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 84
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 84
Benefit Description
Extended Care Benefits/Skilled Nursing Care Facility Benefits (cont.)
Note: See earlier in this section for benefits provided for outpatient physical, occupational, speech, and cognitive rehabilitation therapy, and manipulative treatment services when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs.
Note: If Medicare Part A is your primary payor, we will only provide benefits if Medicare provided benefits for the admission.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: Nothing (no deductible)
Non-member facilities: Nothing (no deductible)
Note: You pay all charges not paid by Medicare after the 30th day.
Basic Option - You Pay
All charges
Extended Care Benefits/Skilled Nursing Care Facility Benefits (cont.)
Note: See earlier in this section for benefits provided for outpatient physical, occupational, speech, and cognitive rehabilitation therapy, and manipulative treatment services when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs.
Note: If Medicare Part A is your primary payor, we will only provide benefits if Medicare provided benefits for the admission.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: Nothing (no deductible)
Non-member facilities: Nothing (no deductible)
Note: You pay all charges not paid by Medicare after the 30th day.
Basic Option - You Pay
All charges
Benefit Description
Not covered:
Phone, television, personal comfort items, such as guest meals and beds, beauty and barber services, recreational outings/trips, stretcher or wheelchair transportation, non-emergent ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason, custodial or long term care (see Definitions), and domiciliary care provided because care in the home is not available or is unsuitable
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
Phone, television, personal comfort items, such as guest meals and beds, beauty and barber services, recreational outings/trips, stretcher or wheelchair transportation, non-emergent ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason, custodial or long term care (see Definitions), and domiciliary care provided because care in the home is not available or is unsuitable
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
Standard Option - You Pay
See the following
Basic Option - You Pay
See the following
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
Standard Option - You Pay
See the following
Basic Option - You Pay
See the following
Benefit Description
Pre-Hospice Enrollment Benefits
Prior approval is not required.
Before home hospice care begins, members may be evaluated by a physician to determine if home hospice care is appropriate. We provide benefits for pre-enrollment visits when provided by a physician who is employed by the home hospice agency and when billed by the agency employing the physician. The pre-enrollment visit includes services such as:
Standard Option - You Pay
Nothing (no deductible)
Basic Option - You Pay
Nothing
Pre-Hospice Enrollment Benefits
Prior approval is not required.
Before home hospice care begins, members may be evaluated by a physician to determine if home hospice care is appropriate. We provide benefits for pre-enrollment visits when provided by a physician who is employed by the home hospice agency and when billed by the agency employing the physician. The pre-enrollment visit includes services such as:
- Evaluating the member’s need for pain and/or symptom management; and
- Counseling regarding hospice and other care options
Standard Option - You Pay
Nothing (no deductible)
Basic Option - You Pay
Nothing
Hospice Care - continued on next page