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Medical Summary Plan
Description
Introduction......................................................................................................................
3
Regence
BlueShield of Idaho Directory .............................................................................4
Summary Plan
Description.................................................................................................5
Summary of Benefits..........................................................................................................6
How to File Your Claim.....................................................................................................8
Hospital
Admission Review...............................................................................................
9
To
Our Employees:
The Company recognizes the need for health
care benefits for its employees and their families, and
provides a plan designed to meet those needs.
At a minimum, everyone covered by the
plan has the ability to use participating providers who have
agreed not to bill you if their charges are more than the
allowable charge. Although
this does not give you or the company cost savings, it does
give you protection from excess fee billing.
In contrast, nonparticipating providers
may charge any amount for services and are able to bill you
for the charges that are more than the allowable charge,
leaving you subject to an
out-of-pocket expense for excess fees.
It is important to you, your family, and
the company that you understand the plan and use it properly
and in the most effective manner.
Therefore, please familiarize yourself with the
information contained in this booklet and keep it for future
reference. If
you have any questions about your benefits, please contact
your local human resources department.
Regence
BlueShield of Idaho Directory
Please use the following addresses and
phone numbers when you need to contact Regence BSI.
If you have questions or need general information about your
benefits, simply call the appropriate phone number specified
below:
Lewiston
Office
1602 21st Avenue Ÿ
P.O. Box 1106
Lewiston, Idaho 83501
General Information Number.....
(208) 746-2671
Boise
Office
1408 West State Street Ÿ
P.O. Box 2560
Boise, Idaho 83701
General Information Number.....
(208) 336-2420
Coeur
d’Alene Office
610 West Hubbard, Suite 129 Ÿ
P.O. Box 2007
Coeur d’Alene, Idaho 83816
General Information Number.....
(208) 667-2761
Idaho
Falls Office
461 River Parkway
Idaho Falls, Idaho 83402
General Information Number.....
(208) 523-9936
Pocatello
Office
Pocatello Creek Office Park Ÿ
1175 Call Place, Suite 100
Pocatello, Idaho 83201
General Information Number.....
(208) 234-0020
Twin
Falls Office
450 Falls Avenue, Suite 102
Twin Falls, Idaho 83301
General Information Number.....
(208) 736-0755
Other
Helpful Phone Numbers:
Toll-Free Number....
1-800-632-2022
Hearing Impaired (TDD) Number.....
(208) 798-2074
Preadmission Review Toll-Free Number....
1-800-351-2370
The Employee Retirement Income Security
Act of 1974 requires that certain information be furnished
to each participant (or eligible participant) in an employee
benefit plan. This
is your Summary Plan Description.
Name
of Plan
This plan is known as The Company Health and Welfare Plan.
Plan
Identification Number
E.I.N.
Plan Number
Type
of Plan
This Plan can be described as a
health and welfare plan that provides dental, vision,
medical, surgical, and hospital benefits for eligible
employees and their dependents.
Type
of Administration
This Plan is sponsored and
administered by:
The Company
Front Avenue
Spokane WA
The claims administrator is:
Regence
BlueShield of Idaho, Inc.
P.O. Box 2007
Coeur d'Alene, ID 83816
(208) 667-2761
End
of Plan Year
The plan year for this Plan ends on
December 31 each year.
Each twelve (12) month period commencing on January
1, consists of an entire Plan Year for the purposes of
accounting and all reports to the United States Department
of Labor and other regulatory bodies.
Sources
of Contributions to the Plan
This plan shall be funded by, and
benefits under the plan shall be paid from the general
assets of the company.
This summary provides a brief description of certain benefits
and terms of your health care plan.
Please review this entire booklet for a complete
explanation of benefits, limitations, exclusions, and
general provisions.
Deductible:
Option 1: $250 per Beneficiary; Option 2:
$500 per Beneficiary.
No family shall be obligated to meet more than two
(2) deductibles in the aggregate in any calendar year.
Benefits are payable after
the deductible has been met.
Out-of-Pocket Expense:
$2,000 per Beneficiary.
No family shall be obligated to meet more than two
(2) out-of-pocket amounts in any calendar year.
Maximum Benefits
- $1,000,000 during an Insured’s lifetime with
automatic reinstatement up to $5,000 each calendar year.
Human Organ and Tissue
Transplants - $150,000 during an Beneficiary’s
lifetime.
Hospital Admission
Review - If not obtained benefits shall be reduced by
25% up to a maximum of $500.
