Persoal Comp Marylad
Why Choose Persoal Comp? For the cost of may of the thigs you buy each day, you ca have security ad peace of mid with health coverage from CareFirst BlueCross BlueShield (CareFirst). Persoal Comp makes health care coverage more maageable by lettig you decide how much of the pla s cost you wat to share through deductibles ad coisurace. The higher the deductible you choose, the lower your premium rate. Your out-of-pocket maximum icludes everythig you pay toward your deductible ad coisurace paymets. Refer to the chart o page 2 to make your selectio. We also offer two HSA-compatible Persoal Comp plas with high-deductible levels which keep your mothly premium costs to a miimum. Both plas meet the federal requiremets ecessary to set up a Health Savigs Accout. Better yet, these deductible pla optios ca be purchased eve if you do ot wat to set up a Health Savigs Accout. The choice is yours. Make sure you re covered by a orgaizatio you ca trust. A compay that has bee there for your eighbors, coworkers ad frieds. Ad oe that will be there for you CareFirst BlueCross BlueShield. 1
Persoal Comp Offers Maximum flexibility eleve beefit optios to choose so you ca fid a pla that s right for you! Tax Savigs Eligibility two high-deductible plas that are eligible for a Health Savigs Accout optio. Choose ay doctor or hospital o referrals to delay your visit to a specialist just make the appoitmet. A Prevetive Care package that saves you moey with o charge for office visits ad screeigs, ot eve a copay ad o deductible to meet! Major Medical coverage with a ulimited policy maximum to protect you agaist the high cost of a legthy illess. Easy access to your beefits with BlueCard Program your direct lik to health care services atiowide. Security of kowig that you re protected by the state s leadig health care isurer protectig idividuals who buy their ow isurace. Maximum Optios Per Idividual 1. Your Deductible 2. You Pay 3. Your Out-of-Pocket Maximum $100 20% $1,000 $200 20% $2,000 $400 25% $2,000 $500 20% $2,000 $800 25% $2,000 $1,000 20% $2,500 $2,500 20% $4,000 $5,000 20% $6,000 $10,000 20% $10,000 $1,700* 20% $4,000 $2,500* 0% $2,500 *Health Savigs Accout-Compatible Plas 2
A Health Pla That You Desig As a member of Persoal Comp, you ca desig a persoal health care program that s right for you ad your budget. You select your deductible ad beefit optios. Geerally, the higher your deductible the lower your premium. Plus, your deductible is applied to your out-of-pocket maximum. All this ca limit the amout of moey you sped o your health care. Prevetive care is icluded with o charge for office visits ad screeigs ot eve a copay. Ad there s o deductible to meet before you ca receive care. Families ever pay more tha twice the idividual deductible eve if there are more tha two family members o the policy. You have the freedom to choose your ow doctors ad hospitals. Carry the card that s recogized ad accepted across Marylad ad throughout the Uited States. Add visio ad/or detal beefits to make your Persoal Comp coverage eve more valuable. How the Pla Works Persoal Comp Pla Optios 1. You pay the deductible. (No deductible required for prevetive care) 2. Persoal Comp pays 75% or 80% of the Allowed Beefit, after you meet the deductible, ad you pay 25% or 20% up to your out-of-pocket maximum per year. 3. After you meet your out-of-pocket maximum, Persoal Comp pays 100% of the allowed beefit for covered services for the rest of the year. 3
Persoal Comp Summary of Beefits Beefit Covered You Pay 80%/20% Pla 75%/25% Pla Idividual deductible optios $100, $200, $500, $400, $800 $1,000, $2,500, $5,000, $10,000 Well-child care 4 Adult prevetive physical exams 4 No charge for No charge for OB/GYN prevetive care 4 office visits ad office visits ad Cacer screeig visits (o charge for 4 screeigs screeigs mammograms, pap tests ad PSAs) Oce you meet out-of-pocket maximum 4 $0 $0 Physicia office visits 4 20% 365 days hospitalizatio 4 20% Emergecy accidet care ($300 Allowed Beefit up frot whe treatmet begis withi 72 hours ad if deductible is $1,500 or less) 4 20% Ipatiet physicia services 4 20% Ipatiet/Outpatiet surgery 4 20% Metal Health 4 20% Materity* ad Preatal care 4 20% Diagostic Tests ad X-rays 4 20% Physical Therapy/Chiropractic services (up to 50 visits per year) Prescriptio coverage (Ulimited coverage) 4 20% 4 20% 25% 25% 25% 25% 25% 25% 25% 25% 25% 25% If you receive care from a provider, icludig behavioral health care providers, that do ot participate with CareFirst, you may be resposible for ay applicable deductible, copaymets ad coisurace plus charges over the allowed beefit. * Please Note: Services redered for materity care i the Persoal Comp pla are subject to a 10-moth pre-existig waitig period. Allowed Beefit is the amout CareFirst has agreed to pay for a covered service. 4
