2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 3. How You Get Care
Where you get covered care:
Covered facility providers
Section 3. How You Get Care
Where you get covered care:
Covered facility providers
• Covered facility providers
Covered facilities include those listed below, when they meet the state’s applicable licensing or certification requirements.
Hospital – An institution, or a distinct portion of an institution, that:
Note: We consider college infirmaries to be Non-Preferred (Member/Non-member) hospitals. In addition, we may, at our discretion, recognize any institution located outside the 50 states and the District of Columbia as a Non-member hospital.
Freestanding Ambulatory Facility – A freestanding facility, such as an ambulatory surgical center, freestanding surgicenter, freestanding dialysis center, or freestanding ambulatory medical facility, that:
Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as freestanding ambulatory facilities.
Residential Treatment Center – Residential treatment centers (RTCs) are licensed by the state, district, or territory and may be accredited, where required, by a nationally recognized organization to provide residential treatment for medical conditions, mental health conditions, and/or substance use disorder. Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group homes, halfway houses, and similar types of facilities) provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual’s medical, physical, mental health, and/or substance use disorder therapy needs. RTCs offer programs for persons who need short-term transitional services designed to achieve predicted outcomes focused on fostering improvement or stability in functional, physical and/or mental health, recognizing the individuality, strengths, and needs of the persons served. If you have questions about treatment at an RTC or need assistance coordinating this care, please contact us at the customer service phone number listed on the back of your ID card.
Blue Distinction® Specialty Care
Blue Distinction Specialty Care, our centers of excellence program, focuses on effective treatment for specialty procedures, such as: Bariatric Surgery, Cardiac Care, Knee and Hip Replacement, Spine Surgery, Transplants, Cancer Care, Cellular Immunotherapy (CAR-T), Gene Therapy, Maternity Care, and Substance Use Treatment and Recovery. Using national evaluation criteria developed with input from medical experts, the Blue Distinction Centers offer comprehensive care delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise. Providers demonstrate quality care, treatment expertise and better overall patient results.
We cover specialty care at designated Blue Distinction Centers at Preferred benefit levels. See Section 5(c) for information regarding enhanced inpatient and outpatient benefits for bariatric, spine, knee and hip surgeries performed at a Blue Distinction Center. We also provide enhanced benefits for covered transplant services performed at the Blue Distinction Centers for Transplant designated centers as described in Section 5(b).
For listings of Blue Distinction Centers, visit https://www.bcbs.com/blue-distinction-center/facility; access our National Doctor & Hospital Finder via www.fepblue.org/provider; or call us at the customer service phone number listed on the back of your ID card.
Cancer Research Facility – A facility that is:
FACT-Accredited Facility
A facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). FACT-accredited cellular therapy programs meet rigorous standards. Information regarding FACT transplant programs can be obtained by contacting the transplant coordinator at the customer service phone number listed on the back of your ID card or by visiting www.factglobal.org.
Skilled Nursing Facility (SNF)
A SNF is a freestanding institution or a distinct part of a hospital which customarily bills insurance as a skilled nursing facility and meets the following criteria:
To be covered, skilled nursing facility care cannot be maintenance or custodial care. The term skilled nursing facility does not include any institution that is primarily for the care and treatment of mental diseases. If you have questions about treatment at a SNF, or need assistance coordinating this care, please contact us at the customer service phone number listed on the back of your ID card.
Other facilities specifically listed in the benefits descriptions in Section 5(c).
Covered facilities include those listed below, when they meet the state’s applicable licensing or certification requirements.
Hospital – An institution, or a distinct portion of an institution, that:
- Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses, treatment, and care of injured and sick persons provided or supervised by a staff of licensed doctors of medicine (M.D.) or licensed doctors of osteopathy (D.O.), for compensation from its patients, on an inpatient or outpatient basis;
- Continuously provides 24-hour-a-day professional registered nursing (R.N.) services; and
- Is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or non-medical personal services.
Note: We consider college infirmaries to be Non-Preferred (Member/Non-member) hospitals. In addition, we may, at our discretion, recognize any institution located outside the 50 states and the District of Columbia as a Non-member hospital.
