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 75
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 75
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Inpatient Hospital
Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. If a Preferred or Member hospital only has private rooms, we base our payment on the contractual status of the facility. If a Non-member hospital only has private rooms, we base our payment on the Plan allowance for your type of admission. Please see Section 10, Definitions, for more information.
See later in this Section and Section 5(e) for inpatient residential treatment coverage.
Other hospital services and supplies, such as:
Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described in this section. See Section 10, Definitions, for more information about these types of services.
Note: Here are some things to keep in mind:
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
Inpatient Hospital
Room and board, such as:
- Semiprivate or intensive care accommodations
- General nursing care
- Meals and special diets
Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. If a Preferred or Member hospital only has private rooms, we base our payment on the contractual status of the facility. If a Non-member hospital only has private rooms, we base our payment on the Plan allowance for your type of admission. Please see Section 10, Definitions, for more information.
See later in this Section and Section 5(e) for inpatient residential treatment coverage.
Other hospital services and supplies, such as:
- Operating, recovery, maternity, and other treatment rooms
- Prescribed drugs and medications
- Diagnostic studies, radiology services, laboratory tests, and pathology services
- Administration of blood or blood plasma
- Dressings, splints, casts, and sterile tray services
- Internal prosthetic devices
- Other medical supplies and equipment, including oxygen
- Anesthetics and anesthesia services
- Take-home items
- Pre-admission testing recognized as part of the hospital admissions process
- Nutritional counseling
- Acute inpatient rehabilitation
Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described in this section. See Section 10, Definitions, for more information about these types of services.
Note: Here are some things to keep in mind:
- You do not need to precertify your delivery; see Section 3 for other circumstances, such as extended stays for you or your newborn.
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 - continued on next page