HomeMy WebLinkAbout990325.tiff RESOLUTION
RE: APPROVE MASTER CONTRACT FOR BLUE CROSS AND BLUE SHIELD OF
COLORADO AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Master Contract for Weld County
Group Insurance between the County of Weld, State of Colorado, by and through the Board of
County Commissioners of Weld County, and Blue Cross and Blue Shield of Colorado,
commencing January 1, 1999, and ending December 31, 1999, with further terms and
conditions being as stated in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said contract, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Master Contract for Weld County Group Insurance between
the County of Weld, State of Colorado, by and through the Board of County Commissioners of
Weld County, and Blue Cross and Blue Shield of Colorado be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 10th day of February, A.D., 1999, nunc pro tunc January 1, 1999.
BOARD OF COUNTY COMMISSIONERS
12714/
COUNTY, C LORADO
ATTEST: /��
a Dal K. Hall, Chair
Weld County Clerk to the 0,0
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BY: Gaceie ALcJ CF= o
♦ �,d Geor e E. xter
APPRE TO FORM: !/
�J — M. J. eile
C Attorney
Glenn Vaa -
990325
BC0027
as BlueAdvantage Addendum To Application For BlueAdvantage
c7A From HMO Colorado
An Independent Licensee of the Blue Cross and Blue Shield Association GROfIR NUaelklb _, ANNIVERSARY MONTH ADDENDUM EFF C1V/E DATE
I
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Complete all information on this Addendum to Application for BlueAdvantage(Addendum)if you are completing the Application for BlueAdvantage.
If you have previously submitted an Addendum,complete only information that is relevant to the change.If a change is not indicated,the previous
Addendum will remain in effect.
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This Addendum is issued to:Weld County Government
("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT)
This Addendum amends provisions of the Application.If we approve this Addendum,we will return the approved Addendum with the effective date
completed. The Addendum will become a part of the Contract. If we do not approve this Addendum, it will be returned. Other than specifically
amended herein,the terms and provisions of the Application and Contract shall remain in full force and effect.
CLASSIFICATION OF EMPLOYEES ELIGIBLE—The Employer requires that all eligible Employees have a regular work week of at least
20 hours per week(minimum of 24 hours per week).Eligible Employees do not include those on a temporary or substitute basis. If
other Eligibility,please explain
The Employer hereby certifies the following number of Employees in each category below:
_Total Employees employed by the employer working at least 24 hours per week(include those not yet eligible) Enrolling for coverage
Total Eligible Employees who have met probationary period Enrolled elsewhere
COBRA or Colorado State law continuation of coverage enrollees No other coverage
Other,please explain:
DEPENDENTS—Unmarried dependent children are covered until the end of the month in which they become age 19,or 25 if financially dependent
upon the parent.
PROBATIONARY PERIOD
1"of the month following first full pay period worked,employer assigns effective date.
GROUP HEALTH COVERAGE APPLIED FOR(select only one):
BlueAdvantage HMO Plan Plan No. 15-1-15/25/40#of Employees enrolling
BlueAdvantage Point of Service Plan No. 15-1-15/25/40$250 deductible#of Employees enrolling
BlueAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 80%to$5,000/$10,000 #of Employees enrolling
Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus.
OPTIONAL GROUP BENEFIT INFORMATION
❑ Optional Chemical Dependency Rehabilitation Program
o Other Eye Health Network eye exam once every 24 months
REMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided
they meet the following criteria and stipulations:
a) Eligible employees must retire from county service with at least ten years of service,or be a county elected official for at least one full four-year
term.
b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office.
c) Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office.
d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65, or becomes eligible for health
insurance coverage with another employer, or becomes eligible for Medicaid ro Medicare coverage before attaining the age of 65. Dependent
coverage if still applicable will be offered under the same terms of COBRA offered employee's dependents.
e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time.The county will be
responsible for paying the 40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner
as provided regular employees.
0 After COBRA,dependents will have the same conversion rights as regular employees and dependents.
The Employer understands that if we approve this Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum.
Dated at C rado this 10th day of February 1999
By Dale K. Hall. Chair
SI N RE F A THORIZE PERSON TITLE
Approved and accepted by HMO orado and Blue oss and Blue Shield of Colorado
By �/" � :::
JJAN 2 61999RR
JAN ? bh
,.; �' 4 ,� :,.:..fa.L
CHIEF EXECUTIVE OFFICER-BLUE CROS$AteD-BbUE SHIELD OF COLORADO
Weld County Govt
990325
as BlueAdvantage Application For BlueAdvantage
Vac ti From HMO Colorado'
INTERNAL USE ONLY
An Independent Licensee of the Blue Cross GROUP NUMBER n ANNIVERSARY MONTH CONTRACT EFFECTIVE DATE
S ® and Blue Shield Association / o n/ /ao /_I /-1-99
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Application for BlueAdvantage(Application)group coverage is hereby made for eligible Employees of the Employer. If this Application
is approved by HMO Colorado and Blue Cross and Blue Shield of Colorado(if applicable),this coverage will be issued to:
Weld County Government
("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT)
915 10`h Street Greeley,CO 80631
(PHYSICAL ADDRESS-STREET, CITY,STATE,ZIP CODE)
(MAILING ADDRESS-IF DIFFERENT)
NOTE: "We,""Us,"and"Our"refer to HMO Colorado.For group sizes of 51 or more Employees,BlueAdvantage is federally qualified in
Adams,Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso,Fremont,Gilpin,Huerfano,Jefferson,Larimer,Otero,Pueblo,
Teller and Weld counties. For groups with 51 or more employees,counties not listed are not federally qualified. For group sizes of 50 or
fewer Employees,BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage
coverage can differ from those required by federal HMO laws and regulations."We,""Us,"and"Our"also refers to Blue Cross and Blue
Shield of Colorado if coverage is provided for BlueAdvantage Custom Plus coverage.
IN CONSIDERATION of the submission of this Application by the Employer,approval thereof by us,and of the payment of premiums in
accordance with the Group Master Contract(Contract), we agree to provide group coverage as described in the Contract, the Benefit
Booklet,and this Application and the Addendum to the Application for BlueAdvantage(Addendum),for any eligible enrolled Employees
and eligible enrolled dependents,and the Employer agrees to abide by the terms,conditions,and limitations contained in such documents.
GENERAL AGREEMENT
1. NATURE OF BUSINESS(please be specific): County Government
Type of organization: O Proprietorship O Corporation O Partnership
2. Do you have current coverage in force? O Yes O No,if"Yes"do you intend to cancel that coverage? O Yes O No. If you are applying
for or retaining other group health coverage in addition to this coverage on some or all Employees specify coverage(s),Carrier,amounts,
and give details:
3. Do you intend to enroll retirees under this group health Plan?(Retirees may enroll for coverage if there are 51 or more Employees
enrolled under this coverage.) O Yes O No If"Yes,"give details:
4. CONTRIBUTION —The Employer will be required to contribute a minimum of 50%toward the Employee's single or 50%of the
Employees portion of the family-cost of membership premiums.
5. PREMIUMS-It is understood that the premiums quoted may change based on the actual enrollment of the group.Premiums will
be billed by us monthly,and will be reviewed in accordance with the Contract and State or Federal requirements.
6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—All eligible Employees of the Employer who have a regular work week as stated
on the Addendum,shall be eligible to enroll.If the Employer reduces the working hours of such Employees to less hours per week than
stated on the Addendum,coverage will be continued for such Employees and their dependents under the same conditions and for the
same premium,if the following conditions are met and the Employer so certifies:
(a) The covered Employee has been continuously employed as an Employee of the Employer and has been insured under the group
Contract, or under any group Contract providing similar benefits which said group Contract replaces, for at least six months
immediately prior to such reduction in working hours;
(b) The Employer has imposed such reduction in working hours due to economic conditions;and
(c) The Employer intends to restore the Employee to a full work week schedule as soon as economic conditions improve.
7. ENROLLMENT PERCENTAGE REQUIREMENTS— For all size groups to apply for and retain group coverage and rates if we
are the sole carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL ELIGIBLE
EMPLOYEES:
• Group size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES
• Group size 51 or more Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES, with no less than 50%of
TOTAL ELIGIBLE EMPLOYEES.
To arrive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following types of group insurance may be excluded,
nless such coverage is offered through THE EMPLOYER:
A Blue Cross and Blue Shield Plan;
A Health Maintenance Organization;
The Federal Employees Program;
Indian Health Services;
Federal Peace Corps;
Colorado Uninsurable Health Insurance Plan,or
Through a commercial carrier.
BLII228M.WPD FORM NO.96064(REV.11/97)
NOTE: In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Application
with prior underwriting approval.
In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Colorado underwriting
regulations and policies and Colorado State law.
If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all times.
When we are a dual carrier, the enrollment percentage requirements do not apply
If the number of eligible Employees enrolled does not comply with the required percentage,we reserve the right to cancel the Contract
upon thirty day advance written notice.
Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee of a subchapter S or C corporation,
limited liability company,or a partnership that has carried on significant business activity for a period of at least one year prior to
application for coverage.
The Employer agrees and warrants that no person who is not an eligible member under this provision will be listed, named, or
otherwise represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any
such person or participant or assist in obtaining or maintaining a Benefit Booklet for such ineligible person. The Employer agrees to
maintain complete records and to furnish to us,upon request,such information as may be requested by us for our underwriting review.
The Employer further agrees to permit a payroll audit by us or by a representative appointed by us.This may include a request for
business tax records.
8. DEPENDENT—Dependent children are covered until they attain the age as stated on the Addendum.
9. PROBATIONARY PERIOD—Probationary period selection is as stated on the Addendum.There will be one open enrollment on
the group's Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point-of-Service Plan.For BlueAdvantage
Custom Plus,late entrants with prior coverage can be added at the group's anniversary date.In addition,if BlueAdvantage Triple
Option coverage is selected by the Employer,members will be allowed to choose between the HMO Plan,Point-of-Service,and Custom
Plus coverage(for Employers with 50 or fewer employees only out-of-state employees can enroll in the Custom Plus).
10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum.
COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET
TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADOTO SMALL EMPLOYERS
OF 2-50 EMPLOYEES,INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN,UPON
THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL GROUP,REGARDLESS OF
THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP.BUSINESS GROUPS
OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN.
11. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laws,rules
and regulations,including but not limited to COBRA,the Family Medical Leave Act,TEFRA,DEFRA,and OBRA.To the extent any
part of this application is inconsistent with such laws, rules, and regulations, such provision shall not be deemed a part of this
application.However,the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing
and notification duties related to COBRA,such information will be stated on the Addendum.
Masoud Shirazi-Shirazi&Assoc 970-356-5151
BROKER TELEPHONE NUMBER
1770 25'h Avenue#302 Greeley, CO 80631
STREET,CITY,STATE,ZIP CODE
The Employer represents, agrees, and warrants that the information contained in this Application is true and correct and forms an
essential basis for our issuance of the Contract. EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED
PREMIUMS OR OTHER FUNDS,THERE WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If
we approve this Application,we will send you a Contract of which this Application will become a part.Your prior coverage
should not be cancelled until you have been notified that your Application has been accepted.No agent can bind coverage,set an effective
date,or waive or alter any provision of this Application.The Contract will specify the effective date of group coverage. If we do not approve
this Application,the submitted funds will be returned to the Employer.
The Employer understands that if we approve this Application,the Employer agrees to be bound by the terms of the Contract.
Dated at c eele olor do this 10th day of February 1999
By - Dale K. Hall . Chair
SIGNATURE 'AUTHORIZED PERSON TITLE
Approved and accepted by HM olorado and Bl ross and Blue Shield of Colorado
By
Date JAN 2 61999
ES T— O O '
2 9
By Date JAN i�77°7
CHIEF EXECUTIVE OFFIC UE LU SHIF,LD OF COLORADO
BLU228M.WPo FORM NO.96064(REV.11/97)
)9c75
HMO COLORADO
GROUP MASTER CONTRACT
TABLE OF CONTENTS
Page No.
SECTION I. APPLICATION-ACCEPTANCE 1
SECTION II. GENERAL AGREEMENTS 1
Contract effective date 1
Anniversary date 1
Employee 1
Employer 1
Remittance 1
Benefit booklet 2
Group administrator 2
Assignment 2
Contract provision changes 2
Notices 2
Governing Laws 2
Attorneys' fees and expenses 3
Enforcement of the contract 3
Interpretation of the contract 3
Termination of the contract 3
Reinstatement of contract 3
SECTION III. PREMIUM: CHANGES, PAYMENT, TERMINATION FOR NON-PAYMENT,
REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT
ACCEPTANCE 4
Changes 4
Payment 4
Termination for non-payment 4
Refund of membership premium 4
Cashing of check not acceptance 5
SECTION IV. MEMBERSHIP/APPLICATION 5
Eligibility 5
Notification of cessation of membership 5
Acceptance of contract 5
Group eligibility requirements 5
BLUH119G C0C 1
9903.725
HMO COLORADO
GROUP MASTER CONTRACT
NO. 99-00772001
For
Weld County Government
Employer
C07720
Group Number
SECTION I. APPLICATION ACCEPTANCE
The application and addendum for group health coverage ("application/addendum") executed by the
employer has been accepted by HMO Colorado(sometimes referred to as "we," "us," and "our"). Such
application/addendum and their contents are incorporated in this group master contract("contract").
In the event of any inconsistency between the terms of the application/addendum and the terms of
the contract, the terms of the contract will control.
SECTION 11. GENERAL AGREEMENTS
The purpose of this contract is to provide under the circumstances specified herein health and
hospitalization benefits to certain of the employer's employees and their dependents. Such persons,
when covered hereunder, are referred to as "members."
1. Contract effective date.The effective date of the contract shall be 12:01 A.M. on the first day
of January, 1999, at Denver, Colorado; the contract shall continue to remain in effect through
December 31, 1999.
2. Anniversary date. The anniversary date is the effective date for (i) coverage; (ii) changes to
group enrollment and benefit eligibility implemented by the employer; and(iii) the date a group
is due for appropriate renewal rating.
3. Employee.An employee as defined in the application/addendum as eligible for enrollment; the
employee is the individual who is employed by the employer.
4. Employer. The employer or organization with whom HMO Colorado has contracted, and by
reason of the contract the employees and their dependents become eligible for the coverage and
benefits described in the contract.
5. Remittance. The employer shall pay to us monthly and prior to the first day in each month,
the required premium on behalf of all enrolled employees and dependents who meet the
eligibility requirements specified in the group application/addendum and benefit booklet that
are incorporated in this contract.
BLOH119G COC 1
99 aid 5
6. Benefit booklet.The definitions and other terms of the benefit booklet are incorporated herein
by reference.
7. Group administrator. The employer will designate a person as the principal contact for all
matters pertaining to HMO Colorado group coverage. That person will assist employees in the
administration and payment of claims. It is understood that HMO Colorado is not the
"administrator" within the meaning of the Employee Retirement Income Security Act (ERISA).
8. Assignment. None of the rights, benefits, duties, or obligations of the employer shall be
assigned without the prior written consent of a duly authorized officer of HMO Colorado. Any
attempted assignment will be void.
9. Contract provision changes.
a. This contract, the benefit booklet and any amendments thereto, and the group
application/addendum constitute the entire agreement between the parties hereto and
supersede all other contracts, either oral or in writing, between the parties with respect to
the subject matter hereof. No course of action, usage or custom or internal policy of HMO
Colorado may amend or become a part of this contract. Except as provided in paragraphs
b. and c. immediately below, no change or modification to this contract shall be valid unless
the same is in writing and signed by the parties hereto.
b. During the initial annual term or any renewal annual term of the contract, the provisions
of this contract may be amended at any time by an endorsement signed only by a duly
authorized officer of HMO Colorado. When the endorsement has been so signed, the
endorsement shall be deemed a part of the contract, effective as of the date specified by the
endorsement.
c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by
the Commissioner of Insurance of the State of Colorado may be made at any time by
endorsement to the contract signed only by a duly authorized officer of HMO Colorado and
shall become effective as of the effective date of such law, regulation, ruling, or approval.
10. Notices. All notices to HMO Colorado shall be sent by United States mail or personal delivery
to HMO Colorado, 700 Broadway, Denver, CO 80203-3441. All notices to employees or the
employer shall be sent by United States mail to the last address appearing in the records of
HMO Colorado or by personal delivery to the office of the employer. The employer shall notify
members in the event that this contract is terminated within ten (10) days of the date that the
employer has notice that this contract is to be or has been terminated, whichever occurs first.
If the employer has engaged the services of a broker/consultant, then delivery of all notices to
the named broker/consultant meets the requirements of this contract. Notice shall be effective
upon mailing.
Notice mailed to the employer or broker/consultant shall be deemed effective notice to each
employee. However, the employer agrees to post each notice promptly in a place reasonably
calculated to facilitate the employees' reading of the notice. The employer agrees to hold us
harmless for its failure to provide notice to the employees of any contract provision changes or
termination.
11. Governing Laws. This contract is made and delivered in the State of Colorado, and will be
interpreted and enforced so as to remain in compliance with Colorado statutes and regulations.
Nothing contained herein shall be interpreted to mean that HMO Colorado is doing business in
any other state of jurisdiction. Any legal action against us must be brought in the City and
County of Denver, Colorado.
2 HILUH119G.COC
12. Attorneys' fees and expenses.
a. Should it become necessary for either party to this contract to seek the assistance of an
attorney for the purpose of litigating or arbitrating any action against the other party
arising from any part of the contract, the prevailing party shall be entitled to recover from
the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be
entitled to recover from the losing party all other reasonably incurred costs and expenses.
b. The Employer shall indemnify and hold harmless HMO Colorado from its costs including
losses, claims, settlements,judgments, or fees, including attorneys'fees and other litigation
costs, and our internal costs if such costs were incurred by us by our participation in
lawsuits or arbitration proceedings related to the obligations undertaken or acts performed
by us under this contract. However, except for costs incurred by us in participating in
lawsuits or arbitration proceedings brought by persons who are ineligible for coverage
hereunder,the employer's obligation to indemnify us shall apply only to costs incurred after
this contract has been cancelled or terminated.
13. Enforcement of the contract. Failure of HMO Colorado or the employer to enforce any of the
provisions of this contract shall not constitute a waiver of rights for that or subsequent breaches.
14. Interpretation of the contract. This contract shall not be interpreted against any party for
the reason of having prepared its language and provisions. Rather, it shall be construed so as
to effect the purposes of the parties in a manner consistent with the terms of this contract and
sound principles of contract interpretation.
15. Termination of the contract.
HMO Colorado may terminate the contract at any time during its term for(i) employer's failure
to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility
requirements, (iii) failure of the group to maintain enrollment percentage requirements, as
provided in the application/addendum, or (iv) misrepresentation of material facts or any other
breach of the contract.
16. Reinstatement of contract.HMO Colorado,at its sole option,may reinstate this contract after
it has been terminated. We may impose such conditions on the contract's reinstatement as we
deem appropriate,including,without limitation, acceptable health statements. It is understood,
however, that there is no right to reinstatement, and any reinstatement will be in the sole
discretion of HMO Colorado.
BL06119G.00C 3
9go3,,2S
SECTION III. PREMIUM: CHANGES, PAYMENT,
TERMINATION FOR NON-PAYMENT,
REFUND OF MEMBERSHIP PREMIUM,
CASHING OF CHECK NOT ACCEPTANCE
1. Changes. From January 1, 1999 thorough December 31, 1999 premium are guaranteed.
HMO Colorado reserves the right to review monthly premium whenever a group, section, or
classification of employees is added to or deleted from enrollment under the contract. The
employer shall notify HMO Colorado no later than 30 days prior to the effective date of such
addition or deletion, and any change in monthly premium which may be required as the result
of an increased or decreased total group enrollment will become effective on the same date as
such addition to or deletion from total enrollment under the contract. This provision shall apply
regardless of the employer's normal rate review date or any other advance rate notification
agreement which may be in effect between HMO Colorado and the employer.
2. Payment. Initial premium shall become payable on or before the effective date of the contract.
Subsequent premium shall be payable on or before the first of each month thereafter. Eligibility
of members, claims processing, and payment will be suspended if premium is not timely paid.
In no event shall coverage under the contract become effective until we accept the
application/addendum and payment of the initial premium is received by HMO
Colorado.
3. Termination for non-payment. The contract shall terminate by its own terms if premium is
not paid on or before 30 days after the first day of the month, and no notice of cancellation other
than this provision shall be required. However,we may by sending notice thereof terminate this
contract before 30 days after the first day of the month if premium is not paid on or before the
first day of the month. When the contract is terminated or cancelled, the effective date of such
cancellation or termination shall be the date to which membership premium was last paid.
Members shall no longer be eligible to receive covered health services and all claims shall be
refused when dates of service are beyond the last day of the month for which payment has been
received. Claims that we deny because the employer fails to submit premium payments in a
timely manner should be submitted for payment to, and may be the responsibility of, the
employer.
4. Refund of membership premium.
a. If the employer terminates the coverage of a member or terminates this contract for any
reason, a refund of membership premium paid beyond the first of the month following the
termination date will be granted only if written notification of termination is received by
HMO Colorado at least 30 days before the termination date, covered health services have
not been provided and benefit payments have not been made for services rendered
subsequent to the termination date. If notification of termination is received less than 30
days before the termination date, no refund of membership premium will be made and
coverage shall cease on the first of the month following the termination date.
4 BLUHh19c.COC
b. If HMO Colorado terminates coverage of a member or terminates this contract for any
reason, a refund of membership premium paid beyond the termination date will only be
granted if covered health services have not been provided and benefit payments have not
been made for services rendered subsequent to the termination date.
5. Cashing of check not acceptance. It is understood that negotiation and deposit of checks
sent to us shall not be deemed to be acceptance by us of such payment, nor shall such
negotiation and deposit of the check prevent us from later returning such payment by issuance
of a check for the amount of the check to us.
SECTION IV. MEMBERSHIP/APPLICATION
1. Eligibility.All employees,who have a regular work week as indicated on the application and/or
addendum, paid for such employment by the employer, and listed as an employee on the
employer's State unemployment insurance tax returns, and the dependents of the employees,
are eligible to enroll for membership under the contract. We may inspect such records, public
and private, as are necessary to verify employment.
Applications of employees and dependents at open enrollment must be received prior to the
anniversary date to be effective on the anniversary date. If applications are not received prior
to the anniversary date, they will not be effective until the next anniversary date.
2. Notification of cessation of membership. The employer shall advise us when the employer
has notice that a member is no longer employed by the employer or otherwise does not satisfy
membership requirements. The employer shall so notify us, at the latest, by the first day of the
month after a member ceases to be employed by employer or otherwise ceases to meet
membership requirements. Such coverage shall terminate at the end of the month in which the
member is no longer employed or does not satisfy membership requirements. The employer
agrees that no person will be kept on the employer's payroll or otherwise be represented as an
employee of the employer for the purpose of obtaining or maintaining coverage when no longer
eligible for such coverage hereunder. The employer agrees to observe the terms thereof,and hold
us harmless for all costs incurred, including attorneys' fees, in the defense of any claim or suit
brought at any time by a person who is ineligible for coverage.
3. Acceptance of contract. The employer's signature on the group application/addendum
constitutes acceptance of this contract.
4. Group eligibility requirements. If the employer does not comply with the group eligibility
requirement, we reserve the right to cancel the contract upon 30 days advance written notice.
Weld County Goverment HMO COLORADO
(Group Name)
By .Thztegyit By 4,-
Dale K. Hall Bev Sloan
Printed or Typed Name Printed or Typed Name
(Title) Chair (02/10/99) (Title) President
(Date) February 10, 1999 (Date) January 25, 1999
ago}1119G.000 5
996&<A5'
ENDORSEMENT NO.: 1
TO GROUP MASTER CONTRACT NO.: 99-00772001
The Contract identified above is hereby amended by this endorsement which is issued to
form part of the Contract with the Employer.
Effective January 1, 1999, this Contract is amended to incorporate benefit booklet no.
97000 (Rev. 6-97) for BlueAdvantage HMO Plan, and any amendment(s) listed below:
Amendment No. Title
96679 (11-97) Amendment for BlueAdvantage HMO Plan Benefit Booklet
BLUPCS.AMC Amendment for BlueAdvantage HMO Plan Benefit Booklet for
Prescription Drugs
BLU122G.AMC Amendment to BlueAdvantage HMO Plan Benefit Booklet for
routine eye exam
HMO COLORADO
By 4(7 al61(4
(Title) President
Date January 26, 1999
BLU003M.ENC
ENDORSEMENT NO.: 2
TO GROUP MASTER CONTRACT NO.: 99-00772001
The Contract identified above is hereby amended by this endorsement which is issued to
form part of the Contract with the Employer.
Effective January 1, 1999, this Contract is amended to incorporate benefit booklet no.
97000 (Rev. 6-97) for the BlueAdvantage HMO Plan, the BlueAdvantage Point-of-Service
Rider no. 96055 (Rev. 6-97), and any amendment(s) listed below:
Amendment No. Title
96679 (11-97) Amendment for BlueAdvantage HMO Plan Benefit Booklet
96680 (11-97) Amendment for BlueAdvantage Point-of-Service Rider
BLUPCS.AMC Amendment for BlueAdvantage HMO Plan Benefit Booklet for
Prescription Drugs
BLU122G.AMC Amendment to BlueAdvantage HMO Plan Benefit Booklet for
routine eye exam
HMO COLORADO
By /45tre >443(44
(Title) President
Date January 26, 1999
BLUP006M.ENC
BlueAdvantage
HMO Plan
Benefit Booklet
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■ Emergency Care (also see page 16)
Emergency care — medical services that are immediately required because
of unforeseen illness or injury. Such services must be or must appear to
be needed immediately to prevent the death of the member or a serious
impairment of the member's health. For example, emergencies may be:
heart attack or suspected heart attack, coma, poisoning, stroke, acute
appendicitis, severe allergic reaction, or loss of respiration. Other acute
conditions may also be considered emergencies.
Within HMOC's service area:
1. If cardiopulmonary resuscitation (CPR) is necessary or if there is an
immediate threat to life or limb, call 911.
Call Your 2. If, because of the severity of the medical problem, you are unable to
o to the nearest medi-
� PCP Within reach your personal care network hospital,
48 Hours cal facility. Unless your condition makes it impossible to do so, you
should notify your PCP within 48 hours of receiving the care or of
being admitted as an inpatient. Use of an emergency room or emer-
gency center for nonemergency services is not covered.
3. If you do not call 911, call your primary care provider's (PCP's)
office for instructions.
Outside HMOC's service area:
1. If cardiopulmonary resuscitation (CPR) is necessary or if there is an
immediate threat to life or limb, call 911.
Call Your 2. If you do not call 911, go to the nearest medical facility. Unless
PCP Within your condition makes it impossible to do so, you should notify your
48 Hours PCP within 48 hours of receiving the care or of being admitted as an
inpatient. Use of an emergency center for nonemergency services is
not covered.
3. Follow-up services received outside of the me area are not covered if the member could have member's sedvtoe
his/her service area to receive care without medicretur to
results. y armful
When you receive the itemized bill from the hospital, send it to HMOC.
HMOC requires proof of payment to reimburse
HMOC will reimburse the provider. You will be responsible for these'emergency care copayment only.
I
Your group's Summary of Benefits and Copayments and the statement of "Member Rights and Responsibilities" are avail-
able in Spanish from HMOC. If you speak Spanish and have questions about your coverage, the Cust
department will gladly assist you.
Omer Service
El Sumario de Beneficios y Copagos de su grupo y la declaration de "Derechos y Responsabilidades del Socio"se pueden
obtener en espanol de HM0C. Si habla es anol ertura el de aLr1dorestadisPuestopaseienePreguntassobresucob
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as BlueAdvantage Weld County Government
boo An`Inndd n`oL�°;e°o�he Blue Cross BlueAdvantage HMO Plan No. 15-1-15
and Blue swaan.K;.ti"" Summary of Benefits Effective Date: January 1, 1999
Your Group's Number: C07720
Summary of Benefits and Copayments
This summary provides you with the copays for and very brief descriptions of your benefits. For more complete
information, see your Member's Benefit Booklet. If an optional benefit that is described in your benefit booklet is
not listed in this summary, your group did not select that benefit.
Benefit Copayment Additional information
Ambulance $50/trip The copay is waived if the member is admitted to the hospital.
services See your benefit booklet for the only kinds of transportation and
situations that are covered.
Chemical dependency treatment
For alcoholism and substance abuse: only short-term detoxi-
Inpatient 50% of billed charges fication is covered.
Optional Chemical dependency rehabilitation
Inpatient 50% of billed charges Inpatient maximum is 45 full or 90 partial days per admission.
`" These days will be reduced for any full or partial days used for
inpatient mental health.
Outpatient $25/visit Outpatient maximum is 20 visits or a payment of$1,000 per
calendar year, whichever is greater.
Chemotherapy and No copay
radiation therapy
Diagnostic services— No copay Diagnostic tests must be ordered by your PCP or referral pro-
laboratory, pathology, vider to be covered services. Screening mammograms are
X-ray covered under"Diagnostic Services."
Emergency care
Emergency room $50Nisit The copay is waived if the member is admitted to the hospital.
Urgent care $30/visit Urgent care may be received from your PCP, or from an urgent
care center with a referral from your PCP.
Home health care No copay Home health care must be delivered under a plan of care by a
licensed home health agency. Members will be informed of
benefit limitations based on medical necessity when they call for
prior authorization.
Hospice care No copay Hospice care must be provided by an HMOC•approved hospice
program during a hospice benefit period.
Hospital/other facility services
Inpatient $100/admission For hospital inpatient readmissions within 72 hours of discharge
for the same condition, an additional copay is not required. The
Outpatient surgery $25/procedure inpatient copay includes surgical procedures.
Maternity care
Prenatal $15/visit A referral is not required from your PCP to receive maternity care
from an HMOC participating OB/gyn physician.
Delivery $100/admission
You must obtain a referral from your PCP to receive benefits for nonemergency services that are not directly
provided by your PCP (for exceptions, see "PCP Referrals" in Section 2:How the Plan Works).
BLUH110G.SBC 15-1-15+CH+PCS REV.11/98 Customer Service: (800) 334-6557 or(303) 831-0161 ^ .,C
'J .'�•t k,�aJ
Weld County Government — C07720
Benefit Copayment Additional information
Mental health services*
Inpatient 50%of billed charges Inpatient services limited to 45 full or 90 partial days per calendar
year.
