2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 76
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 76
Benefit Description
Inpatient Hospital (cont.)
Note: See Section 5(a) for other covered maternity services.
Note: See Section 5(a) for coverage of blood and blood products.
Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. Keep reading this section for more information.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use a Preferred facility.
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: If you are admitted to a Member or Non-member facility due to a medical emergency or accidental injury, you pay a $350 per admission copayment for unlimited days and we then provide benefits at 100% of the Plan allowance.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Note: Your responsibility for maternity care in a Preferred facility, or birthing center, is limited to a $250 copayment associated with the charges incurred during delivery.
Member/Non-member facilities: You pay all charges
Inpatient Hospital (cont.)
- If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See Section 3 for information on requesting additional days.
- We pay inpatient hospital benefits for an admission in connection with the treatment of children up to age 22 with severe dental caries. We cover hospitalization for other types of dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(g).
Note: See Section 5(a) for other covered maternity services.
Note: See Section 5(a) for coverage of blood and blood products.
Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. Keep reading this section for more information.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use a Preferred facility.
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Note: If you are admitted to a Member or Non-member facility due to a medical emergency or accidental injury, you pay a $350 per admission copayment for unlimited days and we then provide benefits at 100% of the Plan allowance.
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Note: Your responsibility for maternity care in a Preferred facility, or birthing center, is limited to a $250 copayment associated with the charges incurred during delivery.
Member/Non-member facilities: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Admission to noncovered facilities, such as nursing homes, extended care facilities, schools, or residential treatment centers (except as described later in this section and in Section 5(e))
- Personal comfort items, such as guest meals and beds, phone, television, beauty and barber services
- Private duty nursing
- Facility room and board expenses when, in our judgment, an admission or portion of an admission is:
- Custodial or long term care (see Definitions)
- Convalescent care or a rest cure
- Domiciliary care provided because care in the home is not available or is unsuitable
- Custodial or long term care (see Definitions)
- Care that is not medically necessary, such as:
- When services did not require the acute hospital inpatient (overnight) setting but could have been provided safely and adequately in a physician’s office, the outpatient department of a hospital, or some other setting, without adversely affecting your condition or the quality of medical care you receive.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Inpatient Hospital - continued on next page