policy. For immunizations, except as specified as a Covered Service in this Policy. For breast reduction Surgery or Surgery for gynecomastia. For nutritional supplements. For replacements or nutritional formulas, except when administered enterally due to impairment in digestion and absorption of an oral diet and is the sole source of caloric need or nutrition in an Insured. For vitamins and minerals, unless required through a written prescription and cannot be purchased over the counter. For alterations or modifications to the 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 which occurred after enrollment. provided outside the United States, which if had been provided in the United States would not be Covered Services under this Policy. Furnished by a Provider or caregiver that is not listed as a Covered Provider, including but not limited to, naturopaths and homeopaths. For Outpatient pulmonary and/or cardiac Rehabilitation. For complications arising from the acceptance or utilization of noncovered services. For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service. For arch supports, orthopedic shoes, and other foot devices. Any services or supplies furnished by a facility that is primarily a health resort, sanatorium, residential treatment facility, transitional living center, or primarily a place for Outpatient treatment or residential facility care of Mental or Nervous Conditions. 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. For dental implants, appliances (with the exception of sleep apnea devices), and/or prosthetics, and/or treatment related to Orthodontia, even when Medically Necessary, unless specified as a Covered Service in this Policy. Choose coverage that fits bcidaho.com. 39

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44 P.O. Box 7408 Boise, ID GO CROSS ( ) bcidaho.com Street Address 3000 East Pine Avenue Meridian, ID Meridian Mailing Address P.O. Box 7408 Boise, ID Claims Inquiries (208) (800) Coeur d Alene 2100 Northwest Boulevard, Suite 120 Coeur d Alene, ID Street Address 1910 Channing Way Idaho Falls, ID Idaho Falls Mailing Address P.O. Box 2287 Idaho Falls, ID Street Address th Street Lewiston, ID Street Address 275 South 5th Avenue Suite 150 Pocatello, ID Street Address 1431 North Fillmore Street Suite 200 Twin Falls, ID Lewiston Pocatello Twin Falls Mailing Address P.O. Box 1468 Lewiston, ID Mailing Address P.O. Box 2578 Pocatello, ID Mailing Address P.O. Box 5025 Twin Falls, ID Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association.