Outpatient $10 for visits 1-5 Outpatient services limited to 20 visits or a payment of$1,000
$25 for visits 6-20 per calendar year, whichever is greater.
Physical rehabilitation(physical,occupational, and speech therapy)
Inpatient $100/admission Inpatient services are limited to 30 days per injury or illness.
Outpatient $15/visit Outpatient services are limited to 30 treatments per injury or
illness.
Physician visits
Inpatient No copay Covered inpatient physician visits do not require a copay.
Office, home $15Nisit
Prescription drugs
Inpatient No copay This covered service is ONLY for prescription drugs administered
during a covered admission. Inpatient prescription drugs are
covered under the hospital admission copayment.
Outpatient $15 generic formulary, $25 HMO benefits are only available if the prescribing provider is the
brand formulary, $40 non- member's PCP or referral provider. The member must fill pre-
formulary/prescription scriptions through a participating pharmacy. Prescriptions can
also be ordered through Managed Prescription Mail Service.
$30 generic formulary, $50
brand formulary, $80 non-
formulary/prescription (60-or
90-day supply through Managed
Prescription Mail Service)
Preventive services
Physical exams $15Nisit See your benefit booklet for covered routine physical examina-
tions Family planning $15/visit (for child and adult). Covered services include routine
mammograms and prostate exams.
Health education $15/visit
Supplies, equipment,and appliances
Inpatient No copay Inpatient supplies, equipment, and appliances are covered under
the hospital admission copayment during covered admissions.
Outpatient durable No copay Outpatient durable medical equipment benefits are limited to a
medical equipment payment of$1,000 per calendar year.
Transplants:
Major organ transplants $100/admission The only transplants covered under this benefit are liver, lung,
heart, heart-lung, and pancreas-kidney. The procedure must be
$15Nisit ordered by a participating physician, preauthorized by HMOC's
medical director, and delivered in an HMOC-approved facility.
There is a$1,000,000 maximum lifetime benefit limitation per
transplant for major organ transplants.
Other transplants $100/admission The only transplants covered under this benefit are corneal,
kidney, and, under specific conditions only, liver and bone mar-
$15/visit row transplants. See your benefit booklet for details.
You must obtain a referral from your PCP to receive benefits for nonemergency services that are not directly
provided by your PCP (for exceptions, see "PCP Referrals" in Section 2: How the Plan Works).
2 Customer Service: (800) 334-6557 or(303) 831-0161 BLUH110G.SBC 15-1-15+CH+PCs REV.11/98
Weld County Government —C07720
Benefit Copayment Additional information
Vision Care
Outpatient eye exam $15/visit A referral is not required from your PCP to receive a eye exam
from a participating Eye Health Network provider. Benefits are
provided once every 24 months.
optional The end of the month in which the employee's unmarried dependent child becomes age 19 or 25
-. Dependent age limit if financially dependent.
* Mental illness does not include treatment of schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive
disorder, obsessive-compulsive disorder, and panic disorder. These conditions are covered as any other physical illness.
990325
You must obtain a referral from your PCP to receive benefits for nonemergency services that are not directly
provided by your PCP (for exceptions, see "PCP Referrals" in Section 2: How the Plan Works).
BLUH110G.SBC 15-1-15+CH+PCS REV.11/98 Customer Service: (800)334-6557 or(303) 831-0161 3
■ Amendment for BlueAdvantage
HMO Plan Benefit Booklet
This amendment is effective January 1, 1998, or your effective date of
membership, whichever is later.
The section entitled Your Plan at a Glance is amended as follows:
The following language is added to the section:
If we do not have an HMOC Provider for a covered service, we will
arrange to make sure that you pay no more than what you would have
paid for such covered service if it had been received from a HMOC
Provider. HMOC will not deny or restrict in-network covered benefits to a
member solely because the member obtained treatment outside the
network.
The paragraph entitled Mental illness or chemical dependency care,
is deleted and the following language is substituted:
Mental illness or chemical dependency care — When you need care
for mental illness (whether biologically based or non-biologically based) or
chemical dependency, all services must be preauthorized by the HMOC
behavioral health administrator prior to receiving services. Contact a
Customer Service representative for the phone number of the
administrator.
The following language is added to the section:
■ Network Access Plan
HMOC strives to provide an extensive provider network that adequately
addresses members' health care needs. The Network Access Plan
describes HMOC's provider network standards for ensuring network
sufficiency in service, access, and availability, as well as assessment
procedures to ensure that the network continues to meet member needs.
To request a copy of this document, call (800) 334-6557. This document is
available for your in-person review at 700 Broadway in Denver, Colorado,
in the Customer Service Department, fourth floor.
The section entitled How the Plan Works, is amended as follows:
The last paragraph following the heading Copayment is deleted and the
following language is substituted therefor:
Members are always liable for a provider's full billed charge for
any noncovered services, and for services received without a
PCP's referral or HMOC approval.
FORM NO.96679(11-97)
99o"--•
0LU0BSM.AMC 1
The heading entitled PCP Referrals is deleted and the following language
is substituted therefor:
■ PCP Referrals
A member must receive a referral from his/her PCP before receiving
nonemergency care from another provider. The PCP will phone or fax the
referral information to HMOC. HMOC or its designee will mail a confir-
mation referral form or a denial of the referral request to the member, the
PCP, and the specialist. Retroactive referrals are not covered; all
referrals must be obtained before receiving services.
If a member chooses to see any other provider — even an HMOC
participating provider — without a referral, the member will be
responsible for all charges. (See "Preventive, Routine, and Family
Planning Services" in Section 3: Covered Services for exceptions and the
NOTE below.)
The referral indicates the number of visits approved and the time period
in which the member must receive the care. If only one visit is authorized,
a second visit will not be covered. The member is responsible for all visits
in excess of those authorized and for any care received before or after
the specified time period.
Note: A referral is not required to visit a participating OB/gyn physician.
The member must choose an OB/gyn physician within her personal care
network; otherwise, coverage will be denied. To visit an OB/gyn physician
outside of her personal care network, the member must get a referral
from her PCP. If the PCP is not part of a Personal Care Network,
OB/GYN care can be provided by any OB/GYN provider in the HMOC
network.
The heading entitled Advanced Benefit Information is deleted and the
following language is substituted therefor:
• Advance Benefit Information
If a member wants to know whether a service will be covered before re-
ceiving that service or filing a claim for it, HMOC may require a written
request. HMOC may require a written statement from the provider iden-
tifying the circumstances of the case and the specific services that will be
provided.
The section entitled Covered Services, is amended as follows:
The heading entitled Mental Illness Treatments is deleted and the
following language is substituted therefor:
• Mental Illness Treatments
Mental illness — a clinically significant behavioral or psychological
syndrome or pattern that is associated with distress or disability, or with
a significantly increased risk of suffering death, pain, disability, or an
important loss of freedom, and for which improvement can be expected
with treatment. HMOC defines mental illness based on the Diagnostic
BL[108NM AMC 2
and Statistical Manual of Mental Disorders published by the American
Psychiatric Association.
Biologically based mental conditions are considered medical conditions
and not mental illness. Biologically based mental illness means
schizophrenia, schizoaffective disorder, bipolar affective disorder, major
depressive disorder, specific obsessive-compulsive disorder and panic
disorder.
Mental illness does not include certain conditions, such as:
• alcohol abuse
• chemical dependency
• sexual dysfunction
For the treatment of alcoholism and/or substance abuse, see "Chemical Dependency Treatments"
Argiso in this section.
Inpatient Mental Illness Treatments
Contact the HMOC behavioral health administrator for
preauthorization and selection of a provider before care is re-
ceived. Call an HMOC Customer Service representative for the
phone number of the administrator.
Inpatient care — care provided by a physician, hospital, or treatment
facility for services provided while a member is confined as an inpatient
in a hospital or other treatment facility. Partial hospitalization is also
considered to be inpatient care. Partial hospitalization is no less than
three and no more than twelve hours of continuous psychiatric care in a
hospital. Two partial hospitalization days equal one full inpatient day.
Benefits for HMOC-authorized inpatient care are limited for each member
to a total of 45 full days or 90 partial days each calendar year for room
expenses and ancillary services received in a facility (see definitions under
"Hospital/Other Facility Services") and include physician visits received
during a covered admission day.
The following services are not covered services:
• services provided or billed by a school, halfway house, or residential
treatment center or members of their staff
• court- or police-ordered treatment that would not otherwise be covered
• psychoanalysis or psychotherapy that a member may use as credit
toward earning a degree or furthering his/her education
• the cost of any damages to a treatment facility caused by the member
If a member is admitted for an inpatient medical/surgical admission and
subsequently needs to be transferred to an inpatient psychiatric unit, or
vice versa, each portion of the inpatient confinement will be considered a
separate admission, subject to its own copayment level (see your group's
Summary of Benefits and Copayments).
990325
BI.U088M AMC 3
Outpatient Mental Illness Treatments
Outpatient care — care provided by a physician, hospital, or other pro-
vider in the provider's office the outpatient department of a hospital,
other facility, or the patient's home.
Coverage is limited per calendar year to 20 visits or $1,000, whichever is
greater, for the outpatient care, evaluation, diagnosis, and/or treatment of
non-biologically based mental illness. Services rendered by psychiatrists,
psychologists, licensed family therapists, and social workers are included
in the 20-visit or $1,000 maximum.
The following services are not covered services:
• services provided or billed by a school, halfway house, or residential
treatment center or members of their staff
• court- or police-ordered treatment that would not otherwise be covered
• biofeedback
• psychoanalysis or psychotherapy that a member may use as credit
toward earning a degree or furthering his/her education
• hypnotherapy
• marital counseling
Under the heading entitled Surgical Services, the subheading entitled
Transplants, Major Organ Transplants is amended to include the
following:
Services after one year for a major organ transplant are covered subject to
the provisions of the benefit booklet for covered services.
The section entitled General Exclusions is amended as follows:
The heading entitled Blood, Plasma, or Derivatives is deleted and the
following is substituted:
Blood, Plasma, or Derivatives
This plan does not cover whole blood, blood plasma, and blood
derivatives. Blood is available through community services.
The heading entitled Post-Termination Services is deleted and the
following is substituted:
When your coverage is terminated for any reason other than nonpayment
of premium, fraud or abuse, we shall provide for continued care for the
member being treated at an inpatient facility until the member is
discharged subject to the terms of the benefit booklet. Benefits under the
benefit booklet end for any other reason except and stated above.
The section entitled Coordination of Benefits and Subrogation is
amended as follows:
Under the heading entitled Automobile No-Fault Insurance
Provisions, the sub-heading entitled If the Member Does Not Have a
Complying Policy is deleted and the following is substituted:
B1.U088MAMC 4
If the Member Does Not Have a Complying Policy
This plan will pay benefits for injuries received by the member while
he/she is riding in or operating a motor vehicle which he/she owns if it is
not covered by an Automobile No-Fault complying policy as required by
law. Benefits will also be available under the terms of this plan for
injuries sustained by a member who is a nonowner operator, passenger, or
pedestrian involved in a motor vehicle accident if that member is not
covered by a complying policy.
In the above events, HMO Colorado may exercise its subrogation rights
under "Third-Party Liability — Subrogation,".
The section entitled General Provisions is amended as follows:
The paragraph entitled Availability of Provider Services is deleted
from the benefit booklet.
This amendment is part of and to be read in conjunction with your
/5tr >1163
Bev Sloan
President
HMO Colorado
990325
I3LU088M AMC 5
■ Amendment to BlueAdvantage HMO Plan
Benefit Booklet
This amendment is effective January 1, 1999, or your effective date of membership,
whichever is later.
In Section 3: Covered Services,the benefits for Prescription Drugs are deleted and the
following is substituted:
■ Prescription Drugs
Prescription drugs and medicines—those that are taken at the direction
and under the supervision of a provider and require a physician's
prescription before being dispensed. All drugs and medicines must be
approved by the Food and Drug Administration, and must not be
"experimental or investigative" (see "Experimental or Investigative
Procedures and Services" in Section 4: General Exclusions). The fact that
a drug is recommended or prescribed does not make it a covered
service.
Drug Formulary— a list of prescription drugs that is approved for use by
HMOC. This list is subject to periodic review and modification by HMOC.
Generic drug—the chemical equivalent of a brand-name prescription
drug. By law, brand-name and generic drugs must meet the same
standards for safety, purity, strength, and quality.
Maintenance medications— prescription drugs taken regularly to treat a
chronic health condition, such as high blood pressure, ulcers, or diabetes.
Coverage for prescription drugs administered by a hospital, home health agency,
hospice, or skilled nursing facility during a covered admission is not available under
this "Prescription Drugs"section. See other headings in this section for drugs used
during a covered admission or home health/hospice visit.
The following take-home prescription drugs (including insulin) are covered
only when prescribed by an HMOC participating provider and dispensed
by an HMOC participating pharmacy:
• prescription drugs, including oral contraceptives (limited to the supply
required for one menstrual cycle), prescription contraceptive devices
purchased from a pharmacy, and insulin — unless a prescription drug
is listed as an exclusion below
• compounded medication of which at least one ingredient is a prescrip-
tion drug
• self-administered injectable insulin, glucagon, Imitrex, and
anaphylactic kits—these are the only injectable medications covered
unless an HMOC prior authorization is obtained
HLUPCS AMC 990325
• insulin needles, syringes, and supplies (e.g., lancets and test strips) if
purchased at the same time as insulin (there will be a separate
copayment for each item purchased)
Important: If a provider prescribes a drug for which an FDA-approved
Class A generic substitute is available, the benefit will be limited to the
cost of the generic substitute. All medically necessary "dispense as written"
or "no substitution" prescriptions do not allow a generic substitution and
require a prior authorization from HMOC. If prior authorization is not
obtained in a nonemergency situation, the member is responsible for the
retail cost difference between the brand-name drug and the generic
substitute, in addition to the copayment. If a member requests a brand-
name equivalent of a drug that has a generic equivalent, payment is
limited to the cost of the generic equivalent, less the copayment. The
copayment is based on whether the drug is listed on the HMOC formulary.
Generic formulary drugs are available at the lowest copyament, brand
formualry drugs at the intermediate copayment, and non-formulary drugs
at the higher copayment.
Retail Pharmacy Program
A member may obtain prescription drugs from participating pharmacies
and pay only a small copayment at the time of purchase. For each
prescription purchased at a participating pharmacy, members pay the
amount specified on their Summary of Benefits and Copayments. (If the
retail price of a prescription drug is less than the copayment, the member's
copayment will be the actual retail price.) Refer to your "HMO Colorado
Pharmacy Roster" or call an HMOC customer service representative for a
list of participating pharmacies.
Members must present their plan ID card to the pharmacist at the
time of purchase to receive this benefit.
If you do not have your ID card with you or if you purchase your
prescription from a nonparticipating provider in an emergency situation,
you must pay for the prescription in full and then submit the claim to the
Retail Pharmacy Program. Prescription drug bills must include pharmacy
name and address, drug name, prescription number, and amount charged.
The bill or receipts must be issued by the pharmacy. For a claim form and
the mailing address, contact HMOC customer service. The reimbursement
for these prescription drug claims is 100 percent of the charge for the drug
minus the copayment amount. (If the reimbursement price is the same as
or less than the copayment amount required, there is no payment to the
member.)
Under the Retail Pharmacy Program, members can obtain a maximum of a
34-day supply. For oral contraceptives, the supply is limited to one
menstrual cycle (normally 28 days). Prescriptions in excess of the number
specified by the physician or those requested more than one year following
the physician's original order date cannot be refilled. (Drugs with a high
degree of intolerance may be filled with a one-week supply initially and, if
the member's response is favorable, the remainder of the prescription will
be filled with no additional copayment.)
BLUPCS AMC
Prescription Mail Service Program
Members taking maintenance medications may enroll in and use the
Prescription Mail Service Program.
The member's copayment amount for each prescription ordered through
the Prescription Mail Service Program is the same as the copayment
amount for a prescription filled at a participating retail pharmacy under
the Retail Pharmacy Program for a 34-day supply, and two times that
amount for a 60- or 90-day supply. See your Summary of Benefits and
Copayments for the exact copayment amount for mail-order prescription
drugs.
To use the Prescription Mail Service Program, complete the following
steps:
• Ask the physician to write a new, original prescription that can be
submitted directly to the mail service pharmacy with the "Mail Service
Pharmacy Order Form." If medication is needed immediately, ask the
doctor to issue two prescriptions —one for an immediate supply to be
taken to the local pharmacy, and a second for an extended supply to be
mailed to the Prescription Mail Service.
• When the physician writes a prescription for a maintenance
medication, ask that the prescription be written for up to a 90-day
supply with up to three refills.
• Complete the "Patient Profile/Registration Information Form" for the
first mail-service order. In the future, if there is additional information
or changes to report, send an updated"Patient Profile/Registration
Information Form" to the Prescription Mail Service.
• Complete the "Mail Service Pharmacy Order Form" for both new and
refill prescriptions. A new order form and envelope will be sent with
each delivery.
• Enclose the original prescription, "Patient Profile/Registration
Information Form," "Mail Service Pharmacy Order Form," and
payment in the preaddressed mail-service envelope and mail the order.
• For information on how to contact the Prescription Mail Service
Program, refer to the Prescription Mail Service brochures for the
phone number or call your HMOC customer service representative.
• Prescriptions will be delivered either by U.S. Postal Service or UPS.
Please allow 10-14 days for delivery from the date the prescription
order was mailed. In an emergency, the prescriptions can be shipped
overnight for an additional fee that is the member's responsibility.
Prescription Drug Exclusions
Coverage is not available under the prescription drug program for:
• nonprescription and over-the-counter drugs, including herbal or
homeopathic preparations, and prescription drugs that have over-the-
counter bioequivalents—unless specifically prior authorized by HMOC
• prescription drugs which are non-formulary and determined by HMOC
to be medically necessary by HMOC require prior approval and are
subject to the same copayment and limitations as prescription drugs
BLUPUS AMC 990325
which are listed in the formualry and offered as a benefit of the Benefit
Booklet.
• infertility medications (for exceptions, see "Infertility Services," under
"Office, Outpatient, and Home Care" in this section)
• drugs approved by the FDA or otherwise, intended for the treatment of
sexual dysfunction (including drugs for the treatment of erectile
dysfunction)
• Nicorette, nicotine patches, or any other drug containing nicotine or
other smoking deterrent medications
• appetite suppressants
• tretinoin (sold under such brand names as Retin-A) for cosmetic
purposes
• prescription drugs dispensed for the purpose of international travel
• any prescription prescribed by a nonparticipating provider (unless
eligible for coverage in an emergency or urgent care situation)
• prescriptions purchased from a nonparticipating pharmacy (unless
eligible for coverage in an emergency or urgent care situation)
• delivery charges
• therapeutic devices or appliances, including support garments and
other nonmedicinal substances (regardless of intended use)
• medications or preparations used for cosmetic purposes (such as
preparations to promote hair growth or medicated cosmetics)
Note: Certain prescription drugs that have the potential for misuse and
most injectable medications require a prior authorization from HMOC.
Your PCP or HMOC participating provider will request the necessary prior
authorization.
This amendment is part of and to be read in conjunction with your BlueAdvantage
HMO Plan Benefit Booklet.
/5tor >43(41
Bev Sloan
President
HMO Colorado
BLUPCS AMC
■ Amendment to BlueAdvantage HMO Plan
Benefit Booklet
This amendment is effective January 1, 1999, or your effective date of
membership, whichever is later.
In Section 3: Covered Services, under Preventive, Routine, and Family
Planning Services, the following benefit is added as a covered service:
• Routine eye refractions are allowed once every 24 months. The
refraction may be preformed by an ophthalmologist or optometrist
who participates in the Eye Health Network. Services from any other
ophthalmologist or optometrist are not covered. Contact Customer
Service at 1-800-334-6557 for a list of Eye Health Network providers.
This amendment is part of and to be read in conjunction with your
BlueAdvantage HMO Plan Benefit Booklet.
deelf.
Bev Sloan
President
HMO Colorado
sLo122c AMC
990325
■ Welcome
Welcome to the BlueAdvantage HMO Plan from HMO Colorado (HMOC)—
your partner in health care. By encouraging physicians, hospitals, other
providers, and members to work together, HMOC works to maintain
reasonable health care costs.
Please take a few minutes to get to know BlueAdvantage and your cover-
age, including limitations and exclusions, by reviewing this important
document and any enclosures. Learning how the BlueAdvantage HMO
Plan works can help you make the best use of your health care plan.
Thank you for selecting BlueAdvantage for your health care coverage.
Sincerely,
i
Stephen T. O'Dell
President
HMO Colorado
Acceptance of coverage under this benefit booklet constitutes accep-
tance of its terms, conditions, limitations, and exclusions. Members are
bound by all of the terms of this benefit booklet.
Your health benefit plan coverage is defined in the following docu-
ments:
• this benefit booklet, the Summary of Benefits and Copayments, and
any amendments or endorsements
• the enrollment/change form(s) for the employee and his/her
dependents
• the identification card
In addition, the employer has important documents that are part of the
terms of the health benefit plan:
• the Group Master Application from the employer
• the Group Master Contract between HMOC and the employer
The above documents constitute all of the terms and conditions of your
health benefit plan. No change or modification to any of these docu-
ments will be valid unless the change or modification is in writing and
signed by an officer of HMOC.
990325
BLOHO7I M.CRC(6-97)
Your Plan at a Glance BlueAdvantage HMO Plan
■ Your Plan at a Glance
Every BlueAdvantage member must select a primary care provider
(PCP) from the HMOC provider network. (If a PCP is not selected, the
member will be covered for emergency care only.)
A PCP provides basic health services, and other medical care, and recom-
mends and oversees any care provided by other health care providers. A
member needing nonemergency hospital care or wanting to see a health
care provider other than his/her own PCP, must first obtain a PCP
referral before receiving the service. If a member does not receive a
referral for services performed by any provider other than his/her PCP, the
plan will not cover those services. (For limited exceptions, see Section 3:
Covered Services.)
Personal care network—A personal care network is a specific network of
providers covering a geographic service area. It includes one hospital and
certain PCPs and specialists. Once a member enrolls with a PCP, he/she
will belong to that PCP's personal care network and must obtain all health
care services through that personal care network.
Referrals are restricted to those specialists who belong to the member's
personal care network. Except for emergency care, all inpatient and
outpatient services must be received through a member's personal care
network. Note: If you and your dependents choose PCPs in different
personal care networks, be aware that each member of your family may be
required to go to different hospitals for care.
In some parts of the HMOC service area, all specialty and facility services
may not be available in a member's personal care network. In these
circumstances, the PCP will refer the member outside of his/her personal
care network.
Your identification card—Your identification (ID) card shows that you
are a member of this plan and provides the information needed when you
require services. Always carry your ID card; any provider may ask to see
it. Have it handy when you call for an appointment and show it to the
receptionist when you sign in for an appointment.
Benefit limitations— To be considered covered services, any services
received must be medically necessary or covered as appropriate preventive,
routine, or family planning services. Services must also be performed,
prescribed, directed, or authorized by the member's PCP (limited
exceptions are described in Section 3: Covered Services). For additional
exclusions and limitations, also see Section 4: General Exclusions.
ii Customer Service:(800)334-6557 or(303)831-0161 BLUH0)1M.CRC(6197)
BlueAdvantage HMO Plan Your Plan at a Glance
Visiting your PCP—To avoid possible delays when scheduling an ap-
pointment with your PCP, follow these steps:
• For routine appointments, call your PCP's office and identify yourself
as a BlueAdvantage member to schedule an appointment.
• For sudden illnesses, call your PCP's office and identify yourself as a
BlueAdvantage member. You will be given instructions to follow.
If you need to cancel an appointment, notify your PCP as soon as possible,
but at least 12 hours before the scheduled appointment. You may be
charged a fee for a missed appointment. This plan will not pay for such a
charge. If you are going to be late for an appointment, please notify your
PCP, who may ask you to reschedule.
Mental illness or chemical dependency care—When you need care for
mental illness or chemical dependency, all services must be preauthorized
by the HMOC behavioral health administrator prior to receiving services.
Contact a Customer Service representative for the phone number of the
administrator.
Routine care—Routine care is service for conditions not requiring imme-
diate attention and can usually be received in the PCP's office, or services
that are usually done periodically within a specific time frame (e.g.,
immunizations or physical exams). Routine care is performed during your
PCP's normal business hours.
Urgent/after-hours care—You must call your PCP for instructions to
receive medical care after your PCP's normal business hours or on week-
ends and holidays, or to receive urgent care within the HMOC service area
for a condition that is not life threatening but that requires prompt medi-
cal attention. If you are outside the HMOC service area, services covered
under this benefit booklet that are received from an HMO-USA facility are
also covered services. See "Emergency and Urgent/After-Hours Care" in
Section 3: Covered Services for important details.
Emergency cam You may get immediate care from any provider for
Call Your true emergency care. However, you should always contact your PCP
. PCP Within within 48 hours of the emergency, unless your condition makes it impos-
e-- 48 Hours sible to do so. For details, please read "Emergency and Urgent/After-Hours
Care" in Section 3: Covered Services.
Specialist or referral care— Except for emergency care, you must obtain a
referral from your PCP before seeing any other provider. Coverage will be
provided only for covered services received from a specialist if your PCP
refers you to that specialist before you receive the care (limited excep-
tions, including female reproductive system services, are described in
Section 3: Covered Services) . Do not make a second appointment with a
specialist if only one visit is authorized. If you receive nonemergency
services before consulting with your PCP, coverage will not be
available and you will be responsible for the entire cost of the
services.
BLLIHO]1M.CRC(6/97) Customer Service:(800)334-6557 or(303)831-0161 ,0190'325 iii
Your Plan at a Glance BlueAdvantage HMO Plan
Nonparticipating provider services— Services performed by a nonpartici-
pating provider (one who has not contracted with HMOC) will be covered
only in an emergency as described under "Emergency and Urgent/After-
Hours Care" in Section 3: Covered Services or when approved in advance
by HMOC.
Hospital admissions—HMOC has contracted with specific hospitals to
provide care to plan members. This plan will cover your nonemergency
inpatient stay if you are admitted by your PCP or by a specialist to whom
your PCP has referred you for care. The admission must be prior autho-
rized by HMOC and you must be admitted to a participating hospital. In
most cases, this will be your personal care network hospital. (Your PCP is
responsible for obtaining all necessary prior authorizations from HMOC.)
Your HealthAdvantage Program—The health management program is
designed to manage the member's use of health care services by informing,
educating, and supporting patients during every step in the health care
decision-making process and in the prevention of illness and injury. These
health management services focus on empowering patients-- not on
managing providers.
When you have questions or concerns, customer service wants to
know. HMOC welcomes your comments and suggestions. Listening to you
helps improve customer service. When appropriate, your concerns will be
shared with your PCP. Your customer service representative is know-
ledgeable about the benefits of your plan, covered services and procedures,
and providers. (Please have your ID card handy when calling a customer
service representative.) Your satisfaction is HMOC's goal— so call when
you have a question or complaint.
Address: HMO Colorado
700 Broadway
Denver, Colorado 80273
Hours: 7:30 A.M. to 5:30 P.M. Monday-Friday
Phone number: (800) 334-6557 or (303) 831-0161
For additional information on HMOC (including the Health Advantage
Program,which provides tips on getting and staying healthy,and our on-line
provider directories),visit our world wide web site at:http://www.bcbsco.com
iv - Customer Service:(800)334-6557 or(303)831-0161 BLUMWIM.CRC(Rev.6/97)
BlueAdvantage HMO Plan Table of Contents
■ Table of Contents
1 How to Use This Booklet 1 Outpatient Services 23
Summary of Benefits and Copayments 1 Kidney Dialysis 23
Looking Up Information 1 Maternity and Newborn Care 23
Optional Coverage and Group Variations . . . . 1 Maternity Services 24
Call Within 48 Hours 1 Newborn Care 25
Cross-References 2 Mental Illness Treatments 26
Deadlines 2 Inpatient Mental Illness Treatments 26
Customer Service 2 Outpatient Mental Illness Treatments 27
Office, Outpatient, and Home Care 27
2 How the Plan Works 3 After-Hours Care 28
Identification Card 3 Allergy Care 28
Enrollment/Change Form 3 Infertility Services 29
PCP Selection and Changes 3 Physical Rehabilitation, Inpatient and
Selecting a PCP 3 Outpatient 30
Changing PCPs 3 Prescription Drugs 32
Copayment 5 Retail Pharmacy Program 33
Out-of-Pocket Limit 5 Managed Prescription Mail Service Program 34
PCP Referrals 6 Prescription Drug Exclusions 35
Nonemergency Hospital Admissions 6 Preventive, Routine, and Family Planning Ser-
Emergency Hospital Admissions 6 vices 35
Authorizations to Obtain Care 7 Physical Exams and Early Detection Servic-
Your HealthAdvantage Program 7 es 36
Personal Benefits Management 7 Family Planning 37
Cost-Effective Alternatives 7 Health Education 38
Advance Benefit Information 8 Supplies, Equipment, and Appliances 38
Surgical Services 40
3 Covered Services 9 Oral Surgery 41
Benefit Period 9 Reconstructive Surgery 41
Maximum Benefits 9 Transplants 42
Ambulance Services 9 Therapies: Chemotherapy and Radiation . . . . 47
Chemical Dependency Treatments 10 TMJ Services 47
Medical Detoxification 11
Optional Chemical Dependency Rehabilita- 4 General Exclusions 48
tion 11 Acupuncture 48
Dental-Related Services 13 Artificial Conception 48
Dental Accidents 13 Auto Accident Injuries 48
Hospitalization for Dental Services 13 Before Effective Date 48
Diagnostic Services 14 Biofeedback 48
Emergency and Urgent/After-Hours Care . . . . 15 Blood, Plasma, or Derivatives 48
Emergency Care 15 Chemical Dependency Rehabilitation . . . . 48
Urgent/After-Hours Care Within Chiropractic Services 49
HMOC's Service Area 16 Convalescent Care or Rest Cures 49
Urgent/After-Hours Care Outside Cosmetic Surgery 49
HMOC's Service Area 17 Custodial Care 49
Home Health Care 17 Dental Services 49
Hospice Care 18 Domiciliary Care 49
Hospital/Other Facility Services 20 Duplicate (Double) Coverage 49
Inpatient Medical/Surgical Services 21 Experimental or Investigative Procedures or
Skilled Nursing Facility Admissions 22 Services 50
Physician Services 22 Genetic Counseling and Testing 50
BWH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 V
Table of Contents BlueAdvantage HMO Plan
Government Institution and Facility Services 50 Late Applicants 67
Hair Loss Treatments 50 Adding a Newborn or Adopted Child 68
Hypnosis 50 Removing a Dependent From Coverage 69
Intractable Pain 50 Leave of Absence 69
Late Claims Filing 51 Coverage Termination 69
Learning Deficiencies and Behavioral Prob- When Coverage Ends 69
lems 51 Conversion Coverage 71
Maintenance Therapy 51 Membership Records 72
Medically Unnecessary Services 51 Certificates of Coverage 72
No Legal Payment Obligation 51
Noncovered Providers of Service 51 8 General Provisions 73
Nonmedical Expenses 52 Advance Directives 73
Nonparticipating Provider Services 52 Availability of Provider Services 73
Nutritional Therapy 53 Binding Arbitration 73
Post-Termination Services 53 Changes to the Benefit Booklet 74
Private Duty Nursing Services 53 Delivery of Documents 74
Sex-Change Operations 53 Disclaimer of Liability 74
Taxes 53 Execution of Papers 74
Therapies (Other) 53 Fraudulent Insurance Acts 74
Travel and Lodging Expenses 53 Independent Contractors 74
Vision 54 Pilot Programs 75
War-Related Conditions 54 Release of Information 75
Weight-Loss Programs 54 Statement of ERISA Rights 76
Work-Related Conditions 54 Utilization Review and Quality Management . . 77
5 Coordination of Benefits and Subrogation 55 Glossary 78
Coordination of Benefits (COB) 55
How Benefits Are Paid 56 Index 84
Responsibility for Timely Notice 57
Facility of Payment 57 Member Rights and
Right of Recovery 57 Responsibilities Inside back cover
Third-Party Liability—Subrogation 57
Automobile No-Fault Insurance Provisions 58
6 Claims Payment and Appeals 60
Acceptable Claims 60
Where and When to Send Your Claim 60
Overpayments 61
Complaint Procedures 61
Grievance Procedures 63
Refusal to Follow Recommended Treatment 63
Catastrophic Events 64
Research Fees 64
Sending Notices 64
Member's Legal Expense Obligations 64
7 Enrollment and Termination Information 65
Who Is Eligible 65
Eligible Dependents 65
Medicare-Eligible Members 65
Notification of Eligibility Changes 66
When Coverage Begins 66
Application for Coverage 66
Open Enrollment 67
Switch Enrollment 67
Special Enrollment 67
vi Customer Service: (800)334-6557 or(303)831-0161 BLUH071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 1: How to Use This Booklet
How to Use This Booklet
This benefit booklet describes the benefits available to members of this
plan and benefit limitations and exclusions. It also describes optional
benefits that may or may not have been chosen by your group.
