Appendix E

APPENDIX E

SUMMARY OF HEALTHMATE
COAST-TO-COAST

September, 2000

GENERAL INFORMATION

Coverage Levels:.

In network - Eligible services are covered in full, less any applicable co-payments, when you use BlueCard PPO Network providers. Members will not be billed for charges beyond the plan allowance.

Out of network - Members may also choose to receive treatment outside the BlueCard PPO Network and still receive coverage at 80% of our allowance, less any deductibles and/or co-payments as noted below. Outpatient mental health and substance abuse services are covered at 50% of our allowance.

Participating Provider Network:

With our BlueCard PPO Network, the member's Blue Cross card is recognized at any Blue Cross participating PPO provider nationwide. In most cases, claims are filed by the provider and paid based on the local plan's allowance; members will not be balance billed beyond applicable co-payments. The HealthNet Blue Network is Blue Cross & Blue Shield of Rhode Island's (BCBSRI) designated BlueCard PPO Network. (www.BlueCares.com).

Pre-authorization:

Authorization is obtained by providers who participate directly with BCBSRI's HealthNet Blue Network. Members are responsible for obtaining pre-authorization when using other Blue Cross Plans' BlueCard PPO providers or non-network providers. Benefits subject to pre-authorization are identified by an asterisk (*).

Annual Deductibles:

No deductibles in network. Out of network - $200 annual deductible per person (3 per family).

Out-of-pocket maximum:

Out of network benefit increased to full coverage after maximum annual expense of $3,000 per individual (3 per family). (The out-of-network deductible, mental health/substance abuse co-payments and office visits co-payments are not applicable to the out of pocket maximum.)

Lifetime maximums:

Unlimited.

PREVENTIVE AND OUTPATIENT SERVICES:

Office Visits (Personal Physician)
$10 co-payment - includes annual physicals and
well-baby visits.

Office Visits (Specialists)
$10 co-payment ($15 allergist & dermatologist) -
includes routine and non-routine visits, annual
gynecological exam. Pre-natal visits, pap smears
and mammograms are covered in full. $10 co-
payment-includes non-routine podiatric services only.

Routine Eye Exams
$10 co-payment - one routine exam per calendar
year at network providers (medically necessary exams as needed).

Lab & X-Ray
100% coverage at network lab and x-ray facilities.

Outpatient Surgery*
100% coverage, includes ambulatory surgi-centers and outpatient surgery.

Prescriptions
Preferred Rx - 20% co-payment at any network pharmacy. Drugs purchased at non-network pharmacies are reimbursed at 50% of our allowance. Generics are required.

EMERGENCY AND URGENT CARE:

Emergency Room
$25 co-payment for treatment of a serious injury or the sudden and unexpected onset of a severe illness or accident that could cause a serious health risk or death if not treated immediately (co-payment waived if admitted).

Urgi-Centers
$10 co-payment.

INPATIENT SERVICES:

Hospitalization*
100% coverage. Unlimited days of care in a semiprivate room. Includes medical/surgical & maternity care. Skilled nursing facility when medically necessary.

Inpatient Rehab Facility
100% coverage limited to 45 days of care.

Organ Transplant*
100% coverage for eligible costs associated with kidney, cornea, allogenic bone marrow, heart, lung, heart-lung, liver, pancreas, and small intestine transplants.

MENTAL HEALTH & SUBSTANCE ABUSE (MSHA)

Inpatient MH*
100% coverage for up to 45 days per calendar year (up to 90 days per admission for serious mental illness). No coverage without pre-authorization. 80% coverage at RI non-participating providers; 50% at out-of-area non-participating providers.

Outpatient MH*
$15 co-payment per individual session/$10 co-payment per group session; up to 20 visits per calendar year. No coverage without pre-authorization.

Inpatient SA*
100% coverage.

Detoxification - 3 admissions per year or 21 days, whichever comes first.
Rehabilitation - 30 days in any 12-month period; lifetime limit of 90 days per member. No coverage without pre-authorization. 80% coverage at RI non-participating providers; 50% at out-of-area non- participating providers.

Outpatient SA*
$15 co-payment per individual session/$10 per group session. Limited to 30 hours per patient, 20 hours for family members, per 12-month period. No coverage without pre-authorization. 80% coverage at RI non-participating providers; 50% at out-of-area non-participating providers.

ADDITIONAL SERVICES:

Physical, Speech & Occupational Therapy - Outpatient
100% coverage in the outpatient hospital department following a hospital stay. 80% coverage in provider's office.

Chiropractic Care
$10 co-payment - limited to 12 visits per calendar year.

Private Duty Nursing* & Ambulance
80% coverage. Includes private ground ambulance services and municipal ambulance services for non- residents. Does not cover air ambulance services or municipal ambulance services for residents.

Durable Medical Equipment
80% coverage. No dollar maximum.

Home & Hospice Care*
100% coverage if received as part of an approved home care program (in lieu of hospitalization). 80% coverage if not received as part of an approved home care program. Includes doctor, nurse, home health aide visits and home infusion therapy.

Dependent Coverage
Spouse and unmarried dependent children through the end of the year in which they turn age 19 (or age 23 if a full-time student).

CUSTOMER EDUCATION AND INTERVENTION STRATEGIES

Programs

Blue Perks - This innovative program is built-in to HealthMate Coast-to-Coast and includes a pre-natal education program, healthy reminder letters and the Advantage Discount Program.