Persoal Comp HSA Lower your health isurace premiums ad save o taxes! Persoal Comp provides two high deductible optios that feature icreased prescriptio coverage, ad eligibility for a valuable Health Savigs Accout optio. What is a Health Savigs Accout? Persoal Comp HSA plas are desiged to work alog with a Health Savigs Accout offered by a idepedet bakig istitutio. A Health Savigs Accout is almost like a idividual retiremet accout (IRA) for health expeses. Key beefits: Tax-exempt savigs. Portable accout cotributios roll over from year-to-year. Access to fuds, eve for o-medical reasos (pealty may apply). Usually lower isurace premiums. How the Pla Works Health Savigs Accout-Compatible Pla Optios 1. You pay the deductible. (No deductible required for prevetive care) If you select Idividual/Child(re), Idividual/Adult or Family coverage, the you must satisfy the etire deductible of $3,400 or $5,000, depedig o which pla you choose, to receive beefits. Oe member of the family ca meet either the $3,400 or $5,000 deductible for the whole family to receive beefits. Or multiple family members may cotribute to the total of $3,400 or $5,000. 2. Persoal Comp pays 80% or 100% of the allowed beefit, ad you pay 20% or 0% up to your out-of-pocket maximum. 3. After you meet your out-of-pocket maximum, Persoal Comp pays 100% of the allowed beefit for covered services for the rest of the year. 5
Persoal Comp HSA Summary of Beefits Beefit Covered Covered 80%/20% Pla 100%/0% Pla Deductibles $1,700 $2,500 Well-child care 4 No charge for No charge for Adult prevetive physical exams 4 office visits ad office visits ad screeigs screeigs OB/GYN prevetive care 4 Cacer screeig visits (o charge 4 for mammograms, pap tests ad PSAs) Oce you meet out-of-pocket maximum 4 $0 $0 Physicia office visits 4 20% 365 days hospitalizatio 4 20% Emergecy accidet care 4 20% Ipatiet physicia services 4 20% Ipatiet/Outpatiet surgery 4 20% Metal Health 4 20% Materity* ad Preatal care 4 20% Diagostic Tests ad X-rays 4 20% Physical Therapy/Chiropractic services (up to 50 visits per year) Prescriptio coverage (Ulimited coverage) 4 20% 4 20% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% If you receive care from a provider, icludig behavioral health care providers, that do ot participate with CareFirst, you may be resposible for ay applicable deductible, copaymets ad coisurace plus charges over the allowed beefit. * Please Note: Services redered for materity care i the Persoal Comp pla are subject to a 10-moth pre-existig waitig period. Allowed Beefit is the amout CareFirst has agreed to pay for a covered service. 6
Detal ad Visio Detal (Optioal) Regular prevetive detal care is a importat part of stayig healthy. Idividual Select Detal HMO offers you detal care with predictable copaymets for routie ad major detal services such as: Prevetive detal care Root caal therapy Surgical extractios Orthodotic treatmet As a member of our Detal Health Maiteace Orgaizatio (Detal HMO) pla, you ll select a geeral detist from a etwork of 580+ participatig providers to coordiate all your detal care eeds. Whe specialized care is eeded, your geeral detist will recommed a specialist withi the Detal HMO etwork. We also offer the Idividual Select Preferred detal pla, which offers a larger detal etwork ad additioal i-etwork savigs for major procedures. If you have questios regardig detal coverage or wish to iquire about participatig providers please cotact a Product Specialist at (800) 544 8703. Visio (Optioal) Additioally, you have the optio of addig eye care beefits to your medical pla through our etwork admiistrator, Davis Visio, Ic.* Beefits iclude aual eye examiatios at participatig providers for a $10 copay at the time of service ad discouts of approximately 30% o eyeglass frames ad leses or cotact leses. For medical eye care please follow your ormal medical procedures. Your visio beefits are ot available util you are approved for medical coverage. Oce you have bee approved for coverage, you will be provided with more specific iformatio about your visio program. To qualify for beefits, you must select the same type of coverage as the medical portio of your pla. To apply for visio coverage simply check Yes ext to Visio Beefits o the applicatio. The cost is as follows: To locate a visio provider, cotact Davis Visio, Ic. at (800) 783-5602 or visit www.carefirst.com. * A idepedet compay that does ot provide CareFirst BlueCross BlueShield products or services. The compay is solely resposible for its products or services metioed. Type of Coverage Visio Idividual $2.00 Idividual & Child $4.00 Idividual & Adult $4.00 Family $5.00 7