■ Summary of Benefits and Copayments
In addition to this benefit booklet, you should have a group Summary of
Benefits and Copayments that shows specific copayment amounts and
benefit options and/or coverage variables chosen by your group. If you do
not have a summary, please contact an HMOC customer service repre-
sentative. You will receive a new Summary of Benefits and Copayments if
changes are made to your health care plan.
• Looking Up Information
This benefit booklet is designed to make it easy for you to determine your
benefits. For example, if you need to know what surgical services are
covered, turn to Section 3: Covered Services. In Section 3, the "Surgical
Services" subsection defines what a surgical service is. The subsection also
describes your benefits and lists the most important limitations and
exclusions to that particular service. Section 4: General Exclusions lists
other limitations and exclusions which apply to all services, whether or
not these items are listed separately within any subsection of
Section 3: Covered Services.
• Optional Coverage and Group Variations
Some coverage is optional and may or may not have been chosen by
Optional
your group. Other coverage features may vary from group to group (for
--0a1 example, dependent age limits). Coverage that is optional and variable
Check Your coop coverage features are identified with these symbols. When you see these
Summary of Benefits
and Copayments symbols, check your separately issued group Summary of Benefits and
Copayments to determine which optional coverages and variable coverage
features are available to you through your group.
Check your Summary of Benefits and Copayments for the above optional benefit or feature.
Call Your • Call Within 48 Hours
iv PCP Within After receiving emergency care, members are asked to contact their PCP
$5"— 48 Hours within 48 hours. This symbol will appear as a reminder to do so. For all
other services, excluding female reproductive system services, you
must contact your PCP before receiving services.
BLUH0]1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325
Section 1:How to Use This Booklet BlueAdvantage HMO Plan
• Cross-References
In Section 3: Covered Services, readers are given cross-references directing
them to read other sections of the booklet when applicable. You will see
this symbol next to all such references.
Day t ■ Deadlines
You will see this symbol when you must take action within a specified
Ltmtt I amount of time. (For example, members have 30 days in which to make
most enrollment changes, and six months in which to file claims.)
• Customer Service
If you have any questions about your coverage, call HMOC's Customer
Service Department. For your convenience, the local and toll-free customer
service numbers are printed at the bottom of every page in this booklet.
Address: HMO Colorado
700 Broadway
Denver, Colorado 80273
Hours: 7:30 A.M. to 5:30 P.M.
Phone number: (800) 334-6557 or(303) 831-0161
2 , Customer Service:(800)334-6557 or(303)831-0161 BLUH071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 2: How the Plan Works
2 How the Plan Works
• Identification Card
Your identification (ID) card shows that you are a member of a plan
administered by HMOC and provides the information needed when you
require services. Always carry your ID card; any provider may ask to see
it. Have your ID card handy when you call for an appointment and show it
to the receptionist when you sign in for an appointment.
• Enrollment/Change Form
If you change your membership in any way, such as adding or deleting
dependents or changing PCPs, you must fill out and submit an enrollment/
change form to HMOC or to your employer. This form is available from
your employer or can be obtained by calling the HMOC Customer Service
Department.
• PCP Selection and Changes
In order to receive covered services, a member must choose a primary care
provider (PCP). When a member needs any nonemergency medical care,
the member must first contact his/her chosen PCP (except when visiting a
participating OB/gyn physician). The PCP will make necessary arrange-
ments for the member's care.
Selecting a PCP
At the time of enrollment, each member must select a PCP. Family mem-
bers are not required to choose the same PCP. They may select their own
PCPs individually. If a PCP is not chosen, the member will be covered for
emergency care only. Also, a PCP must be chosen for an eligible
newborn before its birth to ensure continuous coverage from
birth.
Please refer to your HMOC provider directory for a list of PCPs. Some
providers are listed as accepting established patients only. However, if you
intend to select a PCP that indicates no patient limitations (and you are
not already an established patient of the PCP being chosen), you should
call HMOC customer service or the provider to confirm that he/she is still
accepting new patients.
Changing PCPs
A member may select a new PCP during an open enrollment period by
requesting the change on an enrollment/change form or by calling HMOC
customer service and notifying them of the change. A new ID card will be
sent to the member confirming the PCP change.
BLUHBJ1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 3
Section 2: How the Plan Works BlueAdvantage HMO Plan
The effective date of all member-requested PCP changes will be the first
day of the month following approval. (To have medical records transferred
from one physician to another, contact the former PCP. You are responsi-
ble for any charges related to transferring medical records.)
Any referrals provided by a member's previous PCP must be reviewed by
the new PCP. New referrals must be issued by the new PCP before
referral care will be covered.
Note: Changing PCPs may result in changing your personal care network
also. If your personal care network changes, the hospital where you receive
care may change and the specialists to whom you may be referred may
change. For information on personal care networks, call HMOC customer
service.
Unless listed as an exception below, only one PCP change may be made
before the next open enrollment.
Change of Residence Exception— Within areas serviced by an HMOC
Day PCP, if a member changes primary residence or place of employment to a
Limit I location that is not convenient to his/her current PCP's office, the member
may choose a new PCP nearer to the new residence or place of employ-
ment. The member must notify HMOC within 31 days of a change in
residence or place of employment by submitting an enrollment/change
form.
In-State Student Care Program—The In-State Student Care Program
enables a member who is a full-time student to select a PCP with an office
convenient to the student's residence during the school year.
If a student's residence and school are both within the HMOC service area
but are not close enough geographically to be serviced by the same per-
sonal care network, the student can choose a "primary" PCP either near
his/her residence or near his/her school. For example, if the student
chooses a "primary" PCP near his/her home, the student must contact
HMOC customer service when at school so that a "secondary" PCP can be
authorized for the student. In this example, the "secondary" PCP can only
provide routine and urgent care services when the student is at school. If
the student needs specialty services, the "primary" PCP must be contacted.
The member must contact an HMOC customer service representative prior
to receiving services from the "secondary" PCP or coverage will be denied.
If the HMOC service area covers the residence or school but not both, the
student must select a PCP within the HMOC service area to provide all
services and referrals. If the student is outside the HMOC service area and
requires urgent or after-hours care, refer to "Emergency and Urgent/After-
Hours Care" in Section 3: Covered Services.
4 " Customer Service:(800)334-6557 or(303)831-0161 BLUR0]1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 2: How the Plan Works
Special Change Requests Changing PCPs at times other than those
stated above may be permitted only on an exception basis. In addition to
requesting such a change on an enrollment/change form, documentation
explaining the reason for the change is also required.
■ Copayment
Copayment— the predetermined fixed-dollar amount a member must pay
to receive a specific service. Copayment may also mean a defined percent-
age of charges a member must pay to receive a specific covered service.
Copayments may be required for covered services. Copayments for specific
services are listed in the Summary of Benefits and Copayments.
Members are responsible for making copayments directly to
HMOC participating providers at the time of service.
The contracts between HMOC and its providers include a "hold harmless"
clause which provides that a BlueAdvantage member cannot be liable to
the provider for moneys owed by HMOC for health care services covered
under the BlueAdvantage HMO Plan Benefit Booklet.
Services from nonparticipating providers are covered only under limited
circumstances; nonemergency services from nonparticipating providers are
not covered unless specifically authorized by HMOC before services are
received. However, when prior authorized or for emergency care (as
defined in Section 3), copayments for covered services received from a
nonparticipating provider are the same as for covered services received
from an HMOC participating provider.
Members are always liable for a provider's full billed charge for
any noncovered services, and for services received without a PCP's
referral.
Out-of-Pocket Limit
Once copayments paid by a member during a calendar year for basic
health services (as defined in federal regulations) reach twice the total
annual premium that is normally charged for a single member under this
plan, no further copayments will be due for the remainder of the year.
® Any copayments over that amount will be refunded to the employee if the
Day refund is requested within 45 days after the end of the calendar year. It
limit is the member's responsibility to determine when the out-of-pocket limit
has been reached; therefore, members should maintain accurate records of
copayment amounts.
Specific information on copayments and annual premium can be obtained
from a customer service representative.
BLUHm1M.CRC(Rev.wsr) Customer Service:(800)334-6557 or(303)831-0161 990325 5
Section 2: How the Plan Works BlueAdvantage HMO Plan
■ PCP Referrals
A member must receive a referral from his/her PCP before receiving
nonemergency care from another provider. The PCP will phone or fax the
referral information to HMOC. HMOC or its designee will mail a confirma-
tion referral form or a denial of the referral request to the member, the
PCP, and the specialist. Retroactive referrals are not covered; all
referrals must be obtained before receiving services.
If a member chooses to see any other provider — even an HMOC
participating provider— without a referral, the member will be re-
sponsible for all charges. (See "Preventive, Routine, and Family Plan-
ning Services" in Section 3: Covered Services for exceptions and the NOTE
below.)
The referral indicates the number of visits approved and the time period in
which the member must receive the care. If only one visit is authorized, a
second visit will not be covered. The member is responsible for all visits in
excess of those authorized and for any care received before or after the
specified time period.
Always review the services the PCP recommends and make sure
they are covered under this benefit booklet. A PCP's referral does
not always mean the service is covered.
Note: A referral is not required to visit a participating OB/gyn physician.
The member must choose an OB/gyn physician within her personal care
network; otherwise, coverage will be denied. To visit an OB/gyn physician
outside of her personal care network, the member must get a referral from
her PCP. If the PCP is not part of a Personal Care Network, OB/GYN care
can be provided by any OB/GYN provider in the HMOC network.
• Nonemergency Hospital Admissions
HMOC has contracted with specific hospitals to provide care to plan
members. The plan will cover an inpatient stay if a member is admitted to
an HMOC participating facility by his/her PCP or by a specialist to whom
the PCP has referred the member. However, all such admissions must be
prior authorized by HMOC before the member is admitted.
■ Emergency Hospital Admissions
For true emergency care (as defined in the Glossary), members may get
Call Your immediate care from any provider (see "provider" as defined in the Glos-
o{ P P Within sary); however, the member's PCP should be contacted within 48 hours of
urs
the emergency to arrange follow-up care, unless the nature of the illness or
injury makes it impossible to do so. For details, see "Emergency and
Urgent/After-Hours Care" in Section 3: Covered Services.
6 , Customer Service:(800)334-6557 or(303)831-0161 9wHW1M.CRC(Hev.6/97)
BlueAdvantage HMO Plan Section 2: How the Plan Works
■ Authorizations to Obtain Care
Prior authorizations from HMOC are required before a member can receive
certain services or services outside of the member's personal care network.
The member's PCP is responsible for obtaining all necessary prior
authorizations. Services requiring prior authorization include, but are not
limited to:
• services performed by a provider outside the member's personal care
network
• elective hospital admissions
• home health care
• hospice care
• inpatient and outpatient surgery
• durable medical equipment
The above list is not complete. Check with your PCP, your specialist, or
an HMOC customer service representative if you want to know whether or
not a particular service will require HMOC's prior authorization. Services
requiring prior authorization are subject to review and change by HMOC.
• Your HealthAdvantage Program
Maintaining quality health requires a 24-hours-a-day proactive approach to
life.As a BlueAdvantage member,you can take part in HealthAdvantage—a
program of health management services designed to reduce health risks,
and provide educational services.
• Personal Benefits Management
Personal benefits management is an individualized case management
program that, as early as possible, identifies patients who may require
long-term hospitalization, have complicated discharge planning needs, or
have the potential for high-cost medical expenses. Cost-effective alterna-
tive care arrangements can then be made. Special care arrangements are
coordinated with the provider, the patient, and the patient's family, and
may include coverage for services that are not ordinarily covered.
■ Cost-Effective Alternatives
HMOC may use prudent business judgment by making limited exceptions
to the terms of this plan. When the cost of equivalent services from differ-
ent providers or suppliers varies significantly, HMOC may take these
variations into consideration in determining covered services. Such deci-
sions will be made only after establishing the cost effectiveness of a
medically necessary service and with the member's agreement. Any such
decisions will not, however, prevent HMOC from administering this plan
in strict accordance with its terms in other situations. HMOC may
discontinue making a limited exception to the plan when it determines
that the service is no longer cost effective. rr
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 7
Section 2: How the Plan Works BlueAdvantage HMO Plan
■ Advance Benefit Information
If a member wants to know whether a service will be covered before re-
ceiving that service or filing a claim for it, HMOC may require a written
request. HMOC may require a written statement from the provider iden-
tifying the circumstances of the case and the specific services that will be
provided. An advance confirmation of covered services does not guaran-
tee coverage if the actual circumstances of the case differ from those origi-
nally described. When submitted, claims will be reviewed according to the
terms of this benefit booklet or any other coverage that applies on the date
of service.
8 Customer Service:(800)334-6557 or(303)831-0161 6wHW1M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
3 Covered Services
This section describes the covered services and the coverage options avail-
able to you. Topics are arranged in alphabetical order. To be considered
covered services, services must be medically necessary or covered
as appropriate preventive, routine, or family planning services and
performed, prescribed, directed, or authorized by the member's
PCP (exceptions are described under "Maternity and Newborn Care" and
"Preventive. Routine, and Family Planning Services"). Services performed
by a nonparticipating provider will be covered only in an emergency as de-
scribed in this section under "Emergency and Urgent/After-Hours Care," or
when approved in advance by HMOC.
All services listed in this section are subject to Section 4: General Exclu-
sions, which explains the services, situations, and related expenses that
are not covered.
Benefit Period
Coverage for some services is limited to a specific dollar amount or number
of days or visits allowed during a calendar year benefit period: January 1
through December 31 of the same year. The initial benefit period is from a
member's effective date of coverage through December 31 of the same year.
(A member's initial benefit period may be less than 12 months.) For excep-
tions to this definition, see "Major Organ Transplants" and "Hospice Care"
in this Section 3.
Maximum Benefits
There is no lifetime maximum benefit under this plan. Certain covered
services described in this section have maximum benefit limits per admis-
sion, per calendar year, or during a lifetime.
■ Ambulance Services
Ambulance— a specially designed and equipped vehicle used only for
transporting the sick and injured. It must have customary safety and
lifesaving equipment such as first-aid supplies and oxygen equipment. The
vehicle must be operated by trained personnel and licensed as an
ambulance.
Within the HMOC service area—When the member cannot be safely
transported by any other means in a nonemergency situation, medically
necessary ambulance transportation by a participating ambulance service
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions, see"PCP Referrals" in Section 2:How the Plan Works).
BLUH0]1M.CRC(Rev.6/97) Customer Service:(B00)334-6557 or(303)831-0161 72 9
990
l
Section 3: Covered Services BlueAdvantage HMO Plan
provider to a participating hospital with appropriate facilities, or from one
participating hospital to another, may be covered.
In an emergency situation, the plan covers participating and nonpartici-
4 Call Your pating ambulance services. See "Emergency and Urgent/After-Hours
o{ Pr 48 PoWithin Care," later in this section, for details on obtaining emergency care.
Outside of the HMOC service area—Ambulance transportation is covered
only in an emergency situation. See "Emergency and Urgent/After-Hours
Care," later in this section, for details on obtaining emergency care.
Air ambulance— Ground ambulance is usually the approved method of
transportation. Air ambulance transportation must meet the definition of
"ambulance," and is covered only when terrain, distance, or the member's
physical condition requires the use of air ambulance services, or for high-
risk maternity and newborn transport to tertiary care facilities.
HMOC will determine, on a case-by-case basis, when transportation by air
ambulance is covered. If HMOC determines that ground ambulance
services could have been used, the amount considered for coverage will be
limited to the cost of ground ambulance services.
The following services are not covered services:
• commercial transport, private aviation, or air taxi services
• transportation services that are not specifically listed as covered, such
as private automobile, public transportation, or wheelchair ambulance
• ambulance services required only because other transportation was
not available or for the patient's convenience
• Chemical Dependency Treatments
Chemical dependency —includes both alcoholism and substance abuse.
Alcoholism and substance abuse—conditions defined by patterns of usage
that continue despite occupational, social, marital, or physical problems
that are related to abnormal use of alcohol or other substances. These
conditions may also be defined by significant risk of severe withdrawal
symptoms if the use of alcohol or other substance is discontinued.
Detoxification-- treatment for withdrawal from the physiological effects of
alcohol or drugs.
Inpatient care —care provided by a physician, hospital, or alcoholism
treatment center for services provided while a member is confined as an
inpatient in a hospital or alcohol/substance abuse treatment center.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals° in Section 2:How the Plan Works).
10 Customer Service:(B00)334-6557 or(303)831-0161 6wHm1M.CRC(Rev.6197)
BlueAdvantage HMO Plan Section 3: Covered Services
Outpatient care—care provided by a physician, hospital, alcoholism
treatment center, or other provider in the provider's office or in a facility
when the member is not confined as an inpatient.
Medical Detoxification
Contact the HMOC behavioral health administrator for
preauthorization and selection of a provider before care is re-
ceived. Call an HMOC Customer Service representative for the
phone number of the administrator.
This plan will cover services only for medically necessary inpatient room
expenses and ancillary services related to the medical detoxification
(usually limited to three to five days) from the effects of alcoholism or
substance abuse, and received at a participating facility (see definitions
under "Hospital/Other Facility Services").
The following services are not covered services:
• services provided or billed by a school, halfway house, or residential
treatment center, or members of their staffs
• the cost of any damages to a treatment facility caused by the member
• long-term care (when the member requires long-term care or other
therapeutic resources, HMOC will refer the member to the appropriate
community resource, but will not be responsible for the cost thereof)
• treatment of chronic alcoholism, drug abuse, or other chronic sub-
stance abuse, including rehabilitation (for possible benefits, see "Op-
tional Chemical Dependency Rehabilitation," below)
Optional Chemical Dependency Rehabilitation
Day treatment -- care provided after release as an inpatient or as an
Optional
alternative to inpatient care. Care consists of group and/or individual
therapy, usually no less than three and no more than twelve hours per
Check Your Group day, during which meals are provided. Day treatment is considered to be
Summary at Benefits
and Copa..oems inpatient care, and is subject to the same copayments as inpatient care.
Aftercare— a structured program of reinforcement following the initial
treatment period. This is an outpatient program and is an integral part of
the total episode of care. Aftercare programs vary and may last up to six
months. The cost may be included in the total billed charge for the treat-
ment program or billed separately. If billed separately, the applicable
outpatient copayment will apply.
You must obtain a rem ral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"RCP l'eferrals°in Section 2:How the Plan Works).
6wHo)1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 11
Section 3: Covered Services BlueAdvantage HMO Plan
All chemical dependency services must be prior authorized by the
member's PCP, HMOC, and HMOC's behavioral health administra-
tor. If the member does not complete the entire treatment pro-
gram, the member will be responsible for paying billed charges for
all services related to the chemical dependency episode, regardless
of when the member receives services. See your Summary of Benefits
and Copayments for copayment information.
Inpatient care—Inpatient care for each member is limited to a total of 45
full inpatient days or 90 partial inpatient days per admission for
room expenses and ancillary services. The 45 full inpatient or 90 par-
tial inpatient days will be reduced by any full or partial days used
for inpatient mental illness. Physician visits received during a covered
admission are also covered.
One inpatient day is defined as admission to a facility for a minimum of 24
hours of treatment. Day treatment is covered only when the member
receives care through a day treatment program. Two day treatments equal
one full inpatient day. One day treatment is usually no less than three and
no more than 12 hours of therapy per day.
Family counseling related to the member's inpatient chemical dependency
treatment is available to the family of any member, when directed by the
provider (no additional copayments apply).
Outpatient care— Outpatient care, including chemical dependency testing
and monitoring, is subject to a maximum of 20 visits per calendar year.
See your Summary of Benefits and Copayments for copayment and pay-
ment limit information.
The following inpatient and outpatient services are not covered services:
• outpatient diagnostic services, except testing and monitoring (for
covered diagnostic services, see "Diagnostic Services" in this Section 3)
• services related to medical detoxification (those services are covered
under "Medical Detoxification," above)
• discharge day expenses
• court-ordered treatment that would otherwise not be covered
• services provided or billed by a school, halfway house, or residential
treatment center, or members of their staffs
• the cost of any damages to a treatment facility caused by the member
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals" in Section 2:How the Plan Wmks).
12 Customer Service: (800)334-6557 or(303)831-0161 HLUHm1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• long-term care associated with chemical dependency (when the mem-
ber requires long-term care or other therapeutic resources, HMOC will
refer the member to the appropriate community resource, but will not
be responsible for the cost thereof)
• inpatient and outpatient charges associated with any episode of sub-
stance abuse for which the member did not complete the prescribed
continuum of care
Check your Summary of Benefits and Copeyments for the above optional benefit or feature.
• Dental-Related Services
Accidental injury—a bodily condition that is not the result of illness but is
caused solely by external, traumatic, and unforeseen means. Accidental
injury does not include disease or infection. Dental injury caused by chew-
ing, biting, or malocclusion is not considered an accidental injury.
Dental services— services performed for treatment of conditions related to
the teeth or structures supporting the teeth.
Sound natural teeth — teeth that are whole, without impairment, without
periodontal disease or other conditions, and not in need of treatment for
any reason other than the accidental injury.
s» For services related to oral surgery, see "Surgical Services: Oral Surgery"in this
section.
For services related to the treatment of the temporomandibular joint, see "TMJ
Services"in this section.
Dental Accidents
Coverage is available for the prompt repair of an accidental injury to sound
natural teeth or related body tissue. To be covered, dental services related
to such an injury must be received within 72 hours of the accident.
Hospitalization for Dental Services
Coverage is available for inpatient hospital room expenses and ancillary
services associated with dental services only if the patient has a nonden-
tal, physical condition, such as hemophilia or heart disease, that makes
hospitalization medically necessary. This plan does not cover any costs
associated with the dental service itself(e.g., anesthesia. operating and
recovery room charges, surgeon and anesthesiologist fees).
You must obtain a referral from your PCP to receive benefits for nonemergency care°not directly
provided by your PCP(for exceptions,see"PCP Referrals"in Section 2:How the Plan Works).
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 13
Section 3: Covered Services BlueAdvantage HMO Plan
• Diagnostic Services
Diagnostic services —procedures or services ordered by a provider to de-
termine a definite condition or disease, including:
• Diagnostic medical procedures —procedures that require the use of
technical equipment for evaluation of body systems; examples: electro-
cardiograms (EKGs) and electroencephalograms (EEGs).
• Laboratory and pathology services — testing procedures required for
the diagnosis or treatment of a condition. Generally, these services
involve the analysis of a specimen of tissue or other material removed
from the body.
• X-ray and radiology services -- services including the use of radiology,
nuclear medicine, and ultrasound equipment to obtain a visual image
of internal body organs and structures, and the interpretation of these
images.
Sin For coverage information on invasive diagnostic surgical procedures such as
biopsies and endoscopies, see "Surgical Services"in this section.
For services related to the treatment of an accidental injury or other emergency,
also see "Emergency and Urgent/After-Hours Care"in this section.
Coverage for diagnostic services received during a covered inpatient admission is
described under "Hospital/Other Facility Services"in this section.
For allergy and infertility testing benefits, see "Office, Outpatient, and Home Care"
in this section.
For routine Pap tests, routine prostate exams, routine physicals, or preventive
care, see "Preventive, Routine, and Family Planning Services"in this section.
Coverage is available for diagnostic services, including preadmission
testing, received in the emergency room or outpatient department of a
hospital or other facility, an independent lab or x-ray clinic, or in a provid-
er's office.
To be a covered service, tests must be required to detect or diagnose a
known or suspected illness, monitor a covered pregnancy, or diagnose an
accidental injury (with the exception of screening mammograms and
prostate-specific antigen tests). All diagnostic tests must be ordered by the
member's PCP or referral provider in order to be considered a covered
service.
Covered services include:
• radiology, ultrasound, and nuclear medicine tests
• laboratory and pathology tests
You must obtain a referral from your PCP to receive benefits for nonemef care not directly
provided by your PCP(for exceptions,see "PCP Referrals'. in Section 2:How elm Moo Works),
14 Customer Service:(800)334-6557 or(303)831-0161 BLUH0Z1M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• EKG, EEG, and other electronic diagnostic medical procedures
• audiometric (hearing) and vision tests required for the diagnosis and/or
treatment of an accidental injury or an illness
• mammography screenings based on medically accepted standards as
follows: at least one baseline for women between ages 35-39 and
annually for women 40 and over (or younger if risk factors are present
for breast cancer)
• prostate-specific antigen (PSA) blood test, based on the following
guidelines:
- at least one screening per year for men age 50 and older
- at least one screening per year for men age 40-50, if risk factors
for prostate cancer are present
Diagnostic services related to a noncovered service are not covered.
• Emergency and Urgent/After-Hours Care
Emergency care — means the sudden, and at the time, unexpected onset of
a health condition that requires immediate medical attention, where
failure to provide medical attention would result in serious impairment to
bodily functions or serious dysfunction of a bodily organ or part, or would
place the persons health in serious jeopardy.
Urgent care— situations that are not life threatening but require prompt
medical attention to prevent a serious deterioration in a member's health
(e.g., high fever, cuts requiring stitches).
After-hours care—office services requested after a provider's normal or
published office hours or on weekends and holidays.
Temporarily absent —circumstances such as a vacation or trip in which
the member has left the HMOC service area but intends to return within a
reasonable period of time (no longer than 90 days).
Emergency Care
Emergency care, like all other care, needs to be coordinated by the mem-
ber's PCP whenever possible, even if the member is outside the HMOC
service area. The PCP may direct a member to receive necessary medical
services at an emergency room or urgent care center.
If emergency care results in an immediate admission to the hospital, the
member will be responsible only for the inpatient hospital copayment.
(There will be no separate copayment requirement for emergency room or
ambulance services if the member is directly admitted as an inpatient.)
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions, see"PCP Referrals"in Section 2:How the Plan Works).
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990 325 15
Section 3: Covered Services BlueAdvantage HMO Plan
Emergency care within HMOC's service area:
1. If cardiopulmonary resuscitation (CPR) is necessary or if there is an
immediate threat to life or limb, call 911.
Call Your 2. If, because of the severity of the medical problem, you are unable to
{ PCP Within reach your personal care network hospital, go to the nearest medi-
48 Hours cal facility. Unless your condition makes it impossible to do so, you
should notify your PCP within 48 hours of receiving the care. Use of
an emergency center for nonemergency services is not covered.
3. If you do not call 911, call your PCP's office for instructions.
Emergency care outside HMOC's service area:
1. If cardiopulmonary resuscitation (CPR) is necessary or if there is an
immediate threat to life or limb, call 911.
•
or" "lb Call Your 2. If you do not call 911, go to the nearest medical facility. Unless
PCP Within your condition makes it impossible to do so, you should notify your
Er 48 Hours PCP within 48 hours of receiving the care to arrange follow-up
services. Use of an emergency center for nonemergency services is not
covered.
When you receive the itemized bill from the hospital, send it to HMOC.
HMOC requires proof of payment to reimburse you directly. Otherwise,
HMOC will reimburse the provider. You will be responsible for the emer-
gency care copayment only.
The following services are not covered services:
• follow-up care as a result of an emergency, if the member could have
returned to his/her service area to receive care without medically
harmful results
• services received outside the member's service area if the member
could have foreseen the need for this care before leaving his/her service
area
Urgent/After-Hours Care Within HMOC's Service Area
Urgent and after-hours care received within the HMOC service area is
covered only when it is provided by the member's PCP or by a provider or
urgent care center when the PCP has referred the member.
HMOC will not cover urgent/after-hours care provided more than 50 miles
from a member's service area if the need for care could have been foreseen
before the member left this area, or if the member could have traveled to
the PCP's office without medically harmful results.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals" in Section 2:How the Plan Works).