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Services
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Your Responsibility
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Ambulance
(prior review required for air ambulance)
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20%
coinsurance
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Blood
and Blood Plasma
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20%
coinsurance
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Chemical
Dependency
·
Outpatient services ($500 calendar year
maximum)
·
Inpatient services ($5,000 during a
period of 24 consecutive calendar months; $10,000
lifetime maximum)
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20% coinsurance
20% coinsurance
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Chiropractic
Services
($500 calendar year maximum)
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20%
coinsurance
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Diabetic
Education
($500 calendar year/$1,500 lifetime maximum)
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20%
coinsurance
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Durable
Medical Equipment
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20%
coinsurance
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Extended
Care Facility (30 days per calendar year)
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20%
coinsurance
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Home
Health Care ($5,000 calendar year maximum)
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No
coinsurance required
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Hospice
Care
(limited to $5,000 and a maximum of six months from
the initial date covered care is provided)
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No coinsurance required
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Hospital
Care
·
Outpatient services (surgery, diagnostic
laboratory and x-ray, surgery suite, emergency room,
and dental surgery)
·
Inpatient services (room and board and
general nursing care, cardiac or intensive care units,
ancillary services and supplies, dental surgery, and
routine newborn care)
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20% coinsurance
20% coinsurance
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Maternity
(benefits are not provided for dependent children)
·
Physician services (prenatal and
delivery)
·
Hospital services (room and board and
general nursing care)
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20% coinsurance
20% coinsurance
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Mental
Health
·
Outpatient services (20 visits per
calendar year)
·
Inpatient services (10 days per calendar
year)
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20% coinsurance
20% coinsurance
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Physician/Provider
Services
·
Office, home, outpatient hospital calls,
inpatient hospital calls, surgical services, and
routine newborn care
·
Routine eye and hearing examination (one
per calendar year)
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20% coinsurance
20% coinsurance
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Prescription
Drugs * (per each 34 day supply or 100-unit doses,
whichever is greater)
·
Network pharmacist
·
Nonnetwork pharmacist
·
Mail-Order Program (90 day supply)
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$5 generic/$10 brand name
copayment
$25 copayment, plus 50% of the
balance
$5 generic/$10 brand
name copayment
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Prosthetic
Devices
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20%
coinsurance
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Rehabilitation
·
Inpatient services ($15,000 calendar
year maximum)
·
Outpatient services ($1,000 calendar
year maximum)
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20% coinsurance
20% coinsurance
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Temporomandibular
Joint Disorders ($2,000 lifetime maximum)
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20% coinsurance
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*
Benefits are not subject to the deductible.
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Participating Providers
By presenting your Regence BSI
identification card at the time you receive services the
provider's staff will assist you in completing any forms
that may be required.
Claims for services of providers who are
participating with Regence BSI or a Blue Cross and/or Blue
Shield plan in the state where the provider practices will
usually be submitted directly to Regence BSI.
Nonparticipating Providers
If you receive services from a provider
who is not participating with Regence BSI or a Blue Cross
and/or Blue Shield plan in the state where that provider
practices, you may be required to submit the claim to
Regence BSI yourself. In
this case, send an itemized copy of the billing to Regence
BSI along with your receipt of payment.
The itemized bill needs to identify the patient's
name, the provider's name, the date or dates of service, and
a complete itemization of services rendered.
Because the provider is not
participating with Regence BSI or another Blue Cross and/or
Blue Shield plan, you may be required to pay the bill
yourself. Regence
BSI will reimburse you directly for covered services.
What should I do if my claim for
benefits is denied?
Should your claim be denied in whole or
in part you will receive written notification.
If you disagree with any part of Regence BSI's
decision on your medical expense claim, you have the right
to appeal. Please
refer to the section in this booklet entitled Claims Appeal
Process for specific details.
Claims
and Appeals should be mailed to the following address:
Regence BlueShield of Idaho
P.O. Box 1106
Lewiston, ID 83501
Hospital
Admission Review
What is Hospital Admission Review?
Hospital admission review is Regence
BSI's program to make certain your benefit plan pays only
for medically necessary care and helps employers contain
health care costs. Hospital
admission review is prior authorization for medical
necessity of inpatient stays in a hospital, skilled nursing
home, or psychiatric/chemical dependency treatment facility.
Regence BSI will follow your hospital
stay or course of outpatient treatment.
If your condition requires additional days for
further treatment exceeding the days originally scheduled,
Regence BSI will authorize additional days based on
information provided by the hospital or your doctor.
Hospital Admission Review Offers
Several Benefits:
q
It insures you know the health care
alternatives available to you;
q
It assures you in advance that you meet the
requirements for benefits; and
q
It gives you the opportunity to receive care
in the most appropriate setting.
How Does Hospital Admission Review
Work?
When your doctor recommends a stay in a
hospital of 24 hours or longer, simply call Regence BSI's
toll-free number, 1-800-351-2370.
This telephone line is available
24 hours a day, 7 days a week.
If an answering system receives your call, you will
be asked to leave your name, identification number from your
Regence BSI card, daytime telephone number, and any other
helpful information.
For scheduled admissions, please call as
soon as you know the admission date.
For a maternity stay, call when you know your
expected delivery date. When an emergency visit becomes an inpatient stay, please
call within 48 hours of the admission.
You must obtain prior authorization in order to
receive the full benefits that are available under your
plan. Failure
to obtain prior review will result in a reduction of 25% of
the amount paid by the plan up to a $500 out-of-pocket cost
to you.
Regence BSI will accept calls from
anyone; however, it is ultimately the patient's and/or
family's responsibility to initiate prior review.
The final medical decision regarding your care is
between you and your doctor.
Rising
health care costs affect us all.
Remember, it's your health care dollar; please spend
it wisely.
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