CareEssetials Takig Cotrol of Your Health CareEssetials As a CareFirst member you are ecouraged to take advatage of the CareEssetials program, at o additioal charge. Whether you re lookig for health ad welless tips or support to maage a health coditio you ll fid it with CareEssetials. Optios / Blue365 Discout Programs As a member, you have access to discouts o fitess ceters, acupucture, spas, massages, chiropractic care, utritioal couselig, laser visio correctio, ad more! Visit www.carefirst.com/optios to lear more. Nurse Lie FirstHelp Ay time, day or ight you ca speak with a urse. Registered urses are available to aswer your health care questios ad help guide you to the most appropriate care. Simply call (800) 535-9700 ad a registered urse will ask about your symptoms ad help you decide o the best source of care. My Care First Website Take a active role i maagig your health ad visit My Care First at www.carefirst.com/mycarefirst. Fid early 300 iteractive health related tools, a multi-media sectio with more tha 400 podcasts, ad recipes you ca search by food group or dietary restrictios. Plus, there are videos ad tutorials o chroic diseases ad a ecyclopedia with iformatio o more tha 3,000 coditios. Vitality Magazie Our member magazie has tools to help you achieve a healthier lifestyle. Vitality provides you with updates to your health care pla, a variety of health ad welless topics, icludig food ad utritio, physical fitess ad prevetive health. As a member, you will receive Vitality magazie three times per year. 8
Health News Sig up for our mothly electroic member ewsletter to receive health-related articles ad recipes via email. Visit www.carefirst.com/healthews to subscribe to iformatio about: Makig healthy choices Addig physical activity to your day Preparig utritious ad delicious recipes Gettig the best health care Maagig chroic coditios Health Assessmet The health assessmet is a cofidetial questioaire that asks questios about health-related aspects of your lifestyle. Based o your resposes i the health assessmet, you will receive a immediate picture of your health i a persoalized report. Your report will cotai helpful iformatio with tips o how to prevet or reduce your idividual health risk factors. Health Advisig After you complete the Health Assessmet (available o My Care First), a health advisor may cotact you. The health advisor ca aswer your questios ad discuss your results. The Health Advisig sessio is usually 10 15 miutes log. Olie Health Coachig To help you meet your health goals, take advatage of our cofidetial Webbased health coachig program to help you improve i the followig areas: Weight maagemet Stress maagemet Smokig cessatio Physical activity Overcomig depressio Care for your back 9
Oce you complete your health risk assessmet, you ll receive a email with details o accessig olie health coachig programs. Telephoic Health Coachig Depedig o the results of your Health Assessmet, a health coach may call you. The Telephoic Health Coachig program is desiged to help you build cofidece as you lear ew skills ad positive lifestyle behaviors. You ca iteract with your coach through a private, secure Web-based message board ad by phoe. You ad your coach will work together to develop a persoal health actio pla with milestoes for achievig goals. Your coach will moitor your progress ad provide guidace ad support as eeded. To lear more about the CareEssetials programs please visit www.carefirst.com. Click o the Members & Visitors lik. 10
Frequetly Asked Questios Q: Ca I choose my ow physicia? A: Yes. You have freedom to select ay doctor or hospital. Your membership provides discouts o physicia ad hospital care from Participatig Providers. To view a listig of CareFirst Participatig Providers who automatically file claims for you ad caot balace bill you, please visit us o the web at www.carefirst.com (For more iformatio o balace billig, please read the FAQ o this page titled What is balace billig ad how does it affect my outof-pocket costs? ) Q: What types of health costs should I expect? A: Persoal Comp requires you to first pay your deductible before the isurace will pay. Oce the deductible is met, you will pay a coisurace, a percetage of the total cost, for most visits ad procedures. (Please ote: Persoal Comp prevetive care beefits are covered eve before you meet your deductible.) Q: What is balace billig ad how does it affect my out-of-pocket costs? A: As a member of Persoal Comp you have the optio to visit doctors who do ot participate with CareFirst. I additio to your coisurace, you are also resposible for ay additioal amout the doctor charges over ad above CareFirst s egotiated amout (also called the allowed beefit) for the procedure. For example, if the cost