16 - Customer Service: (800)334-6557 or(303)831-0161 NLUHo71M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
Urgent/After-Hours Care Outside HMOC's Service Area
When a member is temporarily absent from the HMOC service area,
urgent/after-hours medical care is covered only if the member uses the
services of an HMO-USA facility or a facility approved by his/her PCP.
1. To locate the nearest HMO-USA facility, call 1-800-4-HMO-USA
(1-800-446-6872).
2. The HMO-USA operator will tell you if there is a participating HMO in
your area, its location, service hours, and the local HMO coordinator's
phone number. You then call the local HMO coordinator to find out
where to go to obtain care.
3. If there is not an HMO-USA facility nearby, call your PCP to be
referred to a facility. If you do not receive a referral from your PCP
before the care is given, you are responsible for the entire cost of the
service.
HMOC will not cover urgent/after-hours care provided outside the HMOC
service area if the need for care could have been foreseen before the
member left this area, or if the member could have traveled to the PCP's
office without medically harmful results.
■ Home Health Care
Home health services —the following services provided under a plan of
care by a licensed home health agency to a member in his/her place of
residence: skilled nursing services, physical therapy, occupational therapy,
and speech therapy.
Skilled nursing care—care that can be provided only by someone with at
least the qualifications of a licensed practical nurse (L.P.N.) or registered
nurse (R.N.).
a.. For coverage for medical equipment or supplies not covered as home health care
services, see "Supplies, Equipment, and Appliances"in this section.
Home health services are covered if the services are provided under the
direction of the patient's PCP and nursing management is through a par-
ticipating home health agency. Registered nurses must coordinate the
services on behalf of the home health agency and the patient's PCP.
The following home health care services are covered when provided during
a covered visit in the patient's home:
• skilled nursing care provided on an intermittent basis by a registered
nurse or licensed practical nurse
You must obtain s referral from your PCP to receive benefits for nonemergency care not directly
provided by youtrPCP(for exceptions,see "PCP Referrals"in Section 2:How the Phan Works).
BLUH07IM.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 17
Section 3: Covered Services BlueAdvantage HMO Plan
• physical, occupational, and respiratory (inhalation) therapy, by li-
censed or certified physical, occupational, and respiratory therapists,
and speech therapy provided by an American Speech and Hearing
Association certified therapist
• administration of oxygen
• intravenous medications and other prescription drugs ordinarily not
available through a retail pharmacy when prior authorized by HMOC
(if drugs are not provided by the home health care agency, see "Pre-
scription Drugs" in this section)
• physician home visits
The following services are not covered services:
• custodial care (see "Custodial Care" in Section 4: General Exclusions)
• care that is provided by a nurse who ordinarily resides in the patient's
home or is a member of the patient's immediate family
• food or meal services other than dietary counseling
• care related to noncovered services or surgical procedures
• personal comfort or convenience items or services, including home-
maker services
• Hospice Care
Hospice care— an alternative way of caring for terminally ill individuals
in the home or institutional setting, which stresses palliative care as
opposed to curative or restorative care. Hospice care focuses on the pa-
tient/family as the unit of care and addresses physical, social, psycho-
logical, and spiritual needs of the patient. Supportive services are offered
to the family before the death of the patient.
Benefit period—a period of time during which hospice services are cov-
ered. A benefit period is defined as beginning on the date the PCP or
attending physician certifies that the member is terminally ill and has a
life expectancy of six months or less, and ending six months after it began
or on the death of the patient, if sooner.
Palliative care —care that controls pain and relieves symptoms but does
not cure.
Skilled nursing care—care that consists of services that can be provided
only by someone with at least the qualifications of a licensed practical
nurse (L.P.N.) or registered nurse (R.N.).
Terminally ill patient —a patient with a life expectancy of six months or
less as certified in writing by the attending physician.
You must obtain.a referral from your PCP to receive benefits for nonemergency care not directly
provided by your',PCP(for exceptions,see"PCP Referrals" in Section 2:How the Plan Works).
18 „ Customer Service:(800)334-6557 or(303)831-0161 BLUH071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
irk_ For coverage of medical equipment not covered as hospice care, see "Supplies,
Equipment, and Appliances" in this section.
Inpatient and home hospice services for a terminally ill member during a
hospice benefit period are covered when provided by a hospice program
prior authorized by HMOC.
If the patient requires an extension of the hospice benefit period, the
hospice agency must provide a new treatment plan and the attending
physician must recertify the patient's condition to HMOC. No more than
one additional hospice benefit period will be approved.
Coverage for hospice care is available for the following services during a
covered home visit:
• physician visits by hospice physicians
• skilled nursing services of a registered nurse or a licensed practical
nurse
• medical supplies and equipment used during a covered visit (if supplies
are not provided by the hospice agency, see "Supplies, Equipment, and
Appliances" in this section)
• drugs and medications for the terminally ill patient (if drugs are not
provided by the hospice agency, see "Prescription Drugs" in this sec-
tion)
• respite care for a period not to exceed five continuous days for every 60
days of hospice care — no more than two respite care stays are avail-
able during a hospice benefit period (respite care provides a brief break
from total caregiving by the family)
• services of a licensed therapist for physical, occupational, respiratory,
and speech therapy
• medical social services provided by a qualified individual with a degree in
social work, psychology, or counseling, or the documented equivalent in
a combination of education, training, and experience (such services
must be provided at the recommendation of a physician for purposes of
assisting the member or family in dealing with a specified medical
condition)
• services of a home health aide under the supervision of a registered
nurse and in conjunction with skilled nursing care
• nutritional guidance and support, such as intravenous feeding and
hyperalimentation
Benefits are also available for inpatient hospice accommodations and
services.
You must obtain a referral from your PCP°to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Reformat in Sechat 2:How the Plan Works).
BLUH0]1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 9410325 19
Section 3: Covered Services BlueAdvantage HMO Plan
The following services are not covered services:
• food services and meals, other than dietary counseling
• services or supplies for personal comfort or convenience, including
homemaker and housekeeping services, except in crisis periods or in
association with respite care
• private duty nursing
• pastoral and spiritual counseling
• bereavement counseling
• supportive services provided to the family of a terminally ill patient
when the patient is not a member of this plan
■ Hospital/Other Facility Services
Room expenses—expenses that include the cost of the patient's room,
general nursing services, and meal services for the patient.
Special care unit— a designated unit that has concentrated facilities,
equipment, and supportive services to provide an intensive level of care for
critically ill patients. Examples of special care units are intensive care unit
(ICU), cardiac care unit (CCU), subintensive care unit, and isolation room.
Ancillary services —services and supplies (in addition to room expenses)
that a facility regularly makes available for the treatment of a patient's
condition. Such services include, but are not limited to:
• use of operating room, recovery room, emergency room, treatment
rooms, and related equipment
• intensive and coronary care units
• drugs and medicines
• medical supplies (including dressings and supplies, sterile trays, casts,
and splints used in lieu of a cast)
• durable medical equipment owned by the facility and used during a
covered admission
• diagnostic and therapeutic services
• blood processing and transportation costs, blood handling charges, and
administration
Skilled nursing facility— a state-licensed facility providing inpatient
nursing care at the level that requires a registered nurse to deliver or
supervise the delivery of care for a continuous 24-hour period.
You must obtain,a referral!from your PCP to naive benefits for nortentergency.care not directly
provided by your PCP{forsucceptions,see"PCP Referrals"in Section t-How*.Plan Works).
20 Customer Service:(800)334-6557 or(303)831-0161 9wHW,M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
Consultation — a service provided by another physician at the request of
the attending physician (the physician in charge of a specific case) or the
PCP. The consulting physician often has specialized skills that are helpful
in diagnosing or treating the patient's illness or injury.
General condition — a disease, illness, or other condition not related to
nervous or mental illness, alcoholism, or substance abuse.
Medical care— nonsurgical health care services provided for the preven-
tion, diagnosis, and treatment of illness, injury, and other general
conditions.
e« For coverage of services related to alcoholism, substance abuse, or mental
illness, see "Chemical Dependency Treatments"or "Mental Illness Treatments"in
this section.
If services are related to a dental procedure, also see "Dental-Related Services"
for additional information and limitations.
For emergency services, also see "Emergency and Urgent/After-Hours Care"in
this section.
For inpatient treatments related to hospice care, see "Hospice Care"in this
section.
This section also applies to maternity-related services received inpatient, outpa-
tient, or in a freestanding facility such as a birthing center. See "Maternity and
Newborn Care"in this section for more information.
For services related to occupational, physical, or speech therapy, see "Physical
Rehabilitation, Inpatient and Outpatient"in this section.
See other subheadings in this section for limitations and exclusions that apply to
the specific type of service required, such as "Surgical Services."
For coverage of supplies and equipment not specifically covered under"Hospi-
tal/Other Facility Services,"see "Supplies, Equipment, and Appliances,"in this
section.
Inpatient Medical/Surgical Services
When a member receives acute inpatient surgical or medical care in a
hospital for a general condition, covered services received during the
admission include:
• nonprivate or special care unit room expenses
• other ancillary services provided by the facility
Nonparticipating facility services are covered for emergency care only or
when prior authorized by HMOC. See "Emergency and Urgent/After-Hours
Care" in this Section 3.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see °PCP Referrals° in Section 2 How the Plan Works).
BLUHa71M.CRC(Rev.6191) Customer Service:(800)334-6557 or(303)831-0161 990325 21
Section 3: Covered Services BlueAdvantage HMO Plan
The following services are not covered services:
• private room expenses, unless the patient's medical condition requires
isolation to protect him/herself or other patients from exposure to
dangerous bacteria or diseases (conditions that require isolation
include, but are not limited to, severe burns and conditions that re-
quire isolation according to public health laws)
• admissions related to noncovered services or procedures (see "Dental-
Related Services," in this section, for exception)
• discharge day expenses
• admissions primarily for physical rehabilitation (see "Physical Reha-
bilitation, Inpatient and Outpatient" for covered services)
• extended care facility admissions or admissions to similar institutions
Skilled Nursing Facility Admissions—When prior authorized by HMOC,
coverage is available to each member for up to 30 days per calendar year
in a participating skilled nursing facility. Covered services include semipri-
vate room expenses and ancillary services.
Physician Services—With the exception of dental-related services (see
"Dental-Related Services" in this section), the following services when
required for a general condition and received on a covered inpatient hos-
pital day are also considered covered services (and are not subject to an
additional copayment):
• visits that are not related to hospice care (see "Hospice Care" in this
section for benefits) and that are for a condition requiring only medi-
cal care
• consultations (including second opinions) and, if surgery is performed,
inpatient visits by a provider who is not the surgeon and who provides
medical care not related to the surgery (for benefits for the surgeon's
services, see "Surgical Services" in this section)
• medical care requiring two or more physicians at the same time be-
cause of multiple illnesses
• medical care for an eligible newborn (also see "Maternity and Newborn
Care" in this section)
The following services are not covered services:
• consultations or visits related to any noncovered services
• inpatient physician services received on a day for which facility
charges were denied
• telephone consultations
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided,by your PCP(for exceptions,see "PCP Referrals" in Section 2:'How the Plan Works).
22 Customer Service:(800)334-6557 or(303)831-0161 BLUHOl1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
Outpatient Services
Outpatient services—charges for services received in the outpatient
department of a hospital, emergency room, birthing center, ambulatory
surgical facility, freestanding dialysis facility, or other covered outpatient
treatment facility.
Coverage for outpatient ancillary services and related physician or other
professional provider services for the treatment of illness, accidental
injury, or a covered pregnancy depends on the type of service received (for
example, see "Diagnostic Services" in this section) or on special circum-
stances (see "Emergency and Urgent/After-Hours Care" in this section).
■ Kidney Dialysis
Dialysis— the treatment of an acute or chronic kidney ailment during
which impurities are removed from the body with dialysis equipment.
s.. When received during a covered admission and billed as part of the facility ser-
vice, dialysis will be paid in the same manner as the room expenses and other
ancillary services (see "Hospital/Other Facility Services"in this section).
All of the following therapeutic services are covered when performed by a
participating dialysis provider or, when preauthorized by HMOC, in the
patient's home:
• renal dialysis
• hemodialysis
• peritoneal dialysis
• the cost of equipment rentals and supplies for use in home dialysis
• Maternity and Newborn Care
Maternity services services and supplies required by a member for the
diagnosis and care of a pregnancy, including complications of pregnancy,
and for routine delivery services (including scheduled C-sections).
Complications of pregnancy include, but are not limited to:
• placenta abruptio and placenta previa; premature rupture of mem-
branes; threatened abortion or threatened miscarriage when the
pregnancy does not terminate; spontaneous termination of pregnancy
• acute exacerbations of heart condition and/or diabetes; nephritis or
pyelitis of, or aggravated by, pregnancy (inflammation of the kidney
and ureter occurring in pregnancy)
• hyperemesis gravidarum (excessive vomiting related to pregnancy)
You must obtain°a referral from your PCP to receive benefits fornonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals"in Section 2:How the Plan Works).
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 23
Section 3: Covered Services BlueAdvantage HMO Plan
• severe toxemia, with or without seizures
• ectopic pregnancy
Air* Please refer to Section 7: Enrollment and Termination Information under"Adding a
Newborn or Adopted Child"for details on newborn coverage.
For coverage of infertility treatment, see "Office, Outpatient, and Home Care"in
this section.
See other subheadings in this section for limitations that apply to services received
during a pregnancy or by a newborn, such as "Diagnostic Services,"or "Hospital/
Other Facility Services."
Maternity Services
Once a member's pregnancy is confirmed by her PCP or participating
OB/gyn physician, the member may choose either her PCP or a partici-
pating OB/gyn physician to provide maternity care. A referral is not
required if the member chooses an HMOC participating OB/gyn physician
to provide maternity services.
Under Family or Parent/Child coverage, an unmarried, dependent daugh-
ter also has coverage for maternity services. A newborn child of an unmar-
ried dependent son or daughter does not qualify as a dependent under this
plan.
Coverage for maternity services and complications of pregnancy include:
• hospital charges for semiprivate room expenses and ancillary services,
including the use of labor, delivery, or recovery rooms
• prenatal medical care
• maternity-related diagnostic tests
• routine or complicated delivery (including postnatal medical care),
including cesarean section
• necessary anesthesia services by a provider qualified to perform such
services
• services of a physician who actively assists the operating surgeon in
performing a covered delivery or other maternity-related procedure
when the procedure requires an assistant
• spontaneous termination of pregnancy prior to full term
• elective or therapeutic abortions if requested prior to the 12th week of
gestation and performed prior to the end of the first trimester. Elective
termination in the absence of other complicating medical problems
must be performed in an outpatient setting when authorized by the
member's PCP or as a self referral to a participating OB/gyn physician.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals" in Section 2:How the Plan Works).
24 _ Customer Service:(800)334-6557 or(303)831-0161 BLUH071 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
If maternity coverage changes during a pregnancy, the member receives
the coverage in effect on the day the service is received. Maternity services
are covered as any other medical/surgical or general condition. For
example, under this plan, the member is responsible for a hospital copay-
ment for facility services and for office visit copayments for prenatal and
postnatal maternity care.
Note: The Babytrac preconception and prenatal health education program
is designed to help members have a healthy pregnancy. For details, see
"Babytrac" in Section 2: How the Plan Works or call an HMOC customer
service representative.
The following services are not covered services:
• care for deliveries outside of the service area within five weeks of the
anticipated delivery date
• adoption or surrogate expenses
Newborn Care
Routine newborn care includes:
• routine hospital nursery services for a newborn
• routine physician care of a newborn in the hospital after delivery
• pediatrician standby care at a cesarean section
• services related to circumcision of a male newborn
This plan provides coverage for a dependent child's initial routine newborn
Day lr care. Copayment amounts are based on the type of service received.
Limit I However, no additional hospital copayment will be required if the newborn
is discharged on the same day as the mother. The employee must enroll
his/her newborn child for coverage within 31 days of the child's birth.
Nonroutine Newborn Care—An eligible newborn is also covered for
nonroutine medical or surgical services. Copayment amounts will be based
on the type of service received. For example, if surgery is required, see
"Surgical Services" in this section for additional information.
Also, an additional hospital copayment will apply to the newborn's
covered facility charges if the newborn remains in the hospital
longer than his/her mother.
For services related to cleft palate treatment for a newborn, see "Surgical
s«
Services"in this section.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Referrals" in Section 2:How the Plan Works).
6wH071M.CRC(Rev.6197) Customer Service:(800)334-6557 or(303)831-0161 990325 25
Section 3: Covered Services BlueAdvantage HMO Plan
• Mental Illness Treatments
Mental illness— a clinically significant behavioral or psychological
syndrome or pattern that is associated with distress or disability, or with a
significantly increased risk of suffering death, pain, disability, or an
important loss of freedom, and for which improvement can be expected
with treatment. HMOC defines mental illness based on the Diagnostic and
Statistical Manual of Mental Disorders (Fourth edition DSM III)published
by the American Psychiatric Association.
However, mental illness does not include certain conditions, such as:
• alcohol abuse
• chemical dependency
• sexual dysfunction
s.. For the treatment of alcoholism and/or substance abuse, see "Chemical
Dependency Treatments"in this section.
Inpatient Mental Illness Treatments
Contact the HMOC behavioral health administrator for
preauthorization and selection of a provider before care is re-
ceived. Call an HMOC Customer Service representative for the
phone number of the administrator.
Inpatient care care provided by a physician, hospital, or treatment
facility for services provided while a member is confined as an inpatient in
a hospital or other treatment facility. Partial hospitalization is also
considered to be inpatient care. Partial hospitalization is no less than
three and no more than twelve hours of continuous psychiatric care in a
hospital. Two partial hospitalization days equal one full inpatient day.
Benefits for HMOC-authorized inpatient care are limited for each member
to a total of 45 full days or 90 partial days each calendar year for room
expenses and ancillary services received in a facility (see definitions under
"Hospital/Other Facility Services") and include physician visits received
during a covered admission day.
The following services are not covered services:
• services provided or billed by a school, halfway house, or residential
treatment center or members of their staff
• court- or police-ordered treatment that would not otherwise be covered
• psychoanalysis or psychotherapy that a member may use as credit
toward earning a degree or furthering his/her education
• the cost of any damages to a treatment facility caused by the member
You must obtain a reterrai from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions, see "PCP Reformism in Seaton 2:How the Plan Works).
26 " Customer Service:(800)334-6557 or(303)831-0161 BLUMm1M.CRC(Re.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
If a member is admitted for an inpatient medical/surgicaI. admission and
subsequently needs to be transferred to an inpatient psychiatric unit, or
vice versa, each portion of the inpatient confinement will be considered a
separate admission, subject to its own copayment level (see your group's
Summary of Benefits and Copayments).
Outpatient Mental Illness Treatments
Outpatient care—care provided by a physician, hospital. or other provider
in the provider's office, the outpatient department of a hospital, other
facility, or the patient's home.
Coverage is limited per calendar year to 20 visits or $1,000, whichever is
greater, for the outpatient care, evaluation, diagnosis, and/or treatment of
mental illness. Services rendered by psychiatrists, psychologists, licensed
family therapists, and social workers are included in the 20-visit or $1,000
maximum.
The following services are not covered services:
• services provided or billed by a school, halfway house, or residential
treatment center or members of their staff
• court- or police-ordered treatment that would not otherwise be covered
• biofeedback
• psychoanalysis or psychotherapy that a member may use as credit
toward earning a degree or furthering his/her education
• hypnotherapy
• marital counseling
■ Office, Outpatient, and Home Care
General condition a disease, illness, or other condition not related to
nervous or mental illness, alcoholism, or substance abuse.
Medical care—nonsurgical services provided for the prevention, diagno-
sis, and treatment of illness, injury, and other general conditions.
After-hours care—office services requested after normal or published
office hours or services requested on weekends and holidays.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your-PCP(four mentions, see"PCP Referrals" in Section 2:How th Plan Work.
BLUHW1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 27
Section 3: Covered Services BlueAdvantage HMO Plan
IIrkeN• See other subheadings in this section for limitations that apply to special
circumstances or to other services received during a provider visit, such as
"Emergency and UrgentAfter-Hours Care," "Diagnostic Services,"or "Supplies,
Equipment, and Appliances."
For visits related to home health or hospice care, see "Home Health Care"or
"Hospice Care"in this section.
For coverage of inpatient physician visits, see "Hospital/Other Facility Services"in
this section.
For the treatment of alcoholism, substance abuse, or mental illness, see
"Chemical Dependency Treatments"or "Mental Illness Treatments"in this section.
For routine physicals, immunizations, other preventive services, and family
planning services, see "Preventive, Routine, and Family Planning Services"in this
section.
For services related to a dental accident, oral surgery, or TMJ disorders, see
"Dental-Related Services," "Surgical Services: Oral Surgery,"or "TMJ Services"in
this section.
Coverage is available for medical care for general conditions if necessary
for the treatment of an illness, disease, or injury. Covered services include:
• office, urgent care center, home, and hospital emergency room visits
and examinations —when not related to hospice care or payable as
part of a surgical procedure (see "Hospice Care" and "Surgical Ser-
vices" in this section)
• consultations and second surgical opinions
• therapeutic injections administered in a provider's office or in a facility
• medically necessary hearing examinations (nonroutine, nonscreening)
After-Hours Care
To receive office services after hours, call your PCP (or the physician who
is on-call for the PCP) and request instructions. See "Emergency and
Urgent/After-Hours Care" for details.
Allergy Care
Coverage is available for the following allergy care services:
• direct skin (percutaneous and intradermal) and patch allergy tests and
RAST (radioallergosorbent testing)
• allergy injections administered in a provider's office or in a facility
• charges for allergy serum
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your Pep tier exceptions, see"PCP Referrals" in Section 2:How the Plan Works).
28 , , Customer Service:(B00)334-6557 or(303)831-0161 BLUHm,M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
Infertility Services
Infertility—the inability to produce children after one year of sexual
activity not protected by contraception; causes of infertility can be male- or
female-specific.
Covered infertility services are:
• diagnosis of infertility causes, limited to:
- one laparoscopy
- one hysteroscopy
- one hysterosalpingogram
- one endometrial biopsy
- appropriate evaluation of hormonal status
- a maximum of three semen analyses
• treatment of infertility, limited to:
- surgical treatment (e.g., opening an obstructed fallopian tube,
epididymis, or vas deferens), when the obstruction is not the result
of a surgical sterilization (coverage for surgical sterilization is
described under "Preventive, Routine, and Family Planning
Services")
- replacement of deficient naturally occurring hormones, if there is
documented evidence of a deficiency of the hormone being replaced
(hormonal manipulation and excess hormones to increase
production of mature ova for fertilization are not covered)
Female members are not required to obtain a PCP-referral for the services
of a participating OB/gyn physician. For details, see "Maternity and
Newborn Care" and "Preventive, Routine, and Family Planning Services."
Coverage is not available for any service related to infertility that is not
listed as a covered service above, including, but not limited to:
• artificial insemination, test tube fertilization, drugs for induced
ovulation, or other artificial methods of conception
• in-vitro fertilization with husband or other donor sperm and any
related services
• in-vivo fertilization with husband or other donor sperm and any
related services
• Gamete Intrafallopian Transfer (GIFT) or Zygote Intrafallopian
Transfer (ZIFT) and any related services
• cost of donor sperm
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions, see "PCP Referrals" in Section 2:How me Plan Works).
BLUHWIM.CRC(Rev 6/91) Customer Service:(800)334-6557 or(303)831-0161 "n0i325 29
Section 3: Covered Services BlueAdvantage HMO Plan
• Physical Rehabilitation, Inpatient and
Outpatient
Physical rehabilitation —a broad term used to describe occupational,
physical, and speech therapy techniques. Physical rehabilitation does not
include chemical dependency rehabilitation.
Occupational therapy— the use of rehabilitative techniques to improve a
patient's functional ability to live independently.
Physical therapy— the use of physical agents to treat disability resulting
from disease or injury. Physical agents include heat, cold, electrical
currents, ultrasound, ultraviolet radiation, and therapeutic exercise.
Speech therapy— services used for the diagnosis and treatment of speech
and language disorders.
alr* For additional limitations and exclusions for hospital/facility services, see
"Hospital/Other Facility Services"in this section.
All physical rehabilitation treatments must be prior authorized by HMOC.
Physical rehabilitation required due to reinjury or aggravation of an old
injury must be prior authorized again by HMOC, even if therapy was
authorized for the original injury.
All of the following rehabilitation services are covered when performed in
the outpatient or inpatient department of a hospital, freestanding treat-
ment facility or clinic, or a provider's office, when prescribed and/or
provided by the member's PCP or a participating physician:
• occupational therapy performed by a licensed occupational therapist
• physical therapy performed by a physician, licensed physical therapist,
or other professional provider licensed as a physical therapist,
including six osteopathic manipulative therapy (OMT) treatments per
calendar year when prescribed and/or provided by the member's PCP
• speech therapy, evaluation, and treatment, performed by a licensed
and accredited speech/language pathologist
Coverage is limited to 30 treatment days for inpatient physical rehabili-
tation (physical, occupational, and/or speech therapy) per injury or illness.
The services must be received within six months from the date on which
the illness or injury occurred.
Coverage is limited to 30 treatments for outpatient physical rehabilita-
tion (physical, occupational, and/or speech therapy) per illness or injury
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Referrals" in Section 2;How the Plan Works).
30 Customer Service:(800)334-6557 or(303)831-0161 BLUH071 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
and must be received within six months from the date on which the illness
or injury occurred.
To be considered covered services, outpatient occupational, physical, and
speech therapies must meet the following conditions:
• there is a documented condition or delay in recovery that can be ex-
pected to improve with therapy within 60 days of the initial referral;
and
• improvement would not normally be expected to occur without
intervention.
The following services are not covered services:
• cardiac rehabilitation programs
• maintenance therapy or care provided after the patient has reached
his/her rehabilitative potential as determined by HMOC (see "Main-
tenance Therapy" in Section 4: General Exclusions)
• any diagnostic, therapeutic, rehabilitative, or health maintenance
service provided at or by a health spa or fitness center, even if the
service is provided by a licensed or registered provider
• any therapeutic exercise equipment prescribed for home use (e.g.,
treadmill, weights)
• speech therapy or diagnostic testing related to the following conditions:
- learning disorders, whether or not they accompany mental
retardation
- deafness
- personality, developmental, behavioral, voice, or rhythm disorders
when these conditions are not the direct result of a diagnosed
neurological, muscular, or structural abnormality involving the
speech organs
- stuttering, at any age
• long-term occupational, physical, or speech therapies (therapies are
considered long-term if the member's PCP and/or other professional
provider does not believe significant improvement is possible within a
60-day period)
• occupational, physical, or speech therapy for chronic conditions
• chiropractic services
• chronic pain management
You must obtain a referral from your PCP to receive benefits for nonennergency care not directly
provided by-your PCP (for exceptions,see"PCP Referrals" in Section 2:Howtke Plan Works).
BLUH0]1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 090325 31
Section 3: Covered Services BlueAdvantage HMO Plan
■ Prescription Drugs
Prescription drugs and medicines—those that are taken at the direction
and under the supervision of a provider and require a physician's pre-
scription before being dispensed. All drugs and medicines must be
approved by the Food and Drug Administration, and must not be "experi-
mental or investigative" (see "Experimental or Investigative Procedures
and Services" in Section 4: General Exclusions). The fact that a drug is
recommended or prescribed does not make it a covered service.
Drug Formulary— a list of prescription drugs that is approved for use by
HMOC. This list is subject to periodic review and modification by HMOC.
Generic drug— the chemical equivalent of a brand-name prescription
drug. By law, brand-name and generic drugs must meet the same stan-
dards for safety, purity, strength, and quality.
Maintenance medications—prescription drugs taken regularly to treat a
chronic health condition, such as high blood pressure, ulcers, or diabetes.
Ar* Coverage for prescription drugs administered by a hospital, home health agency,
hospice, or skilled nursing facility during a covered admission is not available
under this "Prescription Drugs"section. See other headings in this section for
drugs used during a covered admission or home health/hospice visit.
The following take-home prescription drugs (including insulin) are covered
only when prescribed by an HMOC participating provider, listed in the
HMOC Drug Formulary, and dispensed by an HMOC participating
pharmacy:
• prescription drugs, including oral contraceptives (limited to the supply
required for one menstrual cycle), prescription contraceptive devices
purchased from a pharmacy, and insulin— unless a prescription drug
is listed as an exclusion below
• compounded medication of which at least one ingredient is a prescrip-
tion drug
• self-administered injectable insulin, glucagon, Imitrex, and anaphy-
lactic kits these are the only injectable medications covered unless
an HMOC prior authorization is obtained
• insulin needles, syringes, and supplies (e.g., lancets and test strips) if
purchased at the same time as insulin (there will be a separate
copayment for each item purchased)
Important: If a provider prescribes a drug for which an FDA-approved
Class A generic substitute is available, the member will receive the generic
substitute. All medically necessary "dispense as written" or "no substitu-
You moat obtain a referral from your PCP to receive benefits for nonemergency care net directly
provided':by yolur PCP°(for exceptions,see "PCP Referrals" in Section 2:flow the Plan Works),
32 Customer Service:(800)334-6557 or(303)831-0161 RLUH071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
tion" prescriptions do not allow a generic substitution and require a prior
authorization from HMOC. If prior authorization is not obtained in a
nonemergency situation, the member is responsible for the retail cost
difference between the brand-name drug and the generic substitute, in
addition to the copayment. If a member requests a brand-name equivalent
of a drug that has a generic equivalent, payment is limited to the cost of
the generic equivalent, less the copayment.
Retail Pharmacy Program
A member may obtain prescription drugs from participating pharmacies
and pay only a small copayment at the time of purchase. For each pre-
scription purchased at a participating pharmacy, members pay the amount
specified on their Summary of Benefits and Copayments. (If the retail price
of a prescription drug is less than the copayment, the member's copayment
will be the actual retail price.) Refer to your "HMO Colorado Pharmacy
Roster" or call an HMOC customer service representative for a list of
participating pharmacies.
Members must present their plan ID card to the pharmacist at the
time of purchase to receive this benefit.
If you do not have your ID card with you or if you purchase your prescrip-
tion from a nonparticipating provider in an emergency situation, you must
pay for the prescription in full and then submit the claim to the Retail
Pharmacy Program. Prescription drug bills must include pharmacy name
and address, drug name, prescription number, and amount charged. The
bill or receipts must be issued by the pharmacy. For a claim form and the
mailing address, contact HMOC customer service. The reimbursement for
these prescription drug claims is 100 percent of the charge for the drug
minus the copayment amount. (If the reimbursement price is the same as
or less than the copayment amount required, there is no payment to the
member.)