	APPENDIX E SUMMARY OF HEALTHMATE COAST-TO-COAST

	September, 2000 GENERAL INFORMATION


	Coverage Levels:. In network - Eligible services are covered in full, less any applicable co-payments, when you use BlueCard PPO Network providers. Members will not be billed for charges beyond the plan allowance. Out of network - Members may also choose to receive treatment outside the BlueCard PPO Network and still receive coverage at 80% of our allowance, less any deductibles and/or co-payments as noted below. Outpatient mental health and substance abuse services are covered at 50% of our allowance. Participating Provider Network: With our BlueCard PPO Network, the member's Blue Cross card is recognized at any Blue Cross participating PPO provider nationwide. In most cases, claims are filed by the provider and paid based on the local plan's allowance; members will not be balance billed beyond applicable co-payments. The HealthNet Blue Network is Blue Cross & Blue Shield of Rhode Island's (BCBSRI) designated BlueCard PPO Network. (www.BlueCares.com). Pre-authorization: Authorization is obtained by providers who participate directly with BCBSRI's HealthNet Blue Network. Members are responsible for obtaining pre-authorization when using other Blue Cross Plans' BlueCard PPO providers or non-network providers. Benefits subject to pre-authorization are identified by an asterisk (). Annual Deductibles: No deductibles in network. Out of network - $200 annual deductible per person (3 per family). Out-of-pocket maximum: Out of network benefit increased to full coverage after maximum annual expense of $3,000 per individual (3 per family). (The out-of-network deductible, mental health/substance abuse co-payments and office visits co-payments are not applicable to the out of pocket maximum.) Lifetime maximums: Unlimited. PREVENTIVE AND OUTPATIENT SERVICES: Office Visits (Personal Physician) $10 co-payment - includes annual physicals and well-baby visits. Office Visits (Specialists) $10 co-payment ($15 allergist & dermatologist) - includes routine and non-routine visits, annual gynecological exam. Pre-natal visits, pap smears and mammograms are covered in full. $10 co- payment-includes non-routine podiatric services only. Routine Eye Exams $10 co-payment - one routine exam per calendar year at network providers (medically necessary exams as needed). Lab & X-Ray 100% coverage at network lab and x-ray facilities. Outpatient Surgery 100% coverage, includes ambulatory surgi-centers and outpatient surgery. Prescriptions Preferred Rx - 20% co-payment at any network pharmacy. Drugs purchased at non-network pharmacies are reimbursed at 50% of our allowance. Generics are required. EMERGENCY AND URGENT CARE: Emergency Room $25 co-payment for treatment of a serious injury or the sudden and unexpected onset of a severe illness or accident that could cause a serious health risk or death if not treated immediately (co-payment waived if admitted). Urgi-Centers $10 co-payment. INPATIENT SERVICES: Hospitalization* 100% coverage. Unlimited days of care in a semiprivate room. Includes medical/surgical & maternity care. Skilled nursing facility when medically necessary. Inpatient Rehab Facility 100% coverage limited to 45 days of care. Organ Transplant* 100% coverage for eligible costs associated with kidney, cornea, allogenic bone marrow, heart, lung, heart-lung, liver, pancreas, and small intestine transplants. MENTAL HEALTH & SUBSTANCE ABUSE (MSHA) Inpatient MH* 100% coverage for up to 45 days per calendar year (up to 90 days per admission for serious mental illness). No coverage without pre-authorization. 80% coverage at RI non-participating providers; 50% at out-of-area non-participating providers. Outpatient MH* $15 co-payment per individual session/$10 co-payment per group session; up to 20 visits per calendar year. No coverage without pre-authorization. Inpatient SA* 100% coverage. Detoxification - 3 admissions per year or 21 days, whichever comes first. Rehabilitation - 30 days in any 12-month period; lifetime limit of 90 days per member. No coverage without pre-authorization. 80% coverage at RI non-participating providers; 50% at out-of-area non- participating providers. Outpatient SA* $15 co-payment per individual session/$10 per group session. Limited to 30 hours per patient, 20 hours for family members, per 12-month period. No coverage without pre-authorization. 80% coverage at RI non-participating providers; 50% at out-of-area non-participating providers. ADDITIONAL SERVICES: Physical, Speech & Occupational Therapy - Outpatient 100% coverage in the outpatient hospital department following a hospital stay. 80% coverage in provider's office. Chiropractic Care $10 co-payment - limited to 12 visits per calendar year. Private Duty Nursing* & Ambulance 80% coverage. Includes private ground ambulance services and municipal ambulance services for non- residents. Does not cover air ambulance services or municipal ambulance services for residents. Durable Medical Equipment 80% coverage. No dollar maximum. Home & Hospice Care* 100% coverage if received as part of an approved home care program (in lieu of hospitalization). 80% coverage if not received as part of an approved home care program. Includes doctor, nurse, home health aide visits and home infusion therapy. Dependent Coverage Spouse and unmarried dependent children through the end of the year in which they turn age 19 (or age 23 if a full-time student). CUSTOMER EDUCATION AND INTERVENTION STRATEGIES Programs Blue Perks - This innovative program is built-in to HealthMate Coast-to-Coast and includes a pre-natal education program, healthy reminder letters and the Advantage Discount Program.