of a procedure is $100, CareFirst s egotiated amout for that procedure, whe provided by a Participatig Provider, may oly be $60. Should you choose to use a No-Participatig Provider, you would be resposible for the $40 differece betwee the doctor s actual charge ad CareFirst s allowed beefit. Sice CareFirst has oe of the largest etworks i the regio it is likely that your doctor is already a participat. Q: Is prevetive care covered? A: Yes. Persoal Comp coverage icludes a special package of prevetive care beefits. There is o charge for office visits ad screeigs ot eve a copay ad you do t have to meet your deductible first. Q: Whe does coverage begi? A: Coverage begis the first of the moth after your applicatio is approved! 11
Q: if I eroll i a HSA-compatible pla, am I required to ope a Health Savigs Accout? A: No. Opeig a Health Savigs Accout is a optioal, tax-savigs beefit. Q: How ca I lear more about Health Savigs Accouts? A: Cotactig your bak or speakig with your tax advisor is a good place to start. For additioal iformatio you ca also log o to www.my-healthsavigsaccout.com. Q: Where ca I ope a Health Savigs Accout? A: CareFirst has made it easy for you to ope a health savigs accout. Whe you apply for a Persoal Comp HSA-compatible pla, your cotact iformatio will be set to our preferred bak, The Bacorp Bak* who will sed you a erollmet kit ad applicatio to set up your health savigs accout. The Bacorp Bak offers Persoal Comp HSA members a rage of fiacial ivestmet optios oce the accout balace reaches $2,500. You ll also ear a competitive iterest rate ad be provided with a Bacorp-issued CareFirst Visa check card ad checks to make accessig your moey easy. To sig up for a accout with The Bacorp Bak, please logo to www.my-healthsavigsaccout.com or call toll-free at (866) 435-1373. * A idepedet compay that does ot provide CareFirst BlueCross BlueShield products or services. The compay is solely resposible for its products or services metioed. 12
Apply Today! Applyig for a Persoal Comp pla could t be easier. To be eligible, each family member applyig must be a residet of the state of Marylad, ad must complete a medical questioaire. 1. Apply through your broker, or 2. Apply olie ad be approved i as little as 24 hours at www.carefirst.com/idividual, or 3. Fill out ad mail the eclosed applicatio. Sed o moey whe you apply. We ll begi processig your applicatio right away. Steps to apply. 1. Locate the applicatio form i this packet or apply olie at www.carefirst.com/idividual. Be sure to aswer all questios accurately ad completely, ad do t forget to sig your applicatio. 2. Choose a coverage type. Select from: Idividual Idividual ad Child(re)* Idividual ad Adult ** Family (two eligible adults ad eligible depedets) * Child meas your eligible child up to age 26. Eligibility requiremets are defied i the cotract. ** Adult meas the Spouse or Domestic Parter who satisfies the eligibility requiremets defied i the cotract. 2. Review the pla beefits ad premiums. The eclosed rate chart, which idicates coverage type ad age, shows your mothly premium. Make sure you check yes i the Visio beefit selectio area, if you wat the additioal coverage added to your pla for a additioal cost. 13
Oce you have submitted your applicatio, you ca call the Applicatio Status Hotlie at (877) 746-7515 with questios. Your coverage will become effective the first of the moth followig the moth i which we approve your applicatio. If you have questios, please call our Product Specialists at (410) 356-8000 or toll free at (800) 544-8703, Moday-Friday 8 a.m. 5 p.m. Or, visit the CareFirst website at www.carefirst.com/idividual. 14
Compesatio ad Premium Disclosure Statemet Our compesatio to providers who offer health care services ad behavioral health care services to our isured members or erollees may be based o a variety of paymet mechaisms such as fee-for-service paymets, salary, or capitatio. Bouses may be used with these various types of paymet methods. If you desire additioal iformatio about our methods of payig providers, or if you wat to kow which method(s) apply to your physicia, please call our Member Services Departmet at the umber listed o your idetificatio card, or write to: CareFirst of Marylad, Ic. doig busiess as CareFirst BlueCross BlueShield 10455 Mill Ru Circle Owigs Mills, MD 21117-5559 Attetio: Member Services A. Methods of Payig Physicias The followig defiitios explai how isurace carriers may pay physicias (or other providers) for your health care services with a simple example of how each paymet mechaism works. The examples show how Dr. Joes, a obstetricia gyecologist, would be compesated uder each method of paymet. Salary: A physicia (or other provider) is a employee of the HMO ad is paid