Under the Retail Pharmacy Program, members can obtain a maximum of a
34-day supply. For oral contraceptives, the supply is limited to one
menstrual cycle (normally 28 days). Prescriptions in excess of the number
specified by the physician or those requested more than one year following
the physician's original order date cannot be refilled. (Drugs with a high
degree of intolerance may be filled with a one-week supply initially and, if
the member's response is favorable, the remainder of the prescription will
be filled with no additional copayment.)
Managed Prescription Mail Service Program
Members taking maintenance medications may enroll in and use the Man-
aged Prescription Mail Service Program.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Referrals"in Section 2:How the Plan Works).
BLUHW1M.CRC(Rev.6/97) Customer Service: (800)334-6557 or(303)831-0161 990'325 33
Section 3: Covered Services BlueAdvantage HMO Plan
The member's copayment amount for each prescription ordered through
the Managed Prescription Mail Service Program is the same as the
copayment amount for a prescription filled at a participating retail
pharmacy under the Retail Pharmacy Program for a 30-day supply, and
two times that amount for a 60- or 90-day supply. See your Summary of
Benefits and Copayments for the exact copayment amount for mail-order
prescription drugs.
To use the Managed Prescription Mail Service Program, complete the
following steps:
• Ask the physician to write a new, original prescription that can be
submitted directly to the mail service pharmacy with the "Mail Service
Pharmacy Order Form." If medication is needed immediately, ask the
doctor to issue two prescriptions —one for an immediate supply to be
taken to the local pharmacy, and a second for an extended supply to be
mailed to the Managed Prescription Mail Service.
• When the physician writes a prescription for a maintenance medica-
tion, ask that the prescription be written for up to a 90-day supply
with up to three refills.
• Complete the "Patient Profile/Registration Information Form" for the
first mail-service order. In the future, if there is additional information
or changes to report, send an updated "Patient Profile/Registration
Information Form" to the Managed Prescription Mail Service.
• Complete the "Mail Service Pharmacy Order Form" for both new and
refill prescriptions. A new order form and envelope will be sent with
each delivery.
• Enclose the original prescription, "Patient Profile/Registration Infor-
mation Form," "Mail Service Pharmacy Order Form," and payment in
the preaddressed mail-service envelope and mail the order.
• For information on how to contact the Managed Prescription Mail
Service Program, refer to the Managed Prescription Mail Service
brochures for the phone number or call your HMOC customer service
representative.
• Prescriptions will be delivered either by U.S. Postal Service or UPS.
Please allow 10-14 days for delivery from the date the prescription
order was mailed. In an emergency, the prescriptions can be shipped
overnight for an additional fee that is the member's responsibility.
Prescription Drug Exclusions
Coverage is not available under the prescription drug program for:
• nonprescription and over-the-counter drugs, including herbal or
homeopathic preparations, and prescription drugs that have over-the-
counter bioequivalents—unless specifically prior authorized by HMOC
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP ReMrralsn in Section 2:How the Plan Works).
34 Customer Service:(800)334-6557 or(303)831-0161 BLUHW1M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• infertility medications (for exceptions, see "Infertility Services," under
"Office, Outpatient, and Home Care" in this section)
• Nicorette, nicotine patches, or any other drug containing nicotine or
other smoking deterrent medications
• appetite suppressants
• tretinoin (sold under such brand names as Retin-A) for cosmetic
purposes
• prescription drugs dispensed for the purpose of international travel
• any prescription prescribed by a nonparticipating provider (unless
eligible for coverage in an emergency or urgent care situation)
• prescriptions purchased from a nonparticipating pharmacy (unless
eligible for coverage in an emergency or urgent care situation)
• delivery charges
• therapeutic devices or appliances, including support garments and
other nonmedicinal substances (regardless of intended use)
• medications or preparations used for cosmetic purposes (such as
preparations to promote hair growth or medicated cosmetics)
Note: Certain prescription drugs that have the potential for misuse and
most injectable medications require a prior authorization from HMOC.
Your PCP or HMOC participating provider will request the necessary prior
authorization.
• Preventive, Routine, and Family Planning
Services
Preventive care services— those professional services rendered for the
early detection of asymptomatic illnesses or abnormalities and to prevent
illness or other conditions.
Family planning—use of contraceptive techniques.
s.. For routine mammograms and prostate screening, see "Diagnostic Services"
earlier in this section.
For infertility services, see "Office, Outpatient, and Home Care"in this section.
Your PCP plays a key role coordinating all of your health care. Your PCP
will provide much of your care, including routine physical examinations,
immunizations, health education and counseling, and family planning
services. Your PCP is also responsible for referring you to a specialist when
necessary and for authorizing care ordered by the specialist, such as
hospice care, home health, and surgery. You must receive a referral in
order to receive benefits for nonemergency care provided by anyone other
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals° in Section 2:How the Plan Works).
BLUHW1M.CRC(Hev.8197) Customer Service:(800)334-6557 or(303)831-0161990325 35
Section 3: Covered Services BlueAdvantage HMO Plan
than your PCP. Limited exceptions are made for specified early detection
services listed below and for all female reproductive system services re-
ceived from a participating OB/gyn physician.
Physical Exams and Early Detection Services
Preventive care services are covered only when provided by the member's
PCP and in accordance with the following guidelines:
• six well-baby exams for babies ages 0-11 months
• children ages 12-23 months, three exams
• children ages 2-6, yearly exams
• children ages 7-18, one exam every two years
• adults ages 19-34, one exam every five years
• adults ages 35-59, one exam every two years
• adults age 60 and over, one exam every year
Preventive care services by the member's PCP may be provided during
visits for reasons other than preventive examinations and may be applied
to the member's maximum number of preventive care visits.
Guidelines are provided to the PCP by HMOC based upon recommenda-
tions of the American Academy of Pediatrics, American Board of Family
Practice, the United States Task Force Guide to Preventive Services, and
the Center for Disease Control.
Additional services, when provided by the member's PCP, are covered
under this provision and include:
• prostate examinations
• annual gynecological examination—breast and pelvic examinations,
annual Pap tests, and fitting for contraceptive devices (see "Family
Planning," below) for women over age 18 (a female member may
receive such services from her PCP or go directly to an OB/gyn physi-
cian who participates in her personal care network without a referral).
To visit an OB/gyn physician outside of her personal care network, the
member must get a referral from her PCP, or benefits will be denied.
• pediatric and adult immunizations
• age-appropriate vision and hearing screening exams
The following services are not covered services:
• immunizations required for international travel
• services related to routine physical or screening exams and immuniza-
tions given primarily for insurance, licensing, employment, school,
camp, weight reduction programs, sports, or for any nonpreventive
purpose
• preventive care services in excess of maximum limitations
• hearing aids or any related service or supply
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP (for exceptions,see"PCP Referrals"in Section 2:How the Pion Works).
36 :' Customer Service:(800)334-6557 or(303)831-0161 6wHm1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• routine vision exams to determine prescriptions for lenses
• nonscreening hearing exams
• services provided by an OB/gyn physician for primary care (e.g., cold or
flu symptoms, or abdominal pain) without a PCP referral
Family Planning
Covered family planning services are:
• injection of Depo-Provera for birth control purposes
• fitting of a diaphragm or cervical cap
• surgical implantation and removal of a NORPLANT device
• fitting, inserting, or removing IUDs
• the purchase of IUDs, diaphragms, NORPLANT devices, and cervical
caps provided by a physician in his/her office (if such devices are not
provided by a physician, see "Prescription Drugs" earlier in this
section)
• surgical sterilization (e.g., tubal ligation or vasectomy) and related
services
Female members are not required to obtain a PCP referral for the services
of a participating OB/gyn physician.
Note: Birth control pills are also covered; see "Prescription Drugs" earlier
in this section.
The following services are not covered services:
• reversals of sterilization procedures
• over-the-counter contraceptive products such as condoms and
spermicide
• preconception, paternity, or court-ordered genetic counseling and test-
ing (e.g., tests or discussion of family history or test results to deter-
mine the sex or physical characteristics of an unborn child)
Health Education
Health education provided by a member's PCP is covered, and may include
information on achieving and maintaining physical and mental health and
preventing illness and injury. Members who have been diagnosed as
diabetic may receive coverage for diabetic education classes attended
within the first six months of diagnosis.
s.. For information about your HealthAdvantage programs, see "Your HealthAdv-
antage Program"in Section 2: How the Plan Works.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP#for exceptions,see "PCP Referrals" in Sealant How the Plan Works).
7t
9wN07,M.csc(Rev.6/97) Customer Service:(800)334-6557 or(303)B31-0161 ... i3 0 37
Section 3: Covered Services BlueAdvantage HMO Plan
■ Supplies, Equipment, and Appliances
Durable medical equipment—any equipment that can withstand repeated
use, is made to serve a medical purpose, and is generally considered
useless to a person who is not ill or injured.
Medical supplies— expendable items (except prescription drugs) required
for the treatment of an illness or injury.
Prosthesis— any device that replaces all or part of a missing body organ or
body member.
Orthopedic appliance—a rigid or semirigid support used to eliminate,
restrict, or support motion of a part of the body that is diseased, injured,
weak, or deformed.
aM If oxygen is administered by a home health care agency, also see "Home Health
Care"in this section.
If supplies or equipment are furnished by a hospice agency, also see "Hospice
Care"in this section.
For supplies or equipment used during an inpatient stay or outpatient hospital visit,
see "Hospital/Other Facility Services"in this section.
When medically necessary and ordered by an HMOC participating provider,
the following items are not subject to the durable medical equipment
payment limit:
• durable medical equipment owned by the facility and medical supplies
used during a covered admission or during a covered outpatient visit
• medical supplies (including casts, dressings, and splints used in lieu of
casts) used during covered outpatient visits
• surgically implanted prosthetics or devices preauthorized by HMOC
The following durable medical equipment are subject to the benefit pay-
ment limit shown in the Summary of Benefits and Copayments:
• oxygen and oxygen equipment;
• orthopedic appliances (this does not include orthotics, whether func-
tional or otherwise)
• crutches
• the rental, or at the option of HMOC, the purchase of durable medical
equipment, including repairs, when prescribed by a physician or other
professional provider and required for therapeutic use (e.g., wheel-
chairs and walkers)
You must obtain areferral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Referrals" in Section 2:How the Plan Works).
38 Customer Service:(800)334-6557 or(303)831-0161 13LuHm,M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• prostheses and orthopedic appliances or devices (e.g., surgical bras-
siere after mastectomy, or neck brace); their fitting, adjustment,
repairs, or replacement because of wear or a change in the member's
condition which necessitates a new appliance
Coverage is not available for items such as, but not limited to:
• air conditioners, biofeedback equipment, exercise equipment, humidifi-
ers, purifiers, self-help devices, and whirlpools
• deluxe equipment, such as motor-driven wheelchairs. chair-lifts, or
beds, when standard equipment is available and adequate
• eyeglasses and contact lenses and the costs related to prescribing or
fitting of contact lenses (except for aphakia or keratoconus)
• hearing aids, related services, and supplies
• comfort items such as bedboards, waterbeds, hospital beds, flotation
mattresses, bathtub lifts, over-bed tables, adjustable beds, telephone
arms
• cost of repairs that exceeds the rental price of another unit for the
estimated period of need or that exceeds the purchase price of a new
unit
• medical equipment such as sphygmomanometers and stethoscopes
• supplies not authorized by the member's PCP or the referral provider,
including items used for comfort, convenience, or personal hygiene
• syringes and needles for self-administering covered drugs, medicine, or
insulin (for possible coverage, see "Prescription Drugs")
• contraceptive devices (for coverage, see "Preventive, Routine, and
Family Planning Services" or "Prescription Drugs")
• medical supplies and orthopedic appliances that can be purchased
over-the-counter, including but not limited to colostomy bags, cathe-
ters, dressings for bed sores and burns. gauze, and bandages
■ Surgical Services
Surgical services—any of a variety of technical procedures for treatment
or diagnosis of anatomical disease or injury including, but not limited to:
cutting; microsurgery (use of scopes); laser procedures; grafting, suturing,
castings; treatment of fractures and dislocations; electrical, chemical, or
medical destruction of tissue; endoscopic examinations; anesthetic epidural
procedures; other invasive procedures. Covered surgical services also
include usual and related local anesthesia, and pre- and post-operative
care, including recasting.
Anesthesia — general anesthesia produces unconsciousness in varying
degrees with muscular relaxation and a reduction or absence of pain.
Regional or local anesthesia produces similar effects to a limited region of
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals"in Section 2:How the Plan Works).
BLUH07IM.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 39
Section 3: Covered Services BlueAdvantage HMO Plan
the body without causing loss of consciousness. Anesthesia is administered
by a physician or certified registered nurse anesthetist (CRNA).
Surgical assistance— required surgical services provided by an assistant
to the primary surgeon during a covered surgical procedure.
III�� If you undergo a surgical procedure in a hospital(inpatient or outpatient) or other
facility, see "Hospital/Other Facility Services"in this section for more information.
For maternity-related services, also see "Maternity and Newborn Care"in this sec-
tion.
For services related to infertility treatments, see "Office, Outpatient, and Home
Care"earlier in this section. Coverage for surgical sterilization is described under
"Preventive, Routine, and Family Planning Services."
Coverage is available for surgical services received as part of a covered
hospital admission day or in a provider's office or clinic, urgent care center,
hospital outpatient department or emergency room, or an ambulatory
surgical facility.
Covered surgical services include:
• surgeon's charges for a covered surgical procedure
• necessary anesthesia services by a provider qualified to perform such
services during a covered surgical procedure
• services of a professional provider who actively assists the operating
surgeon in the performance of a covered surgical procedure when the
procedure requires an assistant
The following services are not covered services:
• cosmetic procedures and related expenses
• obesity treatment, unless for the surgical treatment of morbid obesity
for which a prior authorization, requested in writing, has been received
from HMOC
• refractive keratoplasty, including radial keratotomy, or any procedure
to correct visual refractive defect
• sex change operations or complications arising from transsexual
surgery
• subsequent surgical procedures to correct further injury or illness
resulting from the member's noncompliance with prescribed medical
treatment or to care for or correct a complication due to a previous
noncovered procedure
• services of an assistant only because the hospital or other facility re-
quires such services, or services performed by a resident, intern, or
other salaried employee or person paid by the hospital
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions, see "PCP Referrals" in Section 2:How the Plan Works).
40 - Customer Service:(800)334-6557 or(303)831-0161 6LUMW 1M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• services of more than one assistant unless the procedure is identified
by HMOC as requiring the services of more than one assistant
• local anesthesia (coverage for surgical procedures includes an allow-
ance for local anesthesia because it is considered a routine part of the
surgical procedure)
• services of a physician who is on standby unless the procedure is
identified by HMOC as requiring the services of a standby physician
(standby means a physician is available if services are needed)
Oral Surgery
This plan will cover services for mouth conditions (excluding teeth and
gums) arising from disease, trauma, injury, or congenital defect, if deter-
mined to be medically necessary. Upper or lower jaw augmentations or
reductions are not covered.
IIr V For the treatment of accidental injuries to the jaws, mouth, or teeth, or for the
surgical or nonsurgical treatment of TMJ disorders or injuries, see "Dental-Related
Services"or "TMJ Services"in this section.
For services required as a result of a cleft palate or cleft lip, see "Reconstructive
Surgery,"below.
Reconstructive Surgery
Reconstructive surgery— surgery that improves or restores bodily function
to the level experienced before the event which necessitated the surgery, or
in the case of a congenital defect, to a level considered normal. Such
surgeries may have a coincidental cosmetic effect.
Congenital defect— any condition, present from birth, that is significantly
different from the common form; for example, a cleft palate or certain
heart defects.
Reconstructive surgery that is required due to an accidental injury, disease
process or its treatment, or functional congenital defect, or breast recon-
struction following a mastectomy (breast removal), is a covered service.
Further, the member or physician must obtain a prior authorization,
requested in writing, from HMOC before the reconstructive service is
provided. Reconstructive surgeries provided without prior authori-
zation from HMOC are not covered.
Coverage is available for two breast prosthetics for breast reconstruction
after a mastectomy.
You must obtain a referral-from your PCP to receive benefits for nonemergency carne not directly
provided by your PCP(for exceptions,see"PCP Referrals"in Section 2:How the P►an Wades).
BLUH071M.CRC(Rev.6/97( Customer Service:(800)334-6557 or(303)831-0161 990325 41
Section 3: Covered Services BlueAdvantage HMO Plan
Cleft lip or cleft palate—A cleft palate is a birth deformity in which the
palate (the roof of the mouth) fails to close. A cleft lip is a birth deformity
in which the lip fails to close.
A member born with a cleft lip or cleft palate is eligible for the following
medically necessary services:
• oral and facial surgery, surgical management, and follow-up care by
plastic surgeons and oral surgeons
• prosthetic treatment such as obturators, speech appliances, and
feeding appliances
• orthodontic treatment
• prosthodontic treatment
• habilitative speech therapy
• otolaryngology treatment
• audiological assessments and treatment
Transplants
Transplant — a surgical process that involves the removal of an organ
from one person and placement of the organ into another. Transplant can
also mean removal of organs or tissue from a person for the purpose of
treatment and reimplanting the removed organ or tissue into the same
person.
Bone Marrow, Cornea, Kidney, and Specified Liver Transplants— The
following transplant procedures are covered under this provision:
• bone marrow transplant for a member with aplastic anemia, leukemia,
severe combined immunodeficiency disease, or Wiskott-Aldrich
syndrome
• corneal transplant
• kidney transplant
• liver transplant for a child under age 18 with congenital biliary atresia
When the transplant recipient is a member, the surgical procedure,
storage, and transportation costs directly related to the donation of an
organ or bone marrow to be used in a covered transplant are considered
covered services. Coverage is not available for donor costs for a member
who donates an organ to be used in a transplant procedure.
For covered transplants, when the recipient is a member, transportation
costs to and from the hospital for the recipient are also covered. If the
recipient is a minor, transportation costs for one adult to accompany the
recipient are also covered. This coverage includes all reasonable and neces-
sary lodging expenses.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Referrals" in Section 2;How the Plan Works).
42 Customer Service:(B00)334-6557 or(303)831-0161 ewHmI M.CRC(Rev.are»
BlueAdvantage HMO Plan Section 3: Covered Services
Any transplants performed outside of the HMOC service area must be
authorized by HMOC before the service is received.
Major Organ Transplants— Coverage is available for services and supplies
related to a major organ transplant, limited to one or more of the following:
• heart
• heart-lung
• liver (for a child under age 18 with congenital biliary atresia, see
"Bone Marrow, Cornea, Kidney, and Specified Liver Transplants,"
above, for benefits)
• lung
• pancreas-kidney
To be considered covered services, services must be related to a covered
major organ transplant, coordinated by the member's PCP, and authorized
by HMOC.
PCP Referral and Prior Authorization Required —The member is
responsible for ensuring that a referral is received from his/her PCP and
for getting prior authorization from HMOC before scheduling a pretrans-
plant evaluation. A case manager will be assigned to the member and must
later be contacted with the results of the evaluation. Coverage will not be
allowed for a pretransplant evaluation if prior authorization is not received
from HMOC.
If the member is a candidate for a transplant, he/she must ensure that
prior authorization for the actual transplant is received from HMOC.
None of the coverage described here will be available unless the
member has this prior authorization.
Facility Must be Approved by HMOC — Coverage is available only
when the transplant is performed at a facility with a transplant program
approved by HMOC. The member's case manager will work with the
member's provider to determine the most appropriate facility for the
procedure. Call the HMOC health services department for information on
HMOC-approved programs.
Effect of Medicare Eligibility on Coverage —Members who are now
eligible for--or are anticipating receiving eligibility for—Medicare
benefits are solely responsible for contacting Medicare to ensure that the
transplant will be eligible for Medicare benefits. (If Medicare is the
primary carrier when the transplant is received but benefits are denied by
You must obtain a referral from your PCP to receive benefits fot nonemergency care not directly
provided by.your PCP(for exceptions,see"PCP Referrals"in Section 2:How the Plan Work*
BLUH071M.CRC(Rev.6/971 Customer Service:(800)334-6557 or(303)831-0161 9.9.O3255 43
Section 3: Covered Services BlueAdvantage HMO Plan
Medicare, coverage may also be denied by HMOC even if the
member obtained prior authorization for the transplant.)
Maximum Lifetime Benefit for Major Organ Transplants — Cover-
age for a covered major organ transplant and all transplant-related
services, including travel, lodging, and donor expenses or organ procure-
ment costs is limited to a maximum lifetime benefit for major organ trans-
plants of$1,000,000 per member per transplant.
Amounts applied toward the maximum lifetime benefit for major organ
transplants include all covered charges for transplant-related services less
the member's copayment amounts, any hospitalizations and medical ser-
vices related to the transplant, and any subsequent hospitalizations and
medical services related to the transplant. The $10,000 travel and lodging
and the $25,000 donor expense coverages (see below) also apply toward the
maximum lifetime benefit for major organ transplants.
A service or supply is considered transplant-related if it directly relates to
a transplant covered under this "Major Organ Transplants" provision, and
is received during the transplant benefit period (up to five days
before, or within one year following, the transplant). Exception: A
pretransplant evaluation may be received more than five days prior to a
transplant and be considered transplant-related (this exception does not
extend to travel required to receive a pretransplant evaluation). Covered
services received during the evaluation will be subject to the maximum
lifetime benefit for major organ transplants and subject to the limitations
of this "Major Organ Transplants" provision.
If a member receives a covered transplant under this plan (e.g., heart
transplant) and later requires another transplant of the same type (e.g.,
another heart transplant), the covered charges for the new transplant are
applied to the remaining (if any) maximum lifetime benefit available for
the transplant.
Payments under this "Major Organ Transplants" provision are not applied
to other specified benefit maximums and member copayments are not
applied to the out-of-pocket limit listed in this benefit booklet.
Expenses for covered transplant-related services in excess of the
maximum lifetime benefit for major organ transplants are not
payable under this provision or any other portion of this benefit
booklet.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see"PCP Referrals" in section 2:How the Dian Work*).
44 Customer Service:(800)334-6557 or(303)831-0161 BLUH0)1M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
Recipient Travel and Lodging— If the transplant recipient must
temporarily relocate outside of his/her city of residence to receive a covered
major organ transplant, coverage is available for travel to the city where
the transplant will be performed, and for reasonable lodging expenses for
the recipient and one additional adult. (If the transplant recipient is a
dependent child under the age of 18, coverage is available for travel and
lodging expenses for two adults to accompany the member.)
Travel and lodging expenses for the recipient and the accompanying adult(s)
are limited to a lifetime maximum benefit of$10,000 per transplant—
which is part of the maximum lifetime benefit for major organ transplants
under this "Major Organ Transplants" provision. Lodging expenses are
further limited to a maximum of$100 per day.
The member is responsible for monitoring the accumulation of expenses
and for submitting documentation (with properly itemized receipts) to
support travel expenses. No benefits will be paid until after services are
received.
Travel expenses incurred by a donor are not applied to the member's
lifetime travel and lodging expenses benefit maximum but are applied to
both the maximum lifetime benefit for major organ transplants and to the
$25,000 maximum donor surgery benefit (see below).
Coverage is not available for travel costs associated with a pretransplant
evaluation if the travel occurs more than five days prior to the actual
transplant.
Organ Procurement or Donor Expenses for Major Organ
Transplants —Organ procurement and donor expenses are covered up to
a maximum benefit of$25,000 per transplant—which is part of the maxi-
mum lifetime benefit for major organ transplants.
Organ acquisition/procurement costs for the surgical removal, storage, and
transportation of a heart, liver, lung, pancreas, or kidney acquired from a
cadaver are covered.
If there is a living donor that requires surgery to make an organ available
(e.g., liver or kidney), coverage is available only for expenses incurred by
the donor for surgery (including necessary travel), organ storage expenses,
and inpatient follow-up care.
Donor expenses are paid only after the transplant recipient's initial claims
for the transplant have been processed. No coverage is available to the
donor after he/she has been discharged from the transplant facility.
You must obtain a referral from your PCP to receive benefits for nonerncy care not directly',
provided by your PCP(for exceptions, see "PCP Referrals"In Section 2:How the Plan Works).
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 45
Section 3: Covered Services BlueAdvantage HMO Plan
Major Organ Transplant Exclusions— Coverage is not available
under this "Major Organ Transplants" provision for:
• transplant-related services if the actual transplant was performed at a
facility that does not have an HMOC-approved transplant program
• with the exception of a pretransplant evaluation, services received
more than five days prior to or one year following a covered transplant
(these services may be covered elsewhere in this benefit booklet)
• transplant-related services in excess of any maximum benefit amounts
Transplant Exclusions— Coverage is not available under this "Trans-
plants" provision (covering cornea, kidney, bone marrow, specified liver,
and major organ transplants) for:
• the implantation of artificial organs or devices (e.g., mechanical heart)
• nonhuman organ transplants
• any transplant not specifically listed (such as, but not limited to, liver-
intestine, and pancreas-only transplants)
• care for the complications of noncovered transplants, or follow-up care
related to such transplants
• transplant-related services if the member did not receive prior autho-
rization from HMOC for the transplant
• expenses incurred by an HMOC member for the donation of an organ
to another person (such expenses should be paid by the transplant
recipient)
• drugs that are self-administered or for use while at home (these
services may be covered elsewhere in this benefit booklet; see "Pre-
scription Drugs" in this section)
• food, beverage, or meal expenses (other than those incurred at a
hospital as part of covered room and board expenses); laundry or dry
cleaning expenses; phone calls; day care expenses; personal conve-
nience items
• lodging expenses charged to the member only because benefits are
available under this provision (such as lodging received from a member
of the patient's family, or from any other person charging for accommo-
dations in a place that does not ordinarily take in lodgers in return for
payment)
• taxicab or bus fare, vehicle rental expenses, parking expenses, moving
expenses
You must obtain"s referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP for exceptions;see "PCP Referrals"In Section 2:How the Pion Work*
46 , Customer Service: (800)334-6557 or(303)831-0161 BLUHm1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 3: Covered Services
• Therapies: Chemotherapy and Radiation
Chemotherapy—drug therapy administered as treatment for malignant
conditions and diseases of certain body systems.
Radiation therapy—X-ray, radon, cobalt, betatron, telocobalt, and
radioactive isotope treatment for malignant diseases and other medical
conditions.
IIir _ When received during a covered admission and billed as part of the facility ser-
vice, therapy charges will be paid in the same manner as the room expenses and
other ancillary services (see "Hospital/Other Facility Services"in this section).
Treatment of malignant disease by standard chemotherapy and/or radia-
tion therapy are covered when performed in the outpatient department of a
participating hospital, freestanding treatment facility or clinic, provider's
office, or the patient's home.
■ TMJ Services
Temporomandibular joint (TMJ)syndrome— a condition in which the
member may have painful temporomandibular joints, tenderness in the
muscles that move the jaw, clicking of joints, or limitation of jaw
movement.
Sin For coverage of other oral surgery services, see "Surgical Services: Oral Surgery"
in this section.
This plan does not cover any services related to therapy or surgery of the
temporomandibular joint. The plan covers only medical treatment of the
temporomandibular joint when there is a demonstrated underlying
medical condition or defect such as a tumor, a fracture, arthritis, or dis-
placed cartilage, and only when the treatment is prior-authorized by
HMOC.
You must obtain a referral from your PCP to receive benefits for nonemergency care not directly
provided by your PCP(for exceptions,see "PCP Referrals" in Section 2:How the Plan Works).
9LUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 47
Section 4: General Exclusions BlueAdvantage HMO Plan
4 General Exclusions
These general limitations and exclusions apply to all services listed in this
benefit booklet. This plan will not cover any services not authorized by the
member's primary care provider (PCP), except as set forth in Section 3:
Covered Services.
This plan does not cover any service or supply not specifically
listed as a covered service in this benefit booklet. If a service is not
covered, then all services performed in conjunction with that
service are not covered.
This plan will not cover any of the following services, supplies,
situations, or related expenses:
Acupuncture
This plan does not cover acupuncture, whether for medical or anesthetic
purposes.
Artificial Conception
This plan does not cover artificial insemination, "test tube" fertilization,
drugs for induced ovulation, or other artificial methods of conception. See
"Office, Outpatient, and Home Care" for a complete list of covered
infertility treatments.
Auto Accident Injuries
This plan does not cover services resulting from an automobile accident
that are covered under applicable no-fault insurance laws. (See Section 5:
Coordination of Benefits and Subrogation.)
Before Effective Date
This plan does not cover any service received before the member's effec-
tive date of coverage.
Biofeedback
This plan does not cover services related to biofeedback.
Blood, Plasma, or Derivatives
This plan does not cover whole blood, blood plasma, and blood
derivatives.
Chemical Dependency Rehabilitation
This plan does not cover inpatient or outpatient chemical dependency
Optionalrehabilitation unless your group chose the optional "Chemical Depen-
-.me , dency Rehabilitation" coverage. (Your Summary of Benefits and Copay-
Check Your Croup ments will indicate if this coverage is available to you.)
Summary of Concurs
and Copaymenis
Cheek your Summary of Benefits and Copayments for the above optional benefit or'feature.
48 Customer Service:(B00)334-6557 or(303)831-0161 8LUH071 M.CRC(Rev.691)
BlueAdvantage HMO Plan Section 4: General Exclusions
Chiropractic Services
This plan does not cover chiropractic services.
Convalescent Care or Rest Cures
This plan does not cover convalescent care or rest cures.
Cosmetic Surgery
Cosmetic surgery is beautification or aesthetic surgery to improve an
individual's appearance by surgical alteration of a physical characteristic.
This plan does not cover cosmetic surgery for psychiatric or psycho-
logical reasons, or to change family characteristics or conditions due to
aging. This plan does not cover services related to cosmetic surgery, or
required as a result of noncovered cosmetic surgery.
Examples of cosmetic procedures are: nipple reconstruction for any reason;
orthognathic jaw surgery; reconstruction of surgically induced scars; reduc-
tion mammoplasty, breast augmentation, rhinoplasty, surgical alteration
of the eye, and surgical correction of prognathism, or those procedures that
HMOC determines are not required to materially improve the physio-
logical function of an organ or body part.
