2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 58
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 58
Benefit Description
Medical Supplies (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Medical Supplies (cont.)
Not covered:
- Medical foods administered orally, except as described in Section 5(f)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Home Health Services
Home nursing care (skilled) for two hours per day when:
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Benefits for home nursing care are limited to 50 visits per person, per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.
Basic Option - You Pay
Preferred: $35 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Note: Benefits for home nursing care are limited to 25 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Home Health Services
Home nursing care (skilled) for two hours per day when:
- A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services; and
- A physician orders the care
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Benefits for home nursing care are limited to 50 visits per person, per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.
Basic Option - You Pay
Preferred: $35 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Note: Benefits for home nursing care are limited to 25 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Nursing care requested by, or for the convenience of, the patient or the patient’s family
- Services primarily for bathing, feeding, exercising, moving the patient, homemaking, giving medication, or acting as a companion or sitter
- Services provided by a nurse, nursing assistant, health aide, or other similarly licensed or unlicensed person that are billed by a skilled nursing facility, extended care facility, or nursing home, except as described in Section 5(c) under Skilled Nursing Care.
- Private duty nursing
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Manipulative Treatment
Manipulative treatment performed by a professional provider, when the provider is practicing within the scope of his/her license, limited to:
Note: Benefits for manipulative treatment are limited to the services and combined treatment visits stated here.
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Standard Option - You Pay
Preferred: $30 copayment per visit (no deductible)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $35 copayment per visit
Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 20 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Manipulative Treatment
Manipulative treatment performed by a professional provider, when the provider is practicing within the scope of his/her license, limited to:
- Osteopathic manipulative treatment to any body region
- Chiropractic spinal and/or extraspinal manipulative treatment
Note: Benefits for manipulative treatment are limited to the services and combined treatment visits stated here.
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Standard Option - You Pay
Preferred: $30 copayment per visit (no deductible)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: $35 copayment per visit
Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 20 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Manipulative Treatment - continued on next page