compesatio (moetary wages) for providig specific health care services. Sice Dr. Joes is a employee of a HMO, she receives her usual bi-weekly salary regardless of how may patiets she sees or the umber of services she provides. Durig the moths of providig pre-atal care to Mrs. Smith, who is a member of the HMO, Dr. Joes salary is uchaged. Although Mrs. Smith s baby is delivered by Cesarea sectio, a more complicated procedure tha a vagial delivery, the method of delivery will ot have a effect upo Dr. Joes salary. Capitatio: A physicia (or group of physicias) is paid a fixed amout of moey per moth by a HMO for each patiet who chooses the physicia(s) to be his or her doctor. Paymet is fixed without regard to the volume of services that a idividual patiet requires. 15
Uder this type of cotractual arragemet, Dr. Joes participates i a HMO etwork. She is ot employed by the HMO. Her cotract with the HMO stipulates that she is paid a certai amout each moth for patiets who select her as their doctor. Sice Mrs. Smith is a member of the HMO, Dr. Joes mothly paymet does ot chage as a result of her providig ogoig care to Mrs. Smith. The capitatio amout paid to Dr. Joes is the same whether or ot Mrs. Smith requires obstetric services. Fee-for-Service: A physicia (or other provider) charges a fee for each patiet visit, medical procedure, or medical service provided. A HMO pays the etire fee for physicias it has uder cotract ad a isurer pays all or part of that fee, depedig o the type of coverage. The patiet is expected to pay the remaider. Dr. Joes cotract with the isurer or HMO states that Dr. Joes will be paid a fee for each patiet visit ad each service she provides. The amout of paymet Dr. Joes receives will deped upo the umber, types, ad complexity of services, ad the time she speds providig services to Mrs. Smith. Because Cesarea deliveries are more complicated tha vagial deliveries, Dr. Joes is paid more to deliver Mrs. Smith s baby tha she would be paid for a vagial delivery. Mrs. Smith may be resposible for payig some portio of Dr. Joes bill. Discouted Fee-for-Service: Paymet is less tha the rate usually received by the physicia (or other provider) for each patiet visit, medical procedure, or service. This arragemet is the result of a agreemet betwee the payer, who gets lower costs ad the physicia (or other provider), who usually gets a icreased volume of patiets. Like fee-for-service, this type of cotractual arragemet ivolves the isurer or HMO payig Dr. Joes for each patiet visit ad each delivery; but uder this arragemet, the rate, agreed upo i advace, is less tha Dr. Joes usual fee. Dr. Joes expects that i exchage for agreeig to accept a reduced rate, she will serve a certai umber of patiets. For each procedure that she performs. Dr. Joes will be paid a discouted rate by the isurer or HMO. Bous: A physicia (or other provider) is paid a additioal amout over what he or she is paid uder salary, capitatio, fee-for-service, or other type of paymet arragemet. Bouses may be based o may factors, icludig member satisfactio, quality of care, cotrol of costs ad use of services. A HMO rewards its physicia staff or cotracted physicias who have demostrated higher tha average quality ad productivity. Because Dr. Joes has delivered so may babies ad she has bee rated highly by her patiets 16
ad fellow physicias, Dr. Joes will receive a moetary award i additio to her usual paymet. Case Rate: The HMO or isurer ad the physicia (or other provider) agree i advace that paymet will cover a combiatio of services provided by both the physicia (or other provider) ad the hospital for a episode of care. This type of arragemet stipulates how much a isurer or HMO will pay for a patiet s obstetric services. All office visits for preatal ad postatal care, as well as the delivery, ad hospital-related charges are covered by oe fee. Dr. Joes, the hospital, ad other providers (such as a aesthesiologist) will divide paymet from the isurer or HMO for the care provided to Mrs. Smith. B. Percetage of Provider Paymet Methods For its Idemity ad Preferred Provider Orgaizatio (PPO) products, CareFirst of Marylad, Ic. cotracts directly with physicias. All physicias are reimbursed o a discouted fee-for-service basis. C. Distributio of Premium Dollars The bar graph below illustrates the proportio of every $100 i premium used by CareFirst of Marylad, Ic. to pay providers (or other providers) for medical care expeses, ad the proportio used to pay for pla admiistratio. These umbers represet a average for all idemity accouts based o our aual statemet. The ratio of direct medical care expeses to pla admiistratio will vary by accout. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91% Medical 9% Pla Admiistratio 17