Custodial Care
This plan does not cover custodial care, or care in a place that serves
the patient primarily as a residence when the patient does not require
skilled nursing. This plan does not cover services to assist the member
in activities of daily living (such as sitters or homemaker's services), or ser-
vices not requiring the continuous attention of skilled medical or para-
medical personnel, regardless of where they are furnished and by whom
they were recommended.
Dental Services
This plan does not cover dental treatment and surgery, including but
not limited to extraction of teeth, or application of, or cost of, devices or
splints.
Domiciliary Care
This plan does not cover domiciliary care or care provided in a resi-
dential institution, treatment center, halfway house, or school because a
member's own home arrangements are not available or are unsuitable, and
consisting chiefly of room and board, even if therapy is included.
Duplicate (Double) Coverage
This plan does not cover services already covered by other valid cover-
age, or services already paid under Medicare or, in groups of 20 or more
employees, that would have been paid if the member was entitled to Medi-
care, had applied for Medicare, and had claimed Medicare benefits, and is
not subject to Medicare Secondary Payer (MSP) provisions. See Section 5:
Coordination of Benefits and Subrogation for more information.
RLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 9.90325 49
Section 4: General Exclusions BlueAdvantage HMO Plan
Experimental or Investigative Procedures or Services
This plan does not cover any treatment, procedure, facility, equipment,
drug, device, or supply not accepted as standard medical practice, as deter-
mined by HMOC, and thus considered experimental or investigative. In
addition, if federal or other government agency approval is required for use
of any items and such approval was not granted at the time services were
administered, the service is experimental and will not be covered. To be
considered standard medical practice and not experimental or investi-
gative, treatment must meet all five of the following criteria:
• A technology must have final approval from the appropriate govern-
ment regulatory bodies.
• The scientific evidence as published in peer-reviewed literature must
permit conclusions concerning the effect of the technology on health
outcomes.
• The technology must improve the net health outcome.
• The technology must be as beneficial as any established alternatives.
• The improvements must be attainable outside the investigational
settings.
Also, the service must be medically necessary and not excluded under any
provision of this plan.
Genetic Counseling and Testing
This plan does not cover services related to preconception, paternity, or
court-ordered genetic counseling and testing (e.g., tests, or discussion of
family history or test results, to determine the sex or physical characteris-
tics of an unborn child).
Government Institution and Facility Services
This plan does not cover outpatient services or supplies furnished by a
military medical facility operated by, for, or at the expense of federal,
state, or local governments or their agencies, when the service is provided
without charge. This plan does not cover services or supplies furnished
by a Veterans Administration facility for a service-connected disability or
while in active military service.
Hair Loss Treatments
This plan does not cover wigs, artificial hairpieces, hair transplants or
implants, or medication used to promote hair growth or control hair loss,
even if there is a medical reason for hair loss.
Hypnosis
This plan does not cover hypnosis or services related to hypnosis,
whether for medical or anesthetic purposes.
Intractable Pain
This plan does not cover services for the treatment of intractable pain.
Intractable pain means a pain state in which the cause of the pain cannot
be removed and for which no relief or cure can be found.
50 Customer Service:(B00)334-6557 or(303)831-0161 BLUHWIM.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 4: General Exclusions
Late Claims Filing
This plan does not cover services submitted for coverage determination
more than six months after the date of service.
Learning Deficiencies and Behavioral Problems
This plan does not cover special education, counseling, therapy, diag-
nostic testing, or care for learning deficiencies or behavioral problems,
whether or not associated with a manifest mental disorder, retardation, or
other disturbance.
Maintenance Therapy
This plan does not cover any treatment that does not significantly en-
hance or increase the patient's function or productivity, or care provided
after the patient has reached his/her rehabilitative potential, unless ther-
apy is received during an approved hospice benefit period. In the case of a
dispute about whether the patient's rehabilitative potential has been
reached, the member is responsible for furnishing documentation from the
patient's physician supporting that the patient's rehabilitative potential
has not been reached.
Medically Unnecessary Services
This plan does not cover services that are not medically necessary as
defined in the Glossary unless such services are specifically listed as
covered in this benefit booklet (e.g., see "Preventive, Routine, and Family
Planning Services" in Section 3: Covered Services).
HMOC determines whether a service or supply is medically neces-
sary, and, therefore, whether the expense is covered. The fact that
a provider has prescribed, ordered, recommended, or approved a
service or supply does not make it medically necessary or make the
expense a covered service, even though it is not specifically listed
as an exclusion.
No Legal Payment Obligation
This plan does not cover services for which the member has no legal
obligation to pay or that are free, including:
• charges made only because coverage is available under this plan
• services for which the member has received a professional or courtesy
discount
• services provided by the member for him-/herself or a covered family
member, or by a person ordinarily residing in the patient's household,
or by a family member
Noncovered Providers of Service
This plan does not cover services prescribed or administered by a:
• member of the patient's immediate family or a person normally resi-
ding in the patient's home
BLUH011M.CRG(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 91:10
725 51
Section 4: General Exclusions BlueAdvantage HMO Plan
• physician, other person, supplier, or facility not specifically listed as
covered in this benefit booklet, such as a(n):
- health spa or health fitness center (whether or not services are
provided by a licensed or registered provider)
- school infirmary
- halfway house
- massage therapist
- private sanitarium
- extended care facility
- residential treatment center (facility where the primary services
are the provision of room and board and constant supervision or a
structured daily routine for a person who is impaired but whose
condition does not require acute care hospitalization)
- dental or medical department sponsored by or for an employer,
mutual benefit association, labor union, trustee, or any similar
person or group
Nonmedical Expenses
This plan does not cover nonmedical expenses, including but not limited
to:
• adoption expenses
• educational services and supplies not provided by the member's PCP
• vocational or training services and supplies
• mailing and/or shipping and handling expenses
• charges for such expenses as missed appointments, provision of
medical information to perform admission review, filling out of claim
forms, or copies of medical records
• interest expenses
• modifications to home, vehicle, or workplace to accommodate medical
conditions
• membership fees at spas, health clubs, or other such facilities even if
medically recommended—regardless of the therapeutic value
• personal convenience items such as air conditioners, humidifiers, or
physical fitness exercise equipment, or personal services such as hair-
cuts, shampoos and sets, guest meals, and radio or television rentals
• voice synthesizers; other communication devices
Nonparticipating Provider Services
This plan does not cover nonemergency services provided by a nonpar-
ticipating provider unless prior authorized by HMOC.
• When an HMOC participating provider resigns from the HMOC pro-
vider network, services rendered by the nonparticipating provider are
no longer covered.
• The member will be financially responsible for the services unless
referred to the provider in advance by his/her PCP, or if the service did
not require a referral.
52 , Customer Service:(800)334-6557 or(303)831-0161 BLUHO)1M.CRC(Roy.6/97)
BlueAdvantage HMO Plan Section 4: General Exclusions
Nutritional Therapy
This plan does not cover vitamins, dietary/nutritional supplements,
special foods, formulas, mother's milk, or diets.
Post-Termination Services
This plan does not cover services received after a member's coverage
under this health care plan is terminated—even if a prior authorization
was received from HMOC, or the member was hospitalized at the time of
termination.
Private Duty Nursing Services
This plan does not cover private duty nursing services.
Sex-Change Operations
This plan does not cover services related to sex-change operations or
reversals of such procedures.
Taxes
This plan does not cover sales, service, or other taxes imposed by law
that apply to covered services.
Therapies (Other)
This plan does not cover therapies and self-help programs other than
the therapies listed as covered services in this booklet. Noncovered
therapies include but are not limited to:
• recreational, sex, primal scream, sleep, and Z therapies
• self-help, stress management, smoking cessation, and weight-loss
programs
• transactional analysis, encounter groups, and transcendental
meditation (TM)
• sensitivity or assertiveness training and rolfing
• religious counseling
• wellness programs not specifically listed as covered in this benefit
booklet
• educational programs such as behavior modification, cardiac classes, or
arthritis classes (Some educational programs provided by a member's
PCP may be covered; see "Preventive, Routine, and Family Planning
Services" in Section 3: Covered Services for details.)
• splint therapy
• vision therapy
Travel and Lodging Expenses
This plan does not cover travel and lodging expenses except as de-
scribed under "Surgical Services" in Section 3: Covered Services.
ewHwi M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 Qn_ J7(1•:; 5 53
„
Section 4: General Exclusions BlueAdvantage HMO Plan
Vision
This plan does not cover any services related to refractive keratoplasty
(surgery to correct nearsightedness), including radial keratotomy or any
procedure designed to correct farsightedness or astigmatism. This exclu-
sion also applies to eyeglasses, contact lenses, prescriptions associated
with such procedures, and costs related to the prescribing or fitting of
contact lenses. See "Preventive, Routine, and Family Planning Services" in
Section 3: Covered Services for additional information.
War-Related Conditions
This plan does not cover any service required as the result of any act of
war, or for any illness or accidental injury sustained during combat or
active military service.
Weight-Loss Programs
This plan does not cover weight-loss programs, dietary control, or obesi-
ty treatment, except medically necessary surgical treatment of morbid
obesity when the treatment is authorized by HMOC before treatment
begins.
Work-Related Conditions
This plan does not cover services resulting from work-related illness or
injury. This exclusion from coverage applies to all work-related illness or
injury, and includes charges resulting from occupational accidents or
sickness covered under:
• occupational disease laws
• employer's liability
• municipal, state, or federal law (except Medicaid)
• Workers' Compensation Act
In order to obtain payment for a work-related illness or injury, the member
must pursue his/her rights under the Workers' Compensation Act or any of
the above provisions which apply, including filing an appeal. This plan
may cover certain services during that appeal process on the condition that
the member signs an agreement to pay HMOC 100 percent of the amount
paid for such claims by the other coverage.
This plan does not cover charges for services resulting from a work-
related illness or injury, even if:
• the member fails to file a claim within the filing period allowed by the
applicable law
• the member obtains care which is not authorized by Workers' Com-
pensation insurance
• the member's employer fails to carry the required Workers'
Compensation insurance; in this case, the employer may be liable for
any employee's work-related illness or injury expenses
• the member fails to comply with any other provisions of the law
54 Customer Service:(800)334-6557 or(303)831-0161 HLUH071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 5: Coordination of Benefits and Subrogation
5 Coordination of Benefits and Subrogation
■ Coordination of Benefits (COB)
This plan contains a coordination of benefits (COB) provision that prevents
duplication of payments. When a member is eligible for coverage under any
other valid coverage, the total payments from the other valid coverage and
this coverage cannot exceed what the plan would pay as primary coverage.
Other valid coverage means any of the following plans that provide full or
partial coverage or services for hospital, surgical, medical, vision, or dental
care or treatment:
• group insurance coverage
• group service plan contract, group practice, group individual practice,
and other group prepayment coverages
• any group coverage under labor-management trustee plans, union
welfare plans, employer organization plans, employee benefit organi-
zation plans, or self-insured employee benefit plans
Other valid coverage does not include school accident policies or Medicaid.
If a member is covered by both Medicare and this health care plan and is
subject to Medicare Secondary Payer provisions, special COB rules apply.
Contact an HMOC customer service representative for more information.
The following rules determine which coverage pays first:
No COB Provision— If the other valid coverage does not include a COB
provision, that coverage pays first and this health care plan pays
secondary.
Employee/Dependent—If the member who received care is covered as the
employee under one coverage and as a dependent under another, the
employee's coverage pays first. Exception: If the member is also a Medicare
beneficiary, and Medicare is secondary to the plan covering the person as a
dependent of an active employee, then the order of coverage determination
is:
1. Coverage of the plan of an active worker covering the Medicare bene-
ficiary as a dependent;
2. Medicare;
3. Coverage of the plan covering the Medicare beneficiary as the active or
retired employee.
If the member has other valid coverage, contact the other carrier's cus-
tomer service department to determine if the other coverage is primary or
secondary to Medicare. There are many federal regulations regarding
Medicare Secondary Payer provisions, and other coverage may or may not
be subject to those provisions.
BLUNm1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 9°0325 55
Section 5: Coordination of Benefits and Subrogation BlueAdvantage HMO Plan
Dependent Child—If the member who receives care is a dependent child,
the coverage of the parent whose birthday falls earlier in the calendar year
pays first. If the other coverage does not follow the birthday rule, then the
father's coverage pays first.
Dependent Child, Parents Separated or Divorced— If two or more plans
cover a member as a dependent child of divorced or separated parents,
payment for the child is coordinated in the following order:
• Court-Decreed Obligations. Regardless of which parent has custody, if a
court decree specifies which parent is financially responsible for the
child's health care expenses, the coverage of that parent pays first.
• Custodial/Noncustodial. The plan of the custodial parent pays first. The
plan of the spouse of the custodial parent pays second. The plan of the
noncustodial parent pays last.
• Joint Custody. When a court decree specifies that the parents share
joint custody, without stating that one of the parents is responsible for
the health care expenses of the child, the plans covering the child follow
the rules that are applicable to children whose parents are not sepa-
rated or divorced.
Active/Inactive Employee— If the member who received care is covered as
an active employee under one coverage and as an inactive employee under
another, the coverage through active employment pays first. Likewise, if a
member is covered as the dependent of an active employee under one
coverage and as the dependent of the same but inactive employee under
another, the coverage through active employment pays first. If the other
plan does not have this rule and if, as a result, the plans do not agree on
the order of coverage, the next rule applies.
Longer/Shorter Length of Coverage—When none of the above applies,
the plan in effect for the longest continuous period of time pays first. (The
start of a new plan does not include a change in the amount or scope of a
plan's coverage, a change in the entity that pays, provides, or administers
the plan's coverage, or a change from one type of plan to another.)
How Benefits Are Paid
When this plan is the primary plan, benefits will be paid according to the
terms of this benefit booklet. When this plan is the secondary plan, HMOC
may reduce its benefits so that the total benefits paid or provided by all
plans during a claim duration period are not more than the total allowable
expenses.
When HMOC is secondary, all provisions (such as using a PCP or HMOC -
participating provider, and the referral process) must be followed. Failure
to do so may result in no benefits from HMOC.
56 Customer Service:(800)334-6557 or(303)831-0161 BLUH0]1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 5: Coordination of Benefits and Subrogation
Responsibility for Timely Notice
This plan is not responsible for coordination of benefits if timely informa-
tion has not been provided by the complaining party regarding the appli-
cation of this provision.
Facility of Payment
Whenever payments that should have been made by HMOC have been
made under any other plan, HMOC will have the right to pay to that other
plan any amount HMOC determines to be warranted to satisfy the intent
of this provision. Any amount so paid will be considered to be benefits paid
under the agreement, and with that payment HMOC will fully satisfy its
liability under this provision.
Right of Recovery
Whenever payments for covered services have been made by the plan and
those payments are more than the maximum payment necessary to satisfy
the intent of this provision, regardless of who was paid, HMOC has the
right to recover the excess amount from any persons to or for whom those
payments were made, or from any insurance company, service plan, or any
other organizations or persons.
• Third-Party Liability — Subrogation
Third-party liability exists when someone else is or may be legally respon-
sible for a member's condition or injury. If a member suffers any illness or
injury for which a third party may be responsible and if this plan has paid
benefits for that illness or injury, HMOC will have the right to recover all
benefits paid, or which may become payable, for that illness or injury.
When a third party is liable for the costs of any covered service, HMOC has
subrogation rights. This means that HMOC has the right, either as
co-plaintiff or by direct suit, to enforce the member's claim against a third
party for the benefits paid to the member or on his/her behalf. If HMOC
provides payment, HMOC also has a direct priority lien against any money
the member may recover from a third party, any source related to that
third party, or any other source, as a result of the condition or injury.
HMOC's lien must be satisfied by the member regardless of the amount
recovered.
If a third party is or may be liable for the cost of or charges for any covered
services, the following actions must be taken:
1. The member must promptly notify HMOC of the claim against the third
party.
2. The member or his/her attorney must provide for payment to HMOC of
the amount of benefits paid by HMOC in any settlement with the third
party, the third party's insurance carrier, or any other source (such as
uninsured motorist coverage held by the member).
BLUH071M.CRC(Rev.6✓97) Customer Service: (800)334-6557 or(303)831-0161 90,0325 57
Section 5: Coordination of Benefits and Subrogation BlueAdvantage HMO Plan
3. If the member receives money for the claim by suit, settlement, or
otherwise, the member must reimburse HMOC first for the amount paid
under this plan or an agreed upon pro rata share. The member may not
exclude recovery for HMOC payments from any type of damages or
settlement recovered.
4. The member must cooperate in every way necessary to help HMOC
enforce its subrogation rights.
The member may not take any action that might prejudice HMOC's
subrogation rights.
When a member fails to cooperate in satisfying HMOC's subrogation
interest, and HMOC must file a lawsuit against the member or the third
party in order to enforce its rights under this provision, the member or any
dependent of his/hers receiving payment under this plan will be
responsible for attorneys' fees and costs incurred by HMOC.
■ Automobile No-Fault Insurance Provisions
Services resulting from an automobile accident that are covered under
applicable No-Fault insurance laws are not covered. This section explains
how this plan will coordinate its coverage with the coverage of an automo-
bile No-Fault insurance policy.
A complying policy is an insurance policy approved by the Colorado
Division of Insurance that provides at least the minimum coverage
required by law, and one which is subject to the Colorado Auto Accident
Reparations Act (No-Fault). Any state or federal law providing similar
coverage through legislation or No-Fault statute is also considered a com-
plying policy.
How Benefits Are Coordinated With Complying Policies
Benefits under this plan will be coordinated with the minimum coverages
required under the Colorado Auto Accident Reparations Act (No-Fault),
10-4-701 through 10-4-723, Colorado Revised Statutes 1973, as amended,
whether or not the member has auto insurance.
If a complying policy provides coverages in excess of the minimums
required by state law, then this plan will coordinate benefits with the
amount of coverage provided.
What This Plan Will Pay
This plan will pay up to the complying policy's deductible amount for those
services that are covered under this plan.
After this plan pays up to the complying policy's deductible amount, the
complying policy is primary and is responsible for all benefits payable
under the No-Fault statute. If there is more than one complying policy,
58 , Customer Service:(800)334-6557 or(303)831-0161 BLUHm1M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 5: Coordination of Benefits and Subrogation
each will have to pay its maximum No-Fault statutory coverages before
this plan will become liable for any further payments.
If there is a complying policy in effect, and the member waives or fails to
assert his/her rights to such benefits, this plan will not pay benefits that
could be available under a complying policy.
HMO Colorado may require proof that the complying policy has paid all
benefits required by law prior to making any payments on the member's
behalf. Upon payment, HMO Colorado will be entitled to exercise its rights
under this plan and under the No-Fault law. The member must fully
cooperate to make sure that the complying policy has paid all required
benefits. HMO Colorado may require the member to take a physical
examination in disputed cases.
In order for HMOC to pay for any covered service, after the complying
policy has paid all required benefits, the member must then comply with
the terms of this benefit booklet (including payment up to the complying
policy's deductible).
If the Member Does Not Have a Complying Policy
This plan will not pay benefits to the extent of minimum benefits required
by the No-Fault law for injuries received by the member while he/she is
riding in or operating a motor vehicle which he/she owns if it is not covered
by an Automobile No-Fault complying policy as required by law. However,
benefits will be available under the terms of this plan for injuries
sustained by a member who is a nonowner operator, passenger, or
pedestrian involved in a motor vehicle accident if that member is not
covered by a complying policy.
In that event, HMO Colorado may exercise its subrogation rights under
"Third-Party Liability — Subrogation," above.
This Automobile No-Fault Act will apply only where allowed under state
law.
BLUHO]IM CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 59
Section 6: Claims Payment and Appeals BlueAdvantage HMO Plan
6 Claims Payment and Appeals
This section explains when you need to file a claim to receive reimburse-
ment for covered services and how to do so.
• Acceptable Claims
Because HMOC participating providers handle the paperwork for mem-
bers, HMOC does not have standard claim forms. However, if you receive
covered services from a nonparticipating or out-of-area provider, you must
submit itemized bills containing the following information:
• member's number
• member's and employee's name and address
• member's age and relationship to the employee
• date(s) of service or purchase
• diagnosis and type of treatment
• procedure and amount charged
• itemization of charges
• accident or surgery date (when applicable)
• name and address of provider
• copayment paid, if any
Prescription drug bills must include pharmacy name and address, drug
name, prescription number, and amount charged. The bill or receipts must
be issued by the pharmacy. For the mailing address and claim forms,
contact HMOC customer service.
If you want reimbursement for covered charges which you have paid,
please submit proof of payment such as receipts and cancelled checks with
those items listed above. Balance due statements are not acceptable. All
information on the itemized statements must be readable. If information is
missing or is not readable, then HMOC will return it to you or to the
provider.
IN Where and When to Send Your Claim
Make copies of the itemized bills for your own records and send the
original bills to:
HMO Colorado, Inc.
700 Broadway, Suite 612
Denver, CO 80273
Your claim must be filed within six months after the date of service. Any
Day claims filed after this limit may be refused, unless HMOC is satisfied that
Limit I there is a valid reason why you could not submit your claim within this
time limit. Your claim will be processed within 60 days after HMOC
receives it. HMOC will send you written notice of any processing delays.
60 Customer Service:(800)334-6557 or(303)831-0161 BLUH071 M.CRC(Rev.s)w)
BlueAdvantage HMO Plan Section 6: Claims Payment and Appeals
This written notice gives HMOC one more 60-day period to process the
claim.
The right to payment for covered services may be assigned to, and thereby
payment made directly to, a nonparticipating provider of care, but the
assignment must be in writing.
All coverages described in this benefit booklet are personal to the member.
Neither these coverages nor HMOC payments may be assigned to any
person, corporation, or entity, unless it is a nonparticipating provider. Any
attempted assignment will be void. If anyone other than a member
attempts to use this coverage, it will be considered fraud or material
misrepresentation in the use of services or facilities, which may result in
cancellation of coverage for the member and appropriate legal action by
HMOC.
Benefit payments for members eligible for Medicaid are paid to the
Colorado Department of Health Care Policy and Finance or providers when
required by law.
• Overpayments
If this plan makes an erroneous payment, HMOC reserves the right to
recover the payment from the member. The providers of care may also seek
recovery of billed charges from the member for any services received.
HMOC also reserves the right to offset amounts paid in error against new
claims, and to take legal action to correct payments made in error.
• Complaint Procedures
A complaint is an expression of dissatisfaction with the services of HMOC
or the practices of an HMOC participating provider, whether medical or
nonmedical in nature.
Complaints about the quality of care or service by an HMOC participating
provider and/or recommendations to HMOC regarding changes in polices
or services must be submitted to the Customer Service Department in
writing by the member or a designated representative. The member also
has the right to make an appointment with the HMOC Complaint
Committee and appear before the committee to present his/her case.
If you have a complaint concerning the action HMOC has taken
based on the utilization review guidelines, you can appeal the
decision. Utilization review means HMOC's evaluation of the medical
necessity or appropriateness of the service. The determination to approve
or deny an admission or service is based upon the preadmission certifica-
tion guidelines, second surgical opinion guidelines, preauthorization
review, or concurrent hospital review.
1. If you disagree with HMOC's Utilization Review decision, you or your
designated representative can call HMOC's Customer Service office for
BWHm1M.CRC(Rev.6191) Customer Service: (B00)334-6557 or(303)831-0161 090325 61
Section 6: Claims Payment and Appeals BlueAdvantage HMO Plan
a reconsideration. Be sure to include any additional information that
will help support your reason for appealing the decision. HMOC will
give you or your representative a response within 1 working day if care
is for a current or future admission or medical service. Reviews for
past admissions or medical services will be done within 21 working
days.
2. If you are not satisfied with the outcome of the decision, you or your
designated representative can submit a written appeal within 60 days
of HMOC's notice to you of the decision. Be sure to include any addi-
tional information that will help support your reason for appealing the
decision. The appeal will be answered within 21 working days after
receipt of the request. The appeal will be reviewed by a committee,
including a physician and another clinical expert. HMOC will schedule
the committee meeting at a time convenient for you or your
representative to attend, either in person or by telephone.
3. If you are not satisfied with the committee's decision of your first
appeal, you or your representative can submit a second written appeal
within 60 days of HMOC's notice to you of the decision. Be sure to
include any additional information that will help support your reason
for appealing the decision. This appeal will be reviewed by a committee
of appropriate medical experts who are not employed by HMOC.
HMOC will schedule the committee meeting at a time convenient for
you or your representative to attend, either in person or by telephone.
This committee will meet within 45 working days of the receipt of the
appeal. A decision will be provided within 5 working days of the
committee's meeting. HMOC will act upon the committee's decision.
4. HMOC will hold an emergency committee meeting if a response is re-
quired immediately because of a medical emergency.
If your question or complaint does not involve HMOC's utilization
review guidelines, follow these steps on how to appeal the action HMOC
has taken on a claim:
1. Call our Customer Service office for an explanation and review of your
case.
2. If you are not satisfied with the explanation given, send HMOC a
written appeal within 60 calendar days of the decision. Be sure to
include any additional information that will help support your reason
for appealing the decision. HMOC's appeal committee will send a
written response to your appeal within 21 working days after receipt of
your letter. HMOC will schedule the committee meeting at a time
convenient for you or your representative to attend, either in person or
by telephone. If, because of a delay beyond HMOC's control, HMOC
cannot make a final decision within 21 working days, we will send you
written notice of the delay.
62 - Customer Service:(800)334-6557 or(303)831-0161 BLUHW1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 6: Claims Payment and Appeals
3. If you are not satisfied with the committee's decision, you may submit
a second written appeal within 60 days of HMOC's notice to you of the
decision. This appeal will be reviewed by a committee of appropriate
experts who are not employees of HMOC. HMOC will schedule the
committee meeting at a time convenient for you or your representative
to attend, either in person or by telephone. The committee will send a
written response to your appeal within 45 working days after HMOC
receives your appeal. HMOC will act upon their decision. If, because of
a delay beyond HMOC's control, HMOC cannot make a final decision
within 45 working days, HMOC will send you written notice of the
delay.
Send all letters of appeal to:
HMO Colorado
Customer Service appeals
700 Broadway
Denver, CO 80273
• Grievance Procedures
If any party involved is not satisfied with the decision of the HMOC Griev-
ance Committee, he/she may pursue the remedies available under the
Employee Retirement Income Security Act of 1974 (ERISA) or binding
arbitration, whichever is applicable to the member's plan. Any party
alleging a claim against HMOC, including a claim for denial of benefits or
coverage, must follow the appeal and grievance process before instituting a
legal proceeding, suit, or arbitration against HMOC.
Before the member takes legal action against HMOC, the member must
meet all the requirements of this plan and have completed all steps in the
"Complaint" process.
No suit or action in law or equity or arbitration may be taken until 60 days
after HMOC has received a report of services from you or on your behalf on
forms furnished by HMOC.
You may not bring a suit or action in law or equity or arbitration later
than 3 years after the time of written proof of loss is required to be
furnished.
• Refusal to Follow Recommended Treatment
If a member refuses treatment that has been recommended by an HMOC
participating provider, the provider may decide that the member's refusal
compromises the provider-patient relationship and obstructs the provision
of proper medical care. Providers will try to render all necessary and
appropriate professional services according to a member's wishes, when
they are consistent with the provider's judgment. If a member refuses to
follow the recommended treatment or procedure, the member is entitled to
see another provider of the same specialty for a second opinion. The
member can also pursue the appeal process. If the second provider's
opinion upholds the first provider's opinion and the member still refuses to
follow the recommended treatment, then the member's coverage may be
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 0!40125 63
Section 6: Claims Payment and Appeals BlueAdvantage HMO Plan
terminated by HMOC following a 30-day notice to the member. If coverage
is terminated, neither HMOC nor any provider associated with HMOC will
have any further responsibility to provide care to the member.
HMOC may also cancel any member's coverage who acts in a disruptive
manner that prevents the orderly operation of any HMOC participating
provider.
• Catastrophic Events
In case of fire, flood, war, civil disturbance, court order, strike, or other
cause beyond HMOC's control, HMOC may be unable to process claims or
provide prior authorization for services on a timely basis. No suit or action
in law or equity may be taken against HMOC because of a delay caused by
any of these events.
If, due to circumstances not within the control of HMOC or an HMOC
participating provider, such as partial or complete destruction of facilities,
war, riot, prevailing insurrection, disability of an HMOC participating
provider, or similar case, the provision of medical services is delayed or
rendered impractical, HMOC or the provider will have no liability or
obligation on account of delay or failure to provide medical service. No suit
or action in law or equity may be taken against HMOC due to delay on
account of any of these events. HMOC and HMOC participating providers
will, however, make a good-faith effort to provide services.
• Research Fees
HMOC reserves the right to charge an administrative fee when extensive
research is necessary to reconstruct information that has already been
provided to a member in explanations of benefits, letters, or other forms.
■ Sending Notices
All notices to the member are considered to be sent to and received by the
member when deposited in the United States mail with first class postage
prepaid and addressed to either the member at the latest address on
HMOC membership records or to the member's employer. Nothing in this
paragraph will create any notice obligations or fiduciary duties for HMOC
except those expressly identified in this benefit booklet.
• Member's Legal Expense Obligations
The employee and his/her dependents are liable for any actions that may
prejudice HMOC's rights under this plan. If HMOC must take legal action
to uphold its rights and prevails in that action, HMOC will be entitled to
receive and the member will be required to pay HMOC's legal expenses,
including attorneys' fees and court costs.
64 Customer Service:(800)334-6557 or(303)831-0161 HWH0]1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 7: Enrollment and Termination Information
7 Enrollment and Termination Information
■ Who Is Eligible
All employees living within the HMOC service area, who have a regular
workweek as specified in the Group Master Contract are eligible for
coverage. To find out the number of hours you must work per week in
order to qualify, contact your employer.
Other persons in a nonemployee relationship with the group or business
may also be eligible for coverage, if specified in the Group Master Contract
(e.g., retirees or COBRA-eligible members).
HMOC reserves the right to verify an employee's eligibility for coverage by
requesting proof that a valid employer-employee relationship exists and
that the employee otherwise meets the eligibility requirements as stated in
the Group Master Contract and the employee's application. The employer
has agreed to permit HMOC to perform payroll audits.
Eligible Dependents
A dependent child's eligibility is subject to an age limitation. Your group's
Optional
dependent age limit is listed on your Summary of Benefits and
Copayments.
