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 82
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 82
Benefit Description
Blue Distinction® Specialty Care (cont.)
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefit levels do not apply to inpatient facility care related to other services or procedures, or to outpatient facility care, even if the services are performed at a Blue Distinction Center.
Note: See Section 3 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $150 per admission copayment for unlimited days (no deductible)
Basic Option - You Pay
Blue Distinction Center: $100 per day copayment up to $500 per admission for unlimited days
Blue Distinction® Specialty Care (cont.)
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefit levels do not apply to inpatient facility care related to other services or procedures, or to outpatient facility care, even if the services are performed at a Blue Distinction Center.
Note: See Section 3 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $150 per admission copayment for unlimited days (no deductible)
Basic Option - You Pay
Blue Distinction Center: $100 per day copayment up to $500 per admission for unlimited days
Benefit Description
Outpatient facility services related to specific covered bariatric surgical procedures, when the surgery is performed at a designated Blue Distinction Center for Bariatric Surgery.
Outpatient facility services related to specific covered hip and knee replacement or revision surgeries and certain spine surgery procedures, when performed at a designated Blue Distinction Center for hip/knee/spine surgery.
Note: You must meet the pre-surgical requirements listed in our medical policies for bariatric surgeries.
Note: In addition, you must obtain prior approval and verify the facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to the procedure at the customer service phone number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefits do not apply to other types of outpatient surgical services, even when performed at a Blue Distinction Center.
Note: See Section 3 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $100 per day per facility (no deductible)
Basic Option - You Pay
Blue Distinction Center: $25 per day per facility
Outpatient facility services related to specific covered bariatric surgical procedures, when the surgery is performed at a designated Blue Distinction Center for Bariatric Surgery.
Outpatient facility services related to specific covered hip and knee replacement or revision surgeries and certain spine surgery procedures, when performed at a designated Blue Distinction Center for hip/knee/spine surgery.
Note: You must meet the pre-surgical requirements listed in our medical policies for bariatric surgeries.
Note: In addition, you must obtain prior approval and verify the facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to the procedure at the customer service phone number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefits do not apply to other types of outpatient surgical services, even when performed at a Blue Distinction Center.
Note: See Section 3 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $100 per day per facility (no deductible)
Basic Option - You Pay
Blue Distinction Center: $25 per day per facility
Benefit Description
Residential Treatment Center
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC when the care is medically necessary for the treatment of a medical, mental health, and/or substance use disorder:
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC when the care is medically necessary for the treatment of a medical, mental health, and/or substance use disorder:
- Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility.
Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
Residential Treatment Center - continued on next page