Rights & Resposibilities Notice of Privacy Practices CareFirst BlueCross BlueShield (CareFirst) is committed to keepig the cofidetial iformatio of members private. Uder the Health Isurace Portability ad Accoutability Act of 1996 (HIPAA), we are required to sed our Notice of Privacy Practices to members of fully isured groups oly. The otice outlies the uses ad disclosures of protected health iformatio, the idividual s rights ad CareFirst s resposibility for protectig the member s health iformatio. To obtai a copy of our Notice of Privacy Practices, go to www.carefirst.com ad click o Privacy Statemet at the bottom of the page, click o Health Iformatio the click o Notice of Privacy Practices. Or call the Member Services telephoe umber o your member ID card. Members of self-isured groups should cotact their Huma Resources departmet for a copy of their Notice of Privacy Practices. If you do t kow whether your employer is self isured, please cotact your Huma Resources departmet. Member Satisfactio CareFirst wats to hear your cocers ad/or complaits so that they may be resolved. We have procedures that address medical ad o-medical issues. If a situatio should occur for which there is ay questio or difficulty, here s what you ca do: If your commet or cocer is regardig the quality of service received from a CareFirst represetative or related to admiistrative problems (e.g., erollmet, claims, bills, etc.) you should cotact Member Services. If you sed your commets to us i writig, please iclude your member ID umber ad provide us with as much detail as possible regardig ay evets. Please iclude your daytime telephoe umber so that we may cotact you directly if we eed additioal iformatio. If your cocer or complait is about the quality of care or quality of service received from a specific provider, cotact Member Services. A represetative will record your cocers ad may request a writte summary of the issues. To write to us directly with a quality of care or service cocer, you ca: Sed a email to: quality.care.complaits@carefirst.com Fax a writte complait to: (301) 470-5866 Write to: CareFirst BlueCross BlueShield, Quality of Care Departmet, P.O. Box 17636, Baltimore, MD 21297 If you sed your commets to us i writig, please iclude your idetificatio umber ad provide us with as much detail as possible regardig the evet or icidet. Please iclude your daytime telephoe umber so that we may cotact you directly if we eed additioal iformatio. Our Quality of Care Departmet will ivestigate your cocers, share those issues with the provider ivolved ad request a respose. We will the provide you with a summary of our fidigs. CareFirst member complaits are retaied i our provider files ad are reviewed whe providers are cosidered for cotiuig participatio with CareFirst. 18
Virgiia: Complait Itake, Office of Licesure ad Certificatio, Virgiia Departmet of Health, 9960 Marylad Drive, Suite 401, Richmod, VA 23233-1463 Phoe #: (800) 955-1819 or (804) 367-2106 Fax #: (804) 527-4503 Office of the Maaged Care Ombudsma, Bureau of Isurace P.O. Box 1157, Richmod, VA 23218 Phoe #: 1-877-310-6560 or (804) 371-9032 Marylad: Marylad Isurace Admiistratio, Iquiry ad Ivestigatio, Life ad Health, 200 St. Paul Place, Suite 2700, Baltimore, MD 21202 Phoe #: (800) 492-6116 or (410) 468-2244 Office of Health Care Quality, Sprig Grove Ceter, Blad-Bryat Buildig, 55 Wade Aveue, Catosville, MD 21228 Phoe #: (410) 402-8016 or (877) 402-8218 District of Columbia: Departmet of Isurace, Securities ad Bakig 801 1st Street, NE, Suite 701, Washigto, DC 20002 Phoe #: (202) 727-8000 These procedures are also outlied i your Evidece of Coverage. If you wish, you may also cotact the appropriate jurisdictio s regulatory departmet regardig your cocer: For assistace i resolvig a Billig or Paymet Dispute with the Health Pla or a Health Care Provider, cotact the Health Educatio ad Advocacy Uit of the Cosumer Protectio Divisio of the Office of the Attorey Geeral at: Health Educatio ad Advocacy Uit, Cosumer Protectio Divisio, Office of the Attorey Geeral, 200 St. Paul Place, 16th Floor, Baltimore, MD 21202 Phoe #: (410) 528-1840 or (877) 261-8807 Fax #: (410) 576-6571 / web site: www.oag.state.md.us Hearig Impaired To cotact a Member Services represetative, please choose the appropriate hearig impaired assistace umber below, based o the regio i which your coverage origiates. Marylad Relay Program: (800) 735-2258 Natioal Capital Area TTY: (202) 479-3546 Please have your Member Services umber ready. Laguage Assistace: Iterpreter services are available through Member Services. Whe callig Member Services, iform the represetative that you eed laguage assistace. 19