Check Your Group
Summary of Benefits
and Copayments Eligible dependents include:
• a legal spouse
• an unmarried child under 19 years of age and unmarried child under
24 years of age who is financially dependent upon the parent. At the
end of the month of the limiting age, as appropriate, the child is
automatically removed from coverage as a dependent
• an unmarried child of any age who is medically certified as disabled
and dependent upon the parent. We must receive notice of the condi-
tion.
Note: A child includes, natural-born children of the subscriber or the
subscribers spouse, adopted children, a child placed for adoption, or a child
required to be covered because of a court order pursuant to state law. A
child does not include grandchildren or other children unless legal
guardianship has been established pursuant to state law. We may request
proof that a child qualifies as an eligible dependent.
Medicare-Eligible Members
Before a member becomes age 65, or if any member qualifies for Medicare
benefits, the member is responsible for contacting the local Social Security
office to establish Medicare eligibility. The member should then contact
his/her employer to discuss coverage options.
BLUH071M.CRC(Rev.6/97) Customer Service: (800)334-6557 or(303)831-0161 p,n032S 65
a.• C11.
Section 7: Enrollment and Termination Information BlueAdvantage HMO Plan
If an employee qualifies under the provisions of federal law for the work-
ing aged (TEFRA), then the working employee age 65 or over and/or
his/her spouse age 65 or over may continue coverage under this health care
plan. If a TEFRA-eligible Medicare beneficiary selects Medicare as his or
her primary coverage, coverage under this plan ends for this member.
Special Medicare Secondary Payer (MSP) rules apply if a member is receiv-
ing benefits from Medicare due to a disability or end-stage renal disease.
Contact your employer for more information and for eligibility guidelines
that apply to you.
For groups with fewer than 20 employees and all other groups not subject
to MSP provisions, when a member becomes eligible for Medicare Part A
and/or Part B, coverage under this booklet will continue, but benefits will
be coordinated with Medicare with this coverage being secondary to any
Medicare coverage.
Notification of Eligibility Changes
Day ‘4' An employee must notify HMOC within 30 days following any changes
Limit that may affect his/her or a dependent's eligibility by indicating such
changes on an enrollment/change form. It is also the employee's responsi-
bility to notify HMOC of any change to a member's name or address.
IN When Coverage Begins
Your employer will determine the effective date of your coverage according
to the provisions of the Group Master Contract. Your ID card will also
indicate the member's effective date of coverage.
This plan does not cover any service received before the member's effec-
tive date of coverage. Also, if the employee's prior coverage has an
extension of benefits provision, HMOC will not cover charges incurred
after a member's effective date under this plan that are covered under the
prior coverage. If a member is receiving inpatient care on the effective date
of coverage, services will be covered under this benefit booklet if the
member receives services from an HMOC provider.
• Application for Coverage
t Eligible employees can apply for coverage for themselves and their eligible
Limit dependents by submitting an enrollment application to this plan within
30 days after becoming eligible. Employees may also apply within 30 days
of acquisition for coverage of newly acquired dependents (such as a new-
born child, a child placed in the employee's home for the purpose of
adoption, an adopted child, or a new spouse). When dependents are added,
you may need to change to suitable coverage based on the number of family
members being covered. Dependent coverage is effective on the date the
dependent became eligible. With the exception of members who did not
enroll when initially eligible because they had other group coverage which
was subsequently lost, application for coverage from late applicants will be
accepted during open enrollment. See "Late Applicants," below.
66 - Customer Service:(800)334-6557 or(303)831-0161 BLUH071M.CRC(Rev.6197)
BlueAdvantage HMO Plan Section 7: Enrollment and Termination Information
Open Enrollment
An open enrollment period (usually 30 days prior to the renewal date) will
be held annually or at other times as mutually agreed upon by the
employer and HMOC. During the open enrollment period, any eligible
employee and/or his/her eligible dependents may enroll as members under
this plan.
Switch Enrollment
If your group provides a multiple choice health care program to its mem-
bers, during group renewal covered employees may switch coverage for
themselves and their covered dependents, to another product offered by
the group.
Special Enrollment
If the employee declined enrollment for him/herself or his/her dependents
because of other coverage, the employee and dependents may enroll in the
future in this plan provided that the employee requests enrollment within
30 days after the other coverage involuntarily ends. The other coverage
must be lost due to termination of employment or eligibility, reduction in
the number of hours the employee works, the involuntary termination of
creditable coverage, death of a spouse, legal separation or divorce, or the
contribution towards the coverage terminating. Coverage with HMOC will
be effective the day following the loss of other coverage. If the other
coverage that is lost is COBRA or state continuation coverage, enrollment
can only be requested after exhausting COBRA or state continuation
coverage.
A special enrollment can also occur when an employee who was previously
not enrolled, marries or has a new child (as a result of marriage, birth,
adoption or when a child who is under the age of 18 is placed in the
employee's home for the purpose of adoption.) The employee and any
dependents can enroll within 30 days of the marriage or acquisition of the
dependent. Coverage with HMOC will be effective the day following the
marriage or acquisition (charges related to labor and delivery due to the
birth are not covered).
When an employee is required by court or administrative order to provide
coverage for an eligible dependent, the eligible dependent may be enrolled
within 30 days of such order. If not specified in the court order, the eligible
dependent's effective date of coverage will be the date of HMOC's receipt of
the court order. (HMOC must receive a copy of the court order.)
Late Applicants
Anyone eligible who did not enroll during the group's initial enrollment,
within 30 days of becoming eligible, or within 30 days of a special
enrollment is considered a late applicant and will not be allowed to enroll
until the group's next open enrollment. For example, a newborn child add-
ed to coverage more than 30 days after birth or a child placed in the
9LUHo71M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 Q^0325 67
Section 7: Enrollment and Termination Information BlueAdvantage HMO Plan
employee's home for the purpose of adoption added more than 30 days
after legal adoption is a late applicant. A new employee or a new spouse
added to coverage more than 30 days after becoming eligible is also a late
applicant.
If an employee enrolls as a late applicant, eligible dependents seeking
coverage at the same time will also be late applicants.
Adding a Newborn or Adopted Child
The employee must enroll a newborn child, a child placed for adoption, or
Day `4 an adopted child within 30 days of the child's birth, placement, adoption.
Limit (A newborn child of an unmarried dependent son or daughter does not
qualify as a dependent under this plan.)
The following rules apply to newborn children from birth and to adopted
children from the earlier of the date of adoption or placement for adoption
as certified by the public or private agency making the placement:
• Under Individual coverage, an employee's newborn child, adopted
child, or a child placed in the employee's home for the purpose of
adoption, will be covered automatically until the newborn child is
31 days old or the child has been with the employee for 31 days; how-
ever, the employee must submit an enrollment/change form to notify
HMOC of the birth, adoption, or intended adoption, and select a PCP
for the child.
If the child is to continue coverage beyond the 31st day, the employee
must notify HMOC within 30 days after the child's birth, adoption, or
placement in the home. The employee must change to suitable
coverage within that same 30-day period and agree to pay the premium
for such coverage beginning on the 32nd day.
• Under Family coverage, an employee's newborn child, adopted child,
or child placed in the employee's home for the purpose of adoption, will
be covered automatically until the newborn child is 31 days old or the
child has been with the employee for 31 days; however, the employee
must submit an enrollment/change form to notify HMOC of the birth,
adoption, or intended adoption, and select a PCP for the child.
To ensure that coverage is provided beyond the first 31 days, the
employee must submit an enrollment/change form to HMOC within
30 days of birth, adoption, or placement in the home.
Note: The coverage established for a child during the initial 31-day period
is identical to that of the employee. All services provided during the first
31 days of coverage are subject to the terms of this benefit booklet,
including all applicable copayments.
68 , '... Customer Service:(800)334-6557 or(303)831-0161 eWH0]1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 7: Enrollment and Termination Information
If an employee does not change coverage or add the child to existing
coverage within 30 days of birth, adoption, or placement for adoption, the
child will be considered a late applicant and coverage for the child cannot
be added until the group's next open enrollment.
If the mother of the newborn is a dependent child of the employee (i.e., the
newborn is the grandchild of the employee), benefits are not available for
the newborn.
D ■ Removing a Dependent From Coverage
To remove a dependent from coverage, the employee must complete and
"St I submit an enrollment/change form. HMOC must receive this form within
30 days following the effective date of the change. If an employee fails to
timely remove an ineligible dependent, HMOC and the providers of care
may recover benefits erroneously paid to the employee on behalf of the
removed member.
HMOC will not refund membership premiums paid in advance on behalf of
the removed member if:
• the enrollment/change form is not received within 30 days of the
effective date of change; or
• any claims or capitation amounts have been paid on behalf of the
removed member during the period for which premiums have been
paid.
• Leave of Absence
For a leave of absence not covered by the Family and Medical Leave Act
(FMLA) or by state of federal.law, coverage may continue for employees
and eligible dependents covered on the date the leave of absence begins
through the end of the month during which the leave begins. During a
leave of absence covered by the FMLA or state or federal law, coverage will
continue as provided by law. Contact your employer for information.
• Coverage Termination
Any member losing eligibility under this plan may be able to continue as a
group member for a limited period of time. Contact your employer for
information on continuation of BlueAdvantage HMO Plan coverage under
Colorado law or federal law (Consolidated Omnibus Budget Reconciliation
Act of 1985 —COBRA).
This plan does not cover services, even if prior authorized by HMOC,
that are received after a member's coverage under this health care plan is
terminated—even if the services were made necessary by an accident,
illness, or other event that occurred while coverage was in effect, or the
member was hospitalized at the time of termination.
BLUH0J1M.CRC(Rev.&97) Customer Service: (800)334-6557 or(303)831-0161 °°0325 69
Section 7: Enrollment and Termination Information BlueAdvantage HMO Plan
When Coverage Ends
If a member does not elect or does not qualify for continuation coverage,
coverage for any member (including dependents) ends on the earliest of the
following dates:
• When the member's group gives HMOC 30 days' advance written
notice of termination.
Day � • The end of the month following the employee's termination of employ-
Limit ment. If the group fails to notify HMOC within 30 days to remove an
ineligible person from coverage, HMOC reserves the right to recover
any payment made on the employee's or his/her dependent's behalf.
• The date group coverage is discontinued for the entire group or for the
employee's enrollment classification.
• When the member moves and therefore neither resides nor works
within the HMOC service area, unless the member is continuing
coverage under COBRA continuation. The member must notify HMOC
within 30 days of such a change in location. Coverage will end on the
last day of the month in which the change of residence is reported;
until that time, the only out-of-area services covered will be emer-
gency care (see the Glossary). Nonemergency care will not be
covered.
If a member does not notify HMOC of a change of residence or work-
place to an area outside of the HMOC service area, and HMOC later
becomes aware of the change, the member's coverage may be retro-
actively terminated to the date of the change of residence or place of
employment. The member will be liable to HMOC and/or the providers
for payment for any services covered in error.
• Upon the employee's death (surviving eligible dependents remain
covered through the last-paid billing period).
• When HMOC does not receive the premium payment on time.
• When there is a misrepresentation or improper use of the Group
Master Contract, benefit booklet, or ID card, the improper filing of
claims, or false or incomplete information is presented on the
enrollment/change form. The employee is liable for any benefit pay-
ments made as a result of such improper actions.
• When Medicare becomes the member's primary coverage, unless the
member is in a group with fewer than 20 employees (see "Medicare-
Eligible Members," earlier in this section).
• In accordance with "Refusal to Follow Recommended Treatment" in
Section 6: Claims Payment and Appeals, when the member is unable to
establish a positive patient-physician relationship with a PCP.
• When the member acts in a disruptive manner that prevents the
orderly business operation of any HMOC participating provider or is
dishonestly attempting to gain a financial or material advantage.
• When HMOC ceases operations. HMOC will be obligated for services
for the rest of the period for which premiums were already paid.
• When the member is no longer eligible for this group coverage under
the terms of the Group Master Contract.
70 Customer Service:(800)334-6557 or(303)831-0161 9WN071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 7: Enrollment and Termination Information
In addition, coverage will end for any dependent on the earliest of the
above dates or the earliest of the following dates:
• When the dependent child marries.
• At the end of the last-paid billing period for dependent coverage.
• When the dependent no longer qualifies as a dependent under the plan
or reaches the dependent age limit specified on your Summary of
Benefits and Copayments.
• The date of a final divorce decree or legal separation for a dependent
spouse.
• When the employee notifies HMOC in writing to end coverage for a
dependent.
Except for termination of the Group Master Contract or termination due to
loss of eligibility, HMOC will not terminate a member's coverage with
out giving the member 30 days' written notice. Also, if the employer fails to
desubmit premium payments to HMOC on a timely basis, coverage will
Limit terminate for all affected members as of the end of the last-paid billing
period. HMOC will notify the members of any conversion of cover-
age rights.
■ Conversion Coverage
Members who were covered under the group health program may change
to group conversion coverage with HMOC when this group health program
ends, for any reason, other than replacement by the employer with another
group policy, or fraud and abuse in procuring and using the coverage.
HMOC must receive the application for group conversion coverage within
30 days after group coverage i.s terminated. The member must pay group
conversion premium from the date of such termination.
Group conversion is not available to former employees of a group and their
dependents in the following situation:
1. When an employee is not a group member by virtue of not having
been covered under the group plan at the time of termination of
coverage.
2. When a dependent was not covered through the group at the time
of the employee's termination of coverage.
3. When the employer group cancels and replaces coverage with
another insurance carrier or self-insures.
4. When there is fraud and abuse in procuring and using coverage.
5. When an employee or dependent is eligible for Medicare Part A
and/or Part B at the time of eligibility for group conversion cover-
age. Contact HMOC for coverage options available.
NOTE: If you do not want or are not eligible for conversion coverage,
HMOC will consider applications for enrollment of members as new
nongroup members under then-available coverage, rates, and benefits.
HMOC will accept your application subject to applicable rules for non-
group coverage.
BLUH071M CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 pn•1325 71
Section 7: Enrollment and Termination Information BlueAdvantage HMO Plan
• Membership Records
HMOC will keep membership records, and the employer will periodically
forward information to HMOC to administer the coverage of this plan. All
records concerning your membership in HMOC are available for your
inspection during normal business hours given reasonable advance notice.
• Certificates of Coverage
When an individual leaves HMOC, they are entitled to receive a certificate
of coverage which will identify the length of the individuals credited
coverage under the plan. This Certificate of Coverage is needed when the
individual enrolls with another plan that may impose a pre-existing
condition waiting period.
72 i ' Customer Service:(800)334-6557 or(303)831-0161 swHo71 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 8: General Provisions
8 General Provisions
■ Advance Directives
An advance directive is a written instruction, such as a living will or
durable power of attorney for health care, recognized under state law
relating to the provision of health care when the individual is
incapacitated.
The law provides anyone with the right to determine whether health care
services should or should not be provided if he/she were to become in-
capacitated. These advance directives will guide health care providers.
HMOC encourages the member to discuss this with the PCP.
IN Availability of Provider Services
HMOC makes no guarantee as to the type of room or services that will be
available at any hospital or other facility within the HMOC network, nor
does HMOC guarantee that the services of a particular hospital or
physician will be available.
IN Binding Arbitration
The "Binding Arbitration" provision is applicable to all governmental
plans, church plans, and plans maintained outside the United States
primarily for the benefit of persons substantially all of whom are non-
resident aliens. If a dispute about coverage, benefits, or handling of claims
continues after the member has followed and exhausted the "Complaint,
Grievance, and Appeal Procedures" set forth in Section 6. the issue or
claim must be submitted to binding arbitration. Any such arbitration will
be governed by the procedures and rules established by the American
Arbitration Association. To the extent applicable, Colorado law governing
arbitration will govern. Members may obtain a copy of the Rules of Ar-
bitration from a customer service representative.
The decisions in arbitration are binding upon both the member and
HMOC. Judgment on the award given in arbitration may be enforced in
any court that has proper authority.
Damages, if any, are limited to the amount of the benefit payment in
dispute plus reasonable costs. HMOC is not liable for punitive damages or
attorney fees.
BLURm1M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 F e:0325 73
Section 8: General Provisions BlueAdvantage HMO Plan
• Changes to the Benefit Booklet
HMOC may amend this benefit booklet when authorized by an officer of
HMOC. Any amendment will be provided to the employer within 60 days
following the effective date of the amendment.
No employee of HMOC may change this benefit booklet by giving incom-
plete or incorrect information, or by contradicting the terms of this benefit
booklet. Any such situation will not prevent HMOC from administering
this benefit booklet in strict accordance with its terms.
■ Delivery of Documents
HMOC will issue to the employer, or mail to the member's address as
listed on the enrollment/change form, a benefit booklet setting forth the
services to which members are entitled and, for each member, a Blue-
Advantage identification card.
■ Disclaimer of Liability
HMOC has no control over any diagnosis, treatment, care, or other service
provided to a member by any facility or professional provider, whether
participating or not, and is not liable for any loss or injury caused by any
health care provider by reason of negligence or otherwise.
• Execution of Papers
On behalf of yourself and your dependents you must, upon request, execute
and deliver to HMOC any documents and papers necessary to carry out the
provisions of this plan.
• Fraudulent Insurance Acts
It is unlawful to knowingly provide false, incomplete, or mislead-
ing facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties
may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose
of defrauding or attempting to defraud the policyholder or claim-
ant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
• Independent Contractors
The relationship between HMOC and its HMOC participating providers is
that of independent contractors; physicians and other providers are not
agents or employees of HMOC, and HMOC and its employees are not
employees or agents of any HMOC participating provider. HMOC will not
be liable for any claim or demand on account of damages arising out of, or
74 - , Customer Service:(800)334-6557 or(303)831-0161 BLUH071 M.CRC(Rev.6/07)
BlueAdvantage HMO Plan Section 8: General Provisions
in any manner connected with, any injuries suffered by the member while
receiving care from any HMOC participating provider.
The relationship between HMOC and the group is that of independent
contractors; the employer is not an agent or employee of HMOC, and
HMOC and its employees are not employees or agents of the employer.
• Pilot Programs
HMOC may occasionally develop pilot programs to test different services
or recognize different providers. The fact that a pilot program may exist
does not guarantee that all members are eligible for coverage of pilot
program services, or that such services will be covered permanently.
• Release of Information
Ordinarily, HMOC will not release medical information without the
member's written consent. That information is strictly confidential.
Patients are given the opportunity to approve or refuse the release of
medical information. However, a BlueAdvantage member authorizes
HMOC to release medical information without notice or consent when:
• Peer and utilization review boards and/or HMOC medical consultants
need such information, or such information is needed for quality as-
surance activities to ensure that the member is getting appropriate
and medically necessary care and that services are among those
covered by this plan.
• HMOC receives a judicial or administrative subpoena for such infor-
mation.
• The Colorado Division of Insurance requests such information.
• The information is required for coordination of benefits.
• The information is requested or provided in connection with group
utilization data.
A member must provide HMOC with whatever information is necessary to
determine coverage. HMOC may obtain information from any insurance
company, organization, or person when such information is necessary to
carry out the provisions of this plan. Such information may be exchanged
without consent of, or notice to, the member.
Members agree to cooperate at all times (including while hospitalized) by
allowing HMOC access to their medical records to investigate claims or
issues of quality of care, and verify information provided on the
enrollment/change form and/or health statement. Members also agree to
execute whatever documents are necessary in order for HMOC to deter-
mine coverage under this plan. If a member does not cooperate, the
member forfeits all rights to benefit payments on those claims subject to
investigation and acknowledges that his/her coverage may be cancelled.
9wHm1M.CRC(Rev.6191) Customer Service:(800)334-6557 or(303)831-0161 Q^n't25 75
Section 8: General Provisions BlueAdvantage HMO Plan
To help HMOC determine which services qualify for coverage, members
authorize all providers of health care services to provide HMOC with any
medically related information pertaining to their treatment.
Members waive all provisions of law that are subject to waiver, and which
otherwise restrict or prohibit providers of health care services or supplies
from disclosing or testifying to such information.
■ Statement of ERISA Rights
The group health care coverage provided by your employer may be part of
an employee welfare benefit plan governed by the Employee Retirement
Income Security Act of 1974 (ERISA). The statement of ERISA rights is
applicable to all plans except governmental plans, church plans, and plans
maintained outside the United States primarily for the benefit of persons
substantially all of whom are nonresident aliens. As a participant in an
ERISA plan, you are entitled to certain rights and protections under
ERISA. ERISA provides that all plan participants be entitled to:
• Examine at the plan administrator's office, without charge, copies of
all documents filed by the plan with the U.S. Department of Labor,
such as detailed annual reports and plan descriptions.
• Obtain copies of all plan documents and other plan information upon
written request to the plan administrator. The administrator may
make a reasonable charge for the copies.
• Receive a summary of the plan's annual financial report. The plan
administrator is required by law to furnish each participant with a
copy of this summary annual report.
In addition to creating rights for plan participants, ERISA imposes duties
upon the people who are responsible for the operation of the employee
benefit plan. The people who operate your plan, called "fiduciaries" of the
plan, have a duty to do so prudently and in the interest of you and other
plan participants and beneficiaries. No one, including your employer or
any other person, may fire you or otherwise discriminate against you in
any way to prevent you from obtaining health care benefits or exercising
your rights under ERISA.
If your claim for a benefit is denied in whole or in part, you must receive a
written explanation of the reason for the denial. You have the right to have
the plan review and reconsider your claim. You must follow the
"Complaint, Grievance, and Appeal Procedures" set forth in Section 6.
Under ERISA, there are steps you can take to enforce the above rights
after you have exhausted the "Complaint, Grievance, and Appeal Proce-
dures." For instance, if you request materials from the plan and do not
receive them within 30 days, you may file suit in a federal court. In such a
case, the court may require the plan administrator to provide the materials
and pay you up to $100 a day until you receive the materials, unless the
materials were not sent because of reasons beyond the control of the
administrator.
76 Customer Service:(B00)334-6557 or(303)831-0161 6wH W 1 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Section 8: General Provisions
If you have a claim for benefits that is denied or ignored, in whole or in
part, you may file suit in federal court after you have exhausted the
"Complaint, Grievance, and Appeal Procedures" set forth in Section 6. If it
should happen that plan fiduciaries misuse the plan's money, or if you are
discriminated against for asserting your rights, you may seek assistance
from the U.S. Department of Labor, or you may file suit in a federal court.
The court will decide who, if anyone, should pay court costs and legal fees.
If you are successful, the court may order the person you have sued to pay
these costs and fees. If you lose, the court may order you to pay these costs
and fees.
If you have any questions about your plan, contact the plan administrator.
If you have any questions about this statement or about your rights under
ERISA, contact the nearest Area Office of the U.S. Labor-Management
Services Administration, Department of Labor.
Please be advised that this plan document gives the plan administrator or
fiduciary discretionary authority to determine eligibility for benefits or to
construe the terms of the plan. The plan specifically reserves to the plan
administrator or fiduciary, the discretion and authority to make such
determinations. HMOC is not the administrator of your employer's plan,
but is a fiduciary. Contact your employer to find out who is the plan
administrator.
• Utilization Review and Quality Management
Medical records, claims, and requests for covered services may be reviewed
to establish that the services are/were medically necessary, delivered in
the appropriate setting, and consistent with the condition reported and
with generally accepted standards of medical and surgical practice in the
area where performed.
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 77
Glossary BlueAdvantage HMO Plan
■ Glossary
This section defines certain words used throughout the benefit booklet.
Reading this section will help you understand the rest of the benefit
booklet. You may also want to refer back to this section to find out exactly
how—for the purposes of this benefit booklet— a word is used.
Admission— the period of time between the date a patient enters a
facility as an inpatient and the date he or she is discharged as an
inpatient.
After-hours care—office services requested after a provider's normal or
published office hours or services requested on weekends and holidays.
Authorization— see "Prior authorization," below.
Benefit booklet— this document, which explains the benefits, limitations,
exclusions, terms, and conditions of the member's health coverage. The
final interpretation of any specific provision contained in this booklet is
governed by the Group Master Contract.
Billed charges— the full amount the provider charges for a particular
service.
Copayment— the amount the member must pay for a covered service.
Copayments are listed on the Summary of Benefits and Copayments and
are either a predetermined fixed-dollar amount or a percentage of billed
charges.
Covered services— services and supplies which are provided to a member
and for which HMOC has an obligation to pay under the terms of this
benefit booklet.
Dependent—a person entitled to apply for coverage as specified in Sec-
tion 7: Enrollment and Termination Information.
Effective date of coverage— 12:01 A.M. of the date on which coverage for
a member begins.
Emergency care—Means the sudden, and at the time, unexpected onset
of a health condition that requires immediate medical attention, where
failure to provide medical attention would result in serious impairment to
bodily functions or serious dysfunction of a bodily organ or part, or would
place the persons health in serious jeopardy.
78 s ' 1 Customer Service:(800)334-6557 or(303)831-0161 RLUH071M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Glossary
Employee— the individual whose employment or other status, except for
family dependency, is the basis for enrollment eligibility. The term
"employee" may also encompass other persons in a relationship with the
employer, such as retirees, members of the board of directors, etc., if
eligible under terms of the Group Master Contract. The term "employee"
may also refer to a member enrolled as a COBRA participant.
Experimental or investigative— see "Experimental or Investigative Proce-
dures or Services" in Section 4: General Exclusions.
Facility— see "Provider,"below.
Group—a bona fide employer covering employees of such employer for the
benefit of persons other than the employer; or an association, including a
labor union, that has a constitution and bylaws and is organized and
maintained in good faith for purposes other than that of obtaining
insurance.
Group Master Contract a contract for health care services which by its
terms limits eligibility to members of a specified group. The Group Master
Contract includes the group application for coverage and may include
coverage for dependents.
HMO Colorado(HMOC)—a federally qualified health maintenance
organization organized under the laws of the State of Colorado except as
described below.
For employers with 50 or fewer employees, the BlueAdvantage HMO plan
is not federally qualified.
For employers with 51 or more employees, the BlueAdvantage HMO plan
is federally qualified in the following Colorado counties:
Adams Arapahoe Boulder Clear Creek Crowley
Denver Douglas El Paso Fremont Gilpin
Huerfano Jefferson Larimer Otero Pueblo
Teller Weld
For employers with 51 or more employees, if a county is not listed above,
this BlueAdvantage HMO Plan is not federally qualified, but does meet all
the requirements of a federally qualified plan.
HMOC participating provider—either a facility, such as a hospital, or a
professional provider, such as a physician, that has entered into an
agreement with HMOC to bill directly, and to accept this plan's payment
(provided in accordance with the provisions of the contract) plus the mem-
ber's copayment as payment in full for covered services. HMOC will pay
the participating facility or professional provider directly. HMOC may add,
change, or delete specific providers at its discretion or recommend a
specific provider for specialized care as medical necessity warrants.
BLUH071M.CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 99J35 79
Glossary BlueAdvantage HMO Plan
HMOC service area— the geographic area where HMOC is licensed to
conduct business.
HMO-USA— a national network of Blue Cross and Blue Shield-sponsored
HMOs through which nationwide urgent care services are available to
BlueAdvantage members.
Hospital— a health institution offering facilities, beds, and continuous
services 24 hours a day, seven days a week. The hospital must meet all
licensing and certification requirements of local and state regulatory
agencies. Services provided include:
• diagnosis and treatment of illness, injury, deformity, abnormality, or
pregnancy
• clinical laboratory, diagnostic x-ray, and definitive medical treatment
provided by an organized medical staff within the institution
• treatment facilities for emergency and surgical services either within
the institution or through a contractual arrangement with another li-
censed hospital (these contracted services must be documented by a
well-defined plan and related to community needs)
• is not, other than incidentally, a skilled nursing facility, nursing home,
custodial care home, health resort, spa, or sanatorium
• is not a place for rest, for the aging, for the treatment of mental illness,
alcoholism, drug abuse, or pulmonary tuberculosis, and ordinarily does
not provide hospice or rehabilitation care, and is not a residential
treatment facility
Identification card(ID card)— the card HMOC issues to the employee and
each of his/her dependents that identifies the cardholder as a Blue-
Advantage member.
Inpatient—a patient in residence in a hospital or facility for at least one
full night. Any services received as an inpatient are inpatient services (also,
see "Admission"in this section).
Maternity— any condition that is related to pregnancy. Maternity care
includes prenatal and postnatal care, and care for the complications of
pregnancy, such as ectopic pregnancy, spontaneous abortion (miscarriage),
elective abortion, or cesarean section. See "Maternity and Newborn Care"
in Section 3: Covered Services for more information.
Medically necessary—A term used to describe technologies, services, or
supplies received from a provider that HMOC determines are:
• medically appropriate, considering the patient's age and health, for the
symptoms and diagnosis or treatment of the condition, illness, disease,
or injury;
• provided for the diagnosis, or the direct care and treatment of the
member's condition, illness, disease, or injury;
• in accordance with standards of sound medical practice;
80 '4' •.nr.�st.,�cl�tw: Customer Service:(800)334-6557 or(303)831-0161 BWH071M.CRC(Rev.6/97)
(N_t ,
BlueAdvantage HMO Plan Glossary
• not primarily for the convenience of the member, the member's family,
or the member's provider; and
• the most appropriate supply or level of service that can safely be
provided to the member. When applied to hospitalization, this also
means that the member requires inpatient acute care due to the
nature of the services rendered or of the member's condition, and the
member cannot receive safe or adequate care as an outpatient.
Note: HMOC's decision as to whether a service is medically necessary is
based on generally accepted medical or surgical standards. Coverage for
services that are not medically necessary may be denied either before or
after they are rendered.
The fact that a physician may prescribe, order, recommend, or approve a
service does not, by itself, make it medically necessary or a covered service,
even though it is not specifically listed as an exclusion.
Member— the employee or any eligible dependent who is enrolled for
coverage under this plan in accordance with the terms of the Group Master
Contract.
Member's service area— the geographic area serviced by the member's
personal care network.
Nonparticipating provider— an appropriately licensed health care
provider that has not contracted with HMOC. Except as described in
Section 3: Covered Services, HMOC will not cover services provided by a
nonparticipating provider. The member will be financially responsible for
such services unless referred to the provider by his/her PCP, and then only
if the referral is approved by HMOC or if a service does not require a
referral.
Open enrollment—a period of time (usually 30 days) before the renewal
date of the group during which eligible employees and dependents may
select BlueAdvantage coverage.
Out-of-area services—those covered services that are provided to a
member when the member is outside the HMOC service area. See "HMOC
service area," above.