Freestanding Ambulatory Facility – A freestanding facility, such as an ambulatory surgical center, freestanding surgicenter, freestanding dialysis center, or freestanding ambulatory medical facility, that:
- Provides services in an outpatient setting;
- Contains permanent amenities and equipment primarily for the purpose of performing medical, surgical, and/or renal dialysis procedures;
- Provides treatment performed or supervised by doctors and/or nurses, and may include other professional services performed at the facility; and
- Is not, other than incidentally, an office or clinic for the private practice of a doctor or other professional.
Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as freestanding ambulatory facilities.
Residential Treatment Center – Residential treatment centers (RTCs) are licensed by the state, district, or territory and may be accredited, where required, by a nationally recognized organization to provide residential treatment for medical conditions, mental health conditions, and/or substance use disorder. Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group homes, halfway houses, and similar types of facilities) provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual’s medical, physical, mental health, and/or substance use disorder therapy needs. RTCs offer programs for persons who need short-term transitional services designed to achieve predicted outcomes focused on fostering improvement or stability in functional, physical and/or mental health, recognizing the individuality, strengths, and needs of the persons served. If you have questions about treatment at an RTC or need assistance coordinating this care, please contact us at the customer service phone number listed on the back of your ID card.
Blue Distinction® Specialty Care
Blue Distinction Specialty Care, our centers of excellence program, focuses on effective treatment for specialty procedures, such as: Bariatric Surgery, Cardiac Care, Knee and Hip Replacement, Spine Surgery, Transplants, Cancer Care, Cellular Immunotherapy (CAR-T), Gene Therapy, Maternity Care, and Substance Use Treatment and Recovery. Using national evaluation criteria developed with input from medical experts, the Blue Distinction Centers offer comprehensive care delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise. Providers demonstrate quality care, treatment expertise and better overall patient results.
We cover specialty care at designated Blue Distinction Centers at Preferred benefit levels. See Section 5(c) for information regarding enhanced inpatient and outpatient benefits for bariatric, spine, knee and hip surgeries performed at a Blue Distinction Center. We also provide enhanced benefits for covered transplant services performed at the Blue Distinction Centers for Transplant designated centers as described in Section 5(b).
For listings of Blue Distinction Centers, visit https://www.bcbs.com/blue-distinction-center/facility; access our National Doctor & Hospital Finder via www.fepblue.org/provider; or call us at the customer service phone number listed on the back of your ID card.
Cancer Research Facility – A facility that is:
- A National Cooperative Cancer Study Group institution that is funded by the National Cancer Institute (NCI) and has been approved by a Cooperative Group as a blood or marrow stem cell transplant center;
- An NCI-designated Cancer Center; or
- An institution that has a peer-reviewed grant funded by the National Cancer Institute (NCI) or National Institutes of Health (NIH) to study allogeneic or autologous blood or marrow stem cell transplants.
FACT-Accredited Facility
A facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). FACT-accredited cellular therapy programs meet rigorous standards. Information regarding FACT transplant programs can be obtained by contacting the transplant coordinator at the customer service phone number listed on the back of your ID card or by visiting www.factglobal.org.
Skilled Nursing Facility (SNF)
A SNF is a freestanding institution or a distinct part of a hospital which customarily bills insurance as a skilled nursing facility and meets the following criteria:
- Is Medicare-certified as a skilled nursing facility;
- Is licensed in accordance with state or local law or is approved by the state or local licensing agency as meeting the licensing standards (where state or local law provides for the licensing of such facilities);
- Has a transfer agreement in effect with one or more Preferred hospitals; and
- Is primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled or sick persons.
To be covered, skilled nursing facility care cannot be maintenance or custodial care. The term skilled nursing facility does not include any institution that is primarily for the care and treatment of mental diseases. If you have questions about treatment at a SNF, or need assistance coordinating this care, please contact us at the customer service phone number listed on the back of your ID card.
Other facilities specifically listed in the benefits descriptions in Section 5(c).