Please Note: CareFirst appreciates the opportuity to improve the level of quality of care ad services available for you. As a member, you will ot be subject to diserollmet or otherwise pealized as a result of filig a complait or appeal. Cofidetiality of Subscriber/ Member Iformatio All health plas ad providers must provide iformatio to members ad patiets regardig how their iformatio is protected. You will receive a Notice of Privacy Practices from CareFirst or your health pla, ad from your providers as well, whe you visit their office. CareFirst has policies ad procedures i place to protect the cofidetiality of member iformatio. Your cofidetial iformatio icludes Protected Health Iformatio (PHI), whether oral, writte or electroic, ad other opublic fiacial iformatio. Because we are resposible for your isurace coverage, makig sure your claims are paid, ad that you ca obtai ay importat services related to your health care, we are permitted to use ad disclose (give out) your iformatio for these purposes. Sometimes we are eve required by law to disclose your iformatio i certai situatios. You also have certai rights to your ow protected health iformatio o your behalf. Our Resposibilities We are required by law to maitai the privacy of your PHI, ad to have appropriate procedures i place to do so. I accordace with the federal ad state Privacy laws, we have the right to use ad disclose your PHI for treatmet, paymet activities ad health care operatios as explaied i the Notice of Privacy Practices. We may disclose your protected health iformatio to the pla sposor/employer to perform pla admiistratio fuctio. The Notice is set to all policy holders upo erollmet. Your Rights You have the followig rights regardig your ow Protected Health Iformatio. You have the right to: Request that we restrict the PHI we use or disclose about you for paymet or health care operatios. Request that we commuicate with you regardig your iformatio i a alterative maer or at a alterative locatio if you believe that a disclosure of all or part of your PHI may edager you. Ispect ad copy your PHI that is cotaied i a desigated record set icludig your medical record. Request that we amed your iformatio if you believe that your PHI is icorrect or icomplete. A accoutig of certai disclosures of your PHI that are for some reasos other tha treatmet, paymet, or health care operatios. Give us writte authorizatio to use your protected health iformatio or to disclose it to ayoe for ay purpose ot listed i this otice. Iquiries ad Complaits If you have a privacy-related iquiry, please cotact the CareFirst Privacy Office at (800) 853-9236 or sed a email to privacy.office@carefirst.com. 20
Members Rights ad Resposibilities Statemet Members have the right to: Be treated with respect ad recogitio of their digity ad right to privacy. Receive iformatio about the health pla, its services, its practitioers ad providers, ad members rights ad resposibilities. Participate with practitioers i decisio-makig regardig their health care. Participate i a cadid discussio of appropriate or medically ecessary treatmet optios for their coditios, regardless of cost or beefit coverage. Make recommedatios regardig the orgaizatio s members rights ad resposibilities. Voice complaits or appeals about the health pla or the care provided. Members have a resposibility to: Provide, to the extet possible, iformatio that the health pla ad its practitioers ad providers eed i order to care for them. Uderstad their health problems ad participate i developig mutually agreed upo treatmet goals to the degree possible. Follow the plas ad istructios for care that they have agreed o with their practitioers. Pay copaymets or coisurace at the time of service. Be o time for appoitmets ad to otify practitioers/providers whe a appoitmet must be caceled. Eligible Idividuals Rights Statemet Welless ad Health Promotio Services Eligible idividuals have a right to: Receive iformatio about the orgaizatio, icludig welless ad health promotio services provided o behalf of the employer or pla sposors; orgaizatio staff ad staff qualificatios; ad ay cotractual relatioships. Declie participatio or diseroll from welless ad health promotio services offered by the orgaizatio. Be treated courteously ad respectfully by the orgaizatio s staff. Commuicate complaits to the orgaizatio ad receive istructios o how to use the complait process that icludes the orgaizatio s stadards of timeliess for respodig to ad resolvig complaits ad quality issues. Habilitative Services CareFirst provides coverage for habilitative services to members youger tha the age of 19. This icludes habilitative services to treat cogeital or geetic birth defects, icludig a defect existig at or from birth, a hereditary defect, autism or a autism spectrum disorder, ad cerebral palsy. Habilitative services iclude speech, physical ad occupatioal therapies. CareFirst must preapprove all habilitative services. Ay deductibles, copaymets ad coisurace required uder your cotract apply. Policy maximums ad beefit limits apply. Habilitative services are ot couted toward ay visit maximum for therapy services. 21