Pay, paid, or payment—to satisfy a debt or obligation. HMOC may satisfy
its responsibility to providers for covered services under this benefit
booklet by making a monthly fixed payment to the provider, by a negotiat-
ed discount arrangement, by an actual dollar payment, or by any
combination of these three arrangements.
BLUH071M CRC(Rev.6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 81
Glossary BlueAdvantage HMO Plan
Personal care network— a specific network of providers covering a
geographic service area. It includes one hospital and certain PCPs and
specialists. In some parts of the HMOC service area, all specialties and
facility services may not be available in the member's personal care
network. In these circumstances, the member's PCP may refer the member
outside of his/her personal care network.
Physician— a doctor of medicine or osteopathy who is licensed to practice
medicine under the laws of the state or jurisdiction where the services are
provided.
Plan— the benefits, copayments, exclusions, and limitations described in
this benefit booklet and administered by HMOC.
Prior authorization— a requirement for approval from HMOC before
delivery of certain types of services. Before the service is received, the
physician must obtain written approval for coverage.
Provider—a term used to describe any of a wide variety of people or
facilities that render health care services. Many of the different providers
are defined here.
• Facility provider: an alcohol or drug treatment center, day surgery
or ambulatory surgery center, home health agency, skilled nursing
facility, hospital, or other facility that is licensed or certified to perform
designated. covered health care services by the state or jurisdiction
where services are provided.
• Primary care provider (PCP): a physician (or group of physicians)
who has contracted with HMOC to supervise, coordinate, and provide
initial and basic care to members, initiate a referral for specialist care,
and maintain continuity of patient care.
• Professional provider: a physician or other professional provider
who is licensed, certified, or registered by the state or jurisdiction
where services are provided to perform designated, covered health care
services, and who is recognized by HMOC as a health care provider.
Ancillary providers, such as professional suppliers of medical supplies
and equipment may be considered professional providers.
• Referral provider: a provider to whom a PCP has referred a member
for consultation and/or treatment.
Referral— a written authorization form from a member's PCP or from
HMOC, received in advance of services, that allows a member to receive
services from a provider other than the member's PCP.
Routine care— services for conditions not requiring immediate attention
and that can usually be received in the PCP's office, or services that are
usually done periodically within a specific time frame (e.g., immunizations,
physical exams).
d • ` .4
82 -*14..0. • Y,: r Customer Service:(800)334-6557 or(303)831-0161 BLUH071 M.CRC(Rev.6/97)
BlueAdvantage HMO Plan Glossary
Service area— see "HMOC service area," above.
Summary of Benefits and Copayments—The schedule that defines the
member's copayment requirements and optional coverages, along with an
overview of covered services.
Urgent care— situations that are not life-threatening but require prompt
medical attention to prevent a serious deterioration in a member's health.
•
RLUH071M.CRC(Rev.6/91) Customer Service:(800)334-6557 or(303)831-0161 990325 83
Index BlueAdvantage HMO Plan
■ Index
Accident 13,28, 48, 55, 58-60, 69 Experimental 32, 50, 79
Acupuncture 48 Family coverage 68
Adopted child 24, 66, 68 Family planning . ii, 6, 9, 14, 28, 29, 35-37,39, 40, 51, 53, 5
After-hours care . iii, iv, 4, 6, 9, 10, 14-17,21,23, 27, 28, 78 4
Air ambulance 10 Full-time student 4
Alcoholism 10, 11, 21, 26-28, 80 Grievance 63, 73, 76, 77
Allergy 14,28 Group Master Contract i 65, 66, 70, 71, 78, 79, 81
Ambulance 9, 10, 15 Hair loss 50
Anesthesia 13, 24, 39-41 HMO-USA iii, 17, 80
Appeal process 54, 63 Home health care 7, 17, 18, 28, 38
Application for coverage 66, 79 Home visits 18
Arbitration 63, 73 Hospice care 7, 9, 18, 19, 21,22,28, 35, 38
Artificial insemination 29,48 Hospital admissions iv, 6, 7
Authorization . 7, 32, 33, 35, 40, 41, 43,44,46, 53, 64, 78, 8 Hypnosis 50
2 ID card ii, iv, 3, 33, 66, 70, 80
Auto accident 48, 58 Identification card i ii 3 74, 80
Babytrac 25 Immunizations iii,28, 35, 36, 82
Behavioral problems 51 In-state student care 4
Benefit period 9, 18, 19, 44, 51 Individual coverage 68
Billed charges 12, 61, 78 Infertility 14, 24,28, 29, 35, 40, 48
Changing PCPs 3-5 Inpatient . Inside front cover, ii, iv, 6, 7, 10-15, 19-22, 26-28,
Chemical dependency iii 10-13, 21,26, 28, 30, 48 30, 38, 40, 45,48, 66, 78, 80, 81
Chemotherapy 47 Laboratory 14, 80
Chiropractic 31, 49 Late applicants 67, 68
Claims . . . 2, 8, 33, 45, 51, 54, 60, 61, 64, 69, 70, 73, 75, 77 Late claims 51
Cleft lip 41, 42 Learning deficiencies 51
Cleft palate 25, 41, 42 Mammography 15
Conversion 71 Mastectomy 39,41
Coordination of benefits 48, 49, 55, 57, 75 Maternity 9, 10,21-25, 29, 40, 80
Copayment . . . 1, 5, 15, 16, 22, 25, 32-34, 60, 68, 78, 79, 83 Maximum lifetime benefit 44,45
Custodial care 18,49, 80 Medicare 43, 44, 49, 55, 56, 65, 66, 70, 71
Delivery 20, 23-25, 34, 35, 74,82 Medicare Secondary Payer(MSP) 49, 66
Dental 13, 21, 22, 28, 41, 49, 52, 55 Medicare-eligible 65, 70
Dental accidents 13 Member rights Inside front cover, Inside back cover
Dependents i ii 3 64-71, 74, 79-81 Member's service area 81
Detoxification 10-12 Mental illness iii, 12, 21,26-28, 80
Diabetic 37 Newborn care 9 21-23, 25, 29, 40, 80
Diagnostic . . . . 12, 14, 15, 20, 23, 24,26,28,31, 35, 51, 80 Newborn child 24, 25, 66-68
Dialysis 23 Nonemergency care 36, 70
Domiciliary care 49 Nonparticipating provider iv, 5, 9, 33, 52, 61, 81
Durable medical equipment 7, 20, 38 OB/gyn 3, 6, 24,29, 36,37
Emergency Care . . Inside front cover, ii, iii, 1,3, 5, 6, 10, 15, Occupational therapy 17, 30
16, 21, 70, 78 Office visit 25
Enrollment i 2-5, 24, 65-71, 74, 75, 78, 79, 81 Open enrollment 3,4, 67, 69, 81
ERISA 63, 76,77 Optional benefit 1, 13, 48
Espanol Inside front cover Oral surgery 13, 28,41, 47
84 ha?.. a'"1¢aft.. Customer Service:(800)334-6557 or(303)831-0161 ewUmIM.CRC(Rev.6/97)
BlueAdvantage HMO Plan Index
Osteopathic 30 Vision 15, 36, 37, 53-55
Outpatient care 11, 12, 27 Weight-loss 53, 54
Outpatient surgery 7 Work-related conditions 54
Overpayments 61
Participating provider. .32, 35, 38, 52, 56, 60, 61, 63, 64, 70,
74, 75, 79
Pathology 14
PCP . ii, iii, iv, 1, 3-7, 9, 14-18,24, 28-31, 35, 36, 38, 39, 48,
52, 53, 56, 68, 70, 73, 81, 82
Personal care network . . Inside front cover, ii, iv, 4, 6, 7, 16,
36, 81, 82
Physical therapy 17, 30
Pilot programs 75
Preauthorization 11, 26, 61
Prescription drugs 18, 19,32-35, 37-39, 46
Preventive care 14, 35, 36
Primary care provider Inside front cover, ii, 3, 48, 82
Prior authorization . . 7,32, 33, 35, 40, 41, 43, 44,46, 53, 64,
78, 82
Private duty nursing 20, 53
Prostate examinations 15, 36
Prostate-specific antigen test 14, 15
Prosthesis 38
Provider . . H, iii, iv, 3, 5-8, 10, 11, 14-16, 22, 23, 27, 28, 30-3
2, 39,40, 47, 48, 51, 52, 60, 61, 63, 64, 69, 70, 73-76, 7
8-82
Radiation therapy 47
Reconstructive surgery 41
Referral ii, iii, 4-6, 14, 17,24, 36, 39, 56, 81, 82
Rehabilitation 11, 21, 22, 30, 31, 48, 80
Routine care iii, 82
Service area . Inside front cover, ii, iii, 4, 9, 10, 15-17, 25, 43
, 65, 70, 80, 81, 82, 83
Sex-change 53
Skilled nursing 17-20, 22, 32, 49, 80, 82
Spanish, information written in Inside front cover
Specialist iii, iv, 6, 7, 35, 82
Specialist care
Speech therapy 17-19, 21, 30,31,42
Summary of Benefits and Copayments . Inside front cover, i,
1, 5, 12, 13, 27, 33, 34, 38, 48, 65, 71, 78, 83
Supplies . 9, 17, 19-21, 23, 28, 32, 38, 39, 43, 48, 50, 52, 76
, 78, 80, 82
Surgery . 7, 13, 22, 25, 28, 35, 40-42, 45, 47, 49, 54, 60, 82
TEFRA 66
Therapy 11, 12, 17-19,21, 30, 31,42,47, 49, 51, 53
TMJ 13, 28,41, 47
Transplant 42-46
Urgent care Hi, 4, 15, 16, 28, 35,40, 80, 83
Utilization review 61, 62, 75, 77
BLUHm,M.CRC(Rev.6197) Customer Service:(800)334-6557 or(303)831-0161 990325 85
BlueAdvantage HMO Plan Member Rights and Responsibilities
■ Member Rights and Responsibilities
• Member Rights
As a member of BlueAdvantage you are entitled to the following rights:
• The right to be treated with respect and with the recognition of
personal dignity and the need for privacy.
• The right to participate with practitioners in decision making regard-
ing your health care.
• The right to candid discussion of appropriate or medically necessary
treatment options for your condition, regardless of cost or benefit
coverage.
• The right to refuse recommended medical treatment or procedures.
• The right to confidentiality of information concerning your health,
illness, and treatment.
• The right to voice complaints or appeals about the managed care
organization or the care provided.
• The right to offer suggestions for changes in the plan's quality im-
provement policies and procedures.
• The right to information about the managed care organization, its
services, the practitioners and providers providing care, and the rights
and responsibilities of members.
I Member Responsibilities the following responsibilities:
As a member of BlueAdvantage you id r es onsi given by those
• The responsibility to follow instructions and gu
providing health care services.
• The responsibility to provide complete health status information
needed by your health care provider in order to care for you. required
• The responsibility to keep appointments for care and to give
notice when canceling. applicable copayment at the time services
• The responsibility to pay the app
are rendered.
• The responsibility to read and understand all materials concerning health
your health coverage and to share this information with your
care provider.
• The responsibility to notify your PCP within 48 hours after receiving
emergency care without a referral.
• The responsibility to treat your providers and HMOC staff with respect
and recognition of personal dignity.
990325
■ Amendment for BlueAdvantage
Point-of-Service Rider
This amendment is effective January 1, 1998, or your effective date of
membership, whichever is later.
The section entitled Your Plan at a Glance is amended as follows:
The first paragraph is deleted and the following is substituted:
The BlueAdvantage BCBSCO Plan Point-of-Service Rider is designed to
give members the choice of receiving covered services outside of regular
BlueAdvantage HMO Plan requirements. For services covered under this
rider, a member is not required to get a PCP referral, which is required
under the regular BlueAdvantage HMO Plan coverage. A member may
also choose to receive covered services from a provider who is not in the
HMOC network. In other words, the member chooses the level of coverage
received at the "point of service." We will not deny or restrict your
coverage to the BlueAdvantage HMO plan coverage or this Rider.
The section entitled How the Point-of-Service Rider Works, is amended
as follows:
The heading entitled Provider Choices is deleted and the following
language is substituted therefor:
■ Provider Choices
Providers (physicians, hospitals, and other health care facilities and
professionals) may have a participating provider agreement or no
agreement with BCBSCO. (Those with no agreement are referred to as
nonparticipating providers.)
With this BlueAdvantage BCBSCO Plan Point-of-Service Rider, members
have the flexibility to choose providers that are either inside or outside
BCBSCO's participating provider network. However, members can
reduce their out-of-pocket expenses by using participating providers.
If BCBSCO does not have a participating provider for a covered service,
arrangements will be made to make sure that the member pays no more
than what the member would have paid for such covered service if it had
been received by a participating provider.
Participating Providers
Members can take advantage of participating provider agreements that
BCBSCO has with many providers throughout Colorado. When services
are covered under this rider and are received from a provider who partici-
pates with BCBSCO:
FORM NO. 96680(11-97) 325
6LU°OBMAMC 1
• The provider agrees to accept payment under this rider plus the mem-
ber's deductible, coinsurance, and penalty amounts, if any, as pay-
ment in full for covered services. (The provider may request payment
for deductible, coinsurance, and penalty amounts at the time services
are delivered.)
• The member does not file claim forms; the participating provider files
for the member. In return, the provider will be paid directly for
covered services.
Nonparticipating Providers
A nonparticipating provider does not have a contractual agreement with
BCBSCO. When covered services are received from a nonparticipating
provider:
• The member is responsible for paying all billed charges to the provid-
er, which may include amounts greater than BCBSCO's maximum
allowable fee. A member will always pay applicable deductibles, co-
insurance, and penalty amounts.
• Members may have to file their own claims. Payment for covered ser-
vices is usually made directly to the member. (See Section 6: Claims
Payments and Appeals in your BlueAduantage HMO Plan Benefit
Booklet.)
Choosing a Provider — Provider Directories
Your provider choice — participating or nonparticipating— can
make a difference in the amount you pay. Therefore, before choosing
a provider for health care services, you may want to check your BCBSCO
provider directory.
If you do not have a current directory, contact customer service or your
group administrator for a complete list of participating providers.
Although a directory is current as of the date published, it is sub-
ject to change without notice. To verify a provider's current status
with BCBSCO, or if you have any questions about how to use a directory,
contact a customer service representative.
The heading entitled Member's Payment Responsibility for Services is
deleted and the following language is substituted therefor:
• Member's Payment Responsibility for
Services
When you obtain most services under your BlueAdvantage HMO Plan
Benefit Booklet, you pay only a copayment to your HMOC provider. When
you obtain services covered under this rider, however, the provider may
require that you pay in full for these services first, before filing your
claim.
The contracts between HMOC and its providers include a "hold harmless"
clause which provides that a BlueAdvantage HMO Plan member cannot
be liable to the provider for moneys owed by HMOC for health care
services covered under the BlueAdvantage HMO Plan Benefit Book-
BLUP98M AMC 2
let. Services covered under this rider are not subject to this clause, a non-
participating provider may seek payment directly from the member and a
participating provider may seek payment for deductible, coinsurance, or
non-covered services.
The heading entitled Prior Authorization is deleted and the following
language is substituted therefor:
■ Prior Authorization
Members must obtain prior authorization before certain services are re-
ceived, or payment for covered services will be reduced as explained
below.
There is no coverage or payment for any service, procedure,
admission, or portion of an admission that is not medically
necessary.
Prior Nonemergency Admissions — If your provider is participating, the
Authorization provider is responsible for obtaining prior authorization before being
Required— - admitted as an inpatient to a hospital or other treatment facility in a non-
Call Customer emergency situation. If your provider is non-participating, you are
Service responsible for obtaining prior authorization before being admitted as an
impatient to a hospital or other treatment facility for a nonemergency for
these situations:
• a provider recommends that a member be admitted as an inpatient
• a member is transferred from one inpatient facility to another
• a member is readmitted as an inpatient for any reason (other than an
emergency)
Routine newborn care admissions do not require prior authorization if the
newborn is discharged before or on the same date as the mother. If the
newborn remains in the hospital after the mother is discharged, the
member must call HMOC within 48 hours of the mother's discharge to
notify HMOC of the newborn's continued inpatient stay.
Outpatient Services and Surgical Procedures— If your provider is
participating, the provider must obtain prior authorization before
treatment begins for the outpatient services and surgical procedures listed
below. If your provider is non-participating, you are responsible for
obtaining prior authorization before treatment begins for the outpatient
services and surgical procedures listed below, or payment will be reduced
or denied as explained under "Obtaining Prior Authorization", below:
• physical rehabilitation (physical, occupational, or speech therapy)
• home health services
• hospice services
• durable medical equipment purchase or rental
• ambulatory or outpatient surgery
• cochlear implantation of a hearing device (such as an electromagnetic
bone conductor) to facilitate communication for the profoundly hearing
impaired, including any necessary training required to use the device
990325
BLUP98M.AMC 3
• reconstructive surgery (such as septoplasty or the surgical reconstruc-
tion of the nasal septum)
• surgery for obesity, including the surgical treatment of morbid obesity
(morbid obesity means the state of being either twice the ideal body
weight or 100 pounds over ideal body weight)
Obtaining Prior Authorization
Prior To obtain prior authorization, you or your provider must call the HMOC
Authorization health services department (1-800-526-4662 or 303-831-4115, Monday
Required— - through Friday, 8 A.M. to 4:30 P.M., Mountain Time) before receiving the
Call Customer service. The health services representative will explain prior authorization
Service requirements and ask for information about your provider and the pro-
posed services or admission. If the provider has not already requested
authorization for the proposed services, a representative will call his/her
office for more information. The member and his/her provider will be
notified by mail of authorization decisions. The member's treatment may
be reviewed at periodic intervals to ensure services continue to be covered.
Penalty for Not Obtaining Prior Authorization — If authorization for a
non-participating provider is not obtained in advance, but the member
chooses to receive the services anyway, payment may be reduced:
• If there has been no prior authorization for services that would have
been authorized if a request had been received, coinsurance for cov-
ered services will be increased by an additional 20 percent. For
example, if the point-of-service coinsurance (the percent of covered
charges that the member pays) is 30 percent, it will be increased to
50 percent. This penalty amount is in addition to all deductible and
coinsurance requirements. If the member's out-of-pocket limit is
reached, the penalty amount for covered services received without
prior authorization will be 20 percent coinsurance.
• If prior authorization is denied or if the services would not have been
authorized if a request had been received, all related claims will be
denied.
Any penalty amounts the member pays do not contribute to the member's
out-of-pocket limit.
The section entitled Point-of-Service Rider General Exclusions is
deleted and the following language is substituted therefor:
4 Point-of-Service Rider General Exclusions
Section 4: General Exclusions in your BlueAdvantage HMO Plan Benefit
Booklet applies to this Point-of-Service Rider. In addition, this Point-of-
Service Rider includes the following exclusions:
Duplication — If a member receives services that are covered under the
BlueAdvantage HMO Plan Benefit Booklet, those services will not be cov-
ered under this rider.
Il1.UP98M.AMC 4
Point-of-Service Rider Section 4: Point-of-Service Rider General Exclusions
Excluded Services— The following services and supplies are not covered
under this rider, but may be covered under your BlueAdvantage HMO
Plan Benefit Booklet when provided by your PCP or with a PCP referral:
• Ambulance Services (emergency ambulance services are covered
under your BlueAdvantage HMO Plan Benefit Booklet)
• Chemical Dependency Treatments
• Infertility Services
• Major Organ Transplants
• Mental Illness Treatments that are non-biologically based
• Preventive Care Services for members over the age of 13, with
the exception of annual gynecological examinations (i.e., rou-
tine physical examinations for adults, screening mammography,
routine hearing examinations, and adult immunizations)
• Skilled Nursing Facility Care
,/3rior Prior Authorization — Certain services require prior authorization in
Authorization advance. If the member chooses to receive the services from a non-partici-
Required— - pating provider without obtaining prior authorization, payment may be
Call Customer reduced. Reminder: All nonemergency inpatient admissions, physi-
Service cal rehabilitation (physical, occupational, and speech therapy),
durable medical equipment, and home health care require prior
authorization. See "Prior Authorization" in Section 2: How the Point-of
Service Rider Works for a list of services requiring prior authorization and
details on how to obtain authorization and for information on the penalty
amounts for not obtaining prior authorization.
This amendment is part of and to be read in conjunction with your
/51.re jeollfa
Bev Sloan
President
HMO Colorado
990325
BLUPISM AMC 5
■ Amendment to BlueAdvantage HMO Plan
Benefit Booklet
This amendment is effective January 1, 1999, or your effective date of membership,
whichever is later.
In Section 3: Covered Services,the benefits for Prescription Drugs are deleted and the
following is substituted:
■ Prescription Drugs
Prescription drugs and medicines—those that are taken at the direction
and under the supervision of a provider and require a physician's
prescription before being dispensed. All drugs and medicines must be
approved by the Food and Drug Administration, and must not be
"experimental or investigative" (see "Experimental or Investigative
Procedures and Services" in Section 4: General Exclusions). The fact that
a drug is recommended or prescribed does not make it a covered
service.
Drug Formulary— a list of prescription drugs that is approved for use by
HMOC. This list is subject to periodic review and modification by HMOC.
Generic drug— the chemical equivalent of a brand-name prescription
drug. By law, brand-name and generic drugs must meet the same
standards for safety, purity, strength, and quality.
Maintenance medications—prescription drugs taken regularly to treat a
chronic health condition, such as high blood pressure, ulcers, or diabetes.
Coverage for prescription drugs administered by a hospital, home health agency,
hospice, or skilled nursing facility during a covered admission is not available under
this "Prescription Drugs"section. See other headings in this section for drugs used
during a covered admission or home health/hospice visit.
The following take-home prescription drugs (including insulin) are covered
only when prescribed by an HMOC participating provider and dispensed
by an HMOC participating pharmacy:
• prescription drugs, including oral contraceptives (limited to the supply
required for one menstrual cycle), prescription contraceptive devices
purchased from a pharmacy, and insulin — unless a prescription drug
is listed as an exclusion below
• compounded medication of which at least one ingredient is a prescrip-
tion drug
• self-administered injectable insulin, glucagon, Imitrex, and
anaphylactic kits—these are the only injectable medications covered
unless an HMOC prior authorization is obtained
RLUPCS AMC 990325
• insulin needles, syringes, and supplies (e.g., lancets and test strips) if
purchased at the same time as insulin (there will be a separate
copayment for each item purchased)
Important: If a provider prescribes a drug for which an FDA-approved
Class A generic substitute is available, the benefit will be limited to the
cost of the generic substitute. All medically necessary "dispense as written"
or "no substitution" prescriptions do not allow a generic substitution and
require a prior authorization from HMOC. If prior authorization is not
obtained in a nonemergency situation, the member is responsible for the
retail cost difference between the brand-name drug and the generic
substitute, in addition to the copayment. If a member requests a brand-
name equivalent of a drug that has a generic equivalent, payment is
limited to the cost of the generic equivalent, less the copayment. The
copayment is based on whether the drug is listed on the HMOC formulary.
Generic formulary drugs are available at the lowest copyament, brand
formualry drugs at the intermediate copayment, and non-formulary drugs
at the higher copayment.
Retail Pharmacy Program
A member may obtain prescription drugs from participating pharmacies
and pay only a small copayment at the time of purchase. For each
prescription purchased at a participating pharmacy, members pay the
amount specified on their Summary of Benefits and Copayments. (If the
retail price of a prescription drug is less than the copayment, the member's
copayment will be the actual retail price.) Refer to your "HMO Colorado
Pharmacy Roster" or call an HMOC customer service representative for a
list of participating pharmacies.
Members must present their plan ID card to the pharmacist at the
time of purchase to receive this benefit.
If you do not have your ID card with you or if you purchase your
prescription from a nonparticipating provider in an emergency situation,
you must pay for the prescription in full and then submit the claim to the
Retail Pharmacy Program. Prescription drug bills must include pharmacy
name and address, drug name, prescription number, and amount charged.
The bill or receipts must be issued by the pharmacy. For a claim form and
the mailing address, contact HMOC customer service. The reimbursement
for these prescription drug claims is 100 percent of the charge for the drug
minus the copayment amount. (If the reimbursement price is the same as
or less than the copayment amount required, there is no payment to the
member.)
Under the Retail Pharmacy Program, members can obtain a maximum of a
34-day supply. For oral contraceptives, the supply is limited to one
menstrual cycle (normally 28 days). Prescriptions in excess of the number
specified by the physician or those requested more than one year following
the physician's original order date cannot be refilled. (Drugs with a high
degree of intolerance may be filled with a one-week supply initially and, if
the member's response is favorable, the remainder of the prescription will
be filled with no additional copayment.)
�R, *y� BLUF'CS AMC
Prescription Mail Service Program
Members taking maintenance medications may enroll in and use the
Prescription Mail Service Program.
The member's copayment amount for each prescription ordered through
the Prescription Mail Service Program is the same as the copayment
amount for a prescription filled at a participating retail pharmacy under
the Retail Pharmacy Program for a 34-day supply, and two times that
amount for a 60- or 90-day supply. See your Summary of Benefits and
Copayments for the exact copayment amount for mail-order prescription
drugs.
To use the Prescription Mail Service Program, complete the following
steps:
• Ask the physician to write a new, original prescription that can be
submitted directly to the mail service pharmacy with the "Mail Service
Pharmacy Order Form." If medication is needed immediately, ask the
doctor to issue two prescriptions —one for an immediate supply to be
taken to the local pharmacy, and a second for an extended supply to be
mailed to the Prescription Mail Service.
• When the physician writes a prescription for a maintenance
medication, ask that the prescription be written for up to a 90-day
supply with up to three refills.
• Complete the "Patient Profile/Registration Information Form" for the
first mail-service order. In the future, if there is additional information
or changes to report, send an updated"Patient Profile/Registration
Information Form" to the Prescription Mail Service.
• Complete the "Mail Service Pharmacy Order Form" for both new and
refill prescriptions. A new order form and envelope will be sent with
each delivery.
• Enclose the original prescription, "Patient Profile/Registration
Information Form," "Mail Service Pharmacy Order Form," and
payment in the preaddressed mail-service envelope and mail the order.
• For information on how to contact the Prescription Mail Service
Program, refer to the Prescription Mail Service brochures for the
phone number or call your HMOC customer service representative.
• Prescriptions will be delivered either by U.S. Postal Service or UPS.
Please allow 10-14 days for delivery from the date the prescription
order was mailed. In an emergency, the prescriptions can be shipped
overnight for an additional fee that is the member's responsibility.
Prescription Drug Exclusions
Coverage is not available under the prescription drug program for:
• nonprescription and over-the-counter drugs, including herbal or
homeopathic preparations, and prescription drugs that have over-the-
counter bioequivalents---unless specifically prior authorized by HMOC
• prescription drugs which are non-formulary and determined by HMOC
to be medically necessary by HMOC require prior approval and are
subject to the same copayment and limitations as prescription drugs
BLUPCS AMC
990325
which are listed in the formualry and offered as a benefit of the Benefit
Booklet.
• infertility medications (for exceptions, see "Infertility Services," under
"Office, Outpatient, and Home Care" in this section)
• drugs approved by the FDA or otherwise, intended for the treatment of
sexual dysfunction (including drugs for the treatment of erectile
dysfunction)
• Nicorette, nicotine patches, or any other drug containing nicotine or
other smoking deterrent medications
• appetite suppressants
• tretinoin (sold under such brand names as Retin-A) for cosmetic
purposes
• prescription drugs dispensed for the purpose of international travel
• any prescription prescribed by a nonparticipating provider (unless
eligible for coverage in an emergency or urgent care situation)
• prescriptions purchased from a nonparticipating pharmacy (unless
eligible for coverage in an emergency or urgent care situation)
• delivery charges
• therapeutic devices or appliances, including support garments and
other nonmedicinal substances (regardless of intended use)
• medications or preparations used for cosmetic purposes (such as
preparations to promote hair growth or medicated cosmetics)
Note: Certain prescription drugs that have the potential for misuse and
most injectable medications require a prior authorization from HMOC.
Your PCP or HMOC participating provider will request the necessary prior
authorization.
This amendment is part of and to be read in conjunction with your BlueAdvantage
HMO Plan Benefit Booklet
/ater. )1e613(4
Bev Sloan
President
HMO Colorado
BLUPCS AMC
■ Amendment to BlueAdvantage HMO Plan
Benefit Booklet
This amendment is effective January 1, 1999, or your effective date of
membership, whichever is later.
In Section 3: Covered Services, under Preventive, Routine, and Family
Planning Services, the following benefit is added as a covered service:
• Routine eye refractions are allowed once every 24 months. The
refraction may be preformed by an ophthalmologist or optometrist
who participates in the Eye Health Network. Services from any other
ophthalmologist or optometrist are not covered. Contact Customer
Service at 1-800-334-6557 for a list of Eye Health Network providers.
This amendment is part of and to be read in conjunction with your
BlueAdvantage HMO Plan Benefit Booklet.
>143(110
Bev Sloan
President
HMO Colorado
BLU122G.AMC 990325
■ Point-of-Service Rider to BlueAdvantage
HMO Plan Benefit Booklet
Your BlueAdvantage HMO Plan Benefit Booklet is hereby amended in
accordance with the Group Master Contract issued by HMO Colorado
(HMOC) on behalf of Blue Cross and Blue Shield of Colorado (BCBSCO)
and your employer to include this BlueAdvantage BCBSCO Plan Point-of-
Service Rider. Benefits are underwritten by Blue Cross and Blue Shield of
Colorado (BCBSCO). HMOC (or its designee) is an agent for BCBSCO for
administrative functions under this rider. The benefits of this rider are
subject to all provisions of the BlueAdvantage HMO Plan Benefit Booklet
unless otherwise stated.
This rider is effective on the date it is incorporated into your employer's
Group Master Contract or your effective date of coverage, whichever is
later.
Sincerely,
Z 640 a411A1
C. David Kikumoto
Chief Executive Officer
Blue Cross and Blue Shield of Colorado
Some services covered under this rider require prior authorization or payment Will be reduced.See
"Prior Authorization" in Baton 2.
BLUPW2M.RIC(6/97) Customer Service:(B00)334-6557 or(303)831-0161 9g0325
Your Point-of-Service Rider at a Glance Point-of-Service Rider
■ Your Point-of-Service Rider at a Glance
The BlueAdvantage BCBSCO Plan Point-of-Service Rider is designed to
give members the