Please ote that ay therapies provided through the school system are ot covered by this beefit. This coverage applies oly to cotracts sold to busiesses based i Marylad. Check your cotract coverage to determie if you are eligible to receive these beefits. If you have questios regardig ay of these services, cotact Member Services at the telephoe umber o your member ID card. Mastectomy-Related Services CareFirst provides coverage for home visits to members who udergo a mastectomy (the surgical removal of all or part of the breast as a result of breast cacer) or the surgical removal of a testicle. Coverage icludes oe home visit that occurs withi 24 hours after discharge from the hospital or outpatiet facility ad a additioal home visit if prescribed by the member s doctor. To be eligible, the member must be i the hospital less tha 48 hours or have the procedure performed o a outpatiet basis. This coverage applies oly to cotracts sold to busiesses based i Marylad. Please check your cotract coverage to determie if you are eligible for these surgical procedure beefits. CareFirst offers other beefits for mastectomy-related services, icludig: All stages of recostructio of the breast that uderwet the mastectomy. Surgery ad recostructio of the other breast to produce a symmetrical appearace. Prosthesis (artificial breast) ad treatmet of the physical complicatios that occur at all stages of the mastectomy, icludig lymphedema (swellig). You ad your physicia will determie the appropriate pla to treat your coditio. These beefits will be provided subject to the same deductibles ad coisurace applicable to other medical ad surgical beefits covered uder your health pla. Please refer to your Beefit Guide or Evidece of Coverage for more details or call Member Services at the telephoe umber o your member ID card. Care for Mothers, Newbors Uder the Newbors ad Mothers Health Protectio Act, CareFirst offers coverage for ipatiet hospitalizatio services for a mother ad ewbor child for a miimum of: 48 hours of ipatiet hospitalizatio care after a ucomplicated vagial delivery. 96 hours of içpatiet hospitalizatio care after a ucomplicated cesarea sectio. If the mother ad ewbor remai i the hospital for at least the legth of time provided, coverage icludes: A home visit if prescribed by the attedig physicia. The mother may request a shorter legth of stay if, after talkig with her physicia, she decides that less time is eeded for her recovery. If the mother ad ewbor have a shorter hospital stay tha listed above, coverage icludes oe home visit scheduled to occur withi 24 hours after hospital discharge ad a additioal home visit if prescribed by the attedig physicia. 22
Experimetal/Ivestigatioal Services Please Note: Experimetal/Ivestigatioal services are ot covered uder this health pla. CareFirst s defiitio of Experimetal Medical Care also refereced as Experimetal/Ivestigatioal Services is as follows: The term experimetal/ivestigatioal describes services or supplies that are i the developmetal stages ad are i the process of huma or aimal testig. Services or supplies that do ot meet all (5) of the criteria listed below are deemed to be experimetal/ivestigatioal: 1. The techology* must have fial approval from the appropriate govermet regulatory bodies; ad 2. The scietific evidece must permit coclusios cocerig the effect of the techology o health outcomes; ad 3. The techology must improve the et health outcome; ad 4. The techology must be as beeficial as ay established alteratives; ad 5. The improvemet must be attaiable outside the ivestigatioal settig. 23
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Policy Form Numbers: CFMI/DB/PERS COMP (5/07) CFMI/DB/HSA (10/08) as ameded. Not all services ad procedures are covered by your beefits cotract. This pla summary is for compariso purposes oly ad does ot create rights ot give through the beefit pla. 10455 Mill Ru Circle Owigs Mills, Marylad 21117 www.carefirst.com Beefits provided uder the Agreemet are ot a gradfathered health beefit pla uder the Patiet Protectio ad Affordable Care Act. CareFirst BlueCross BlueShield is a idepedet licesee of the Blue Cross ad Blue Shield Associatio, providig access to the Preferred Provider Orgaizatio Network oly ad does ot assume ay fiacial risk or obligatio with respect to claims. Registered trademark of the Blue Cross ad Blue Shield Associatio. Registered trademark of CareFirst of Marylad, Ic. BRC5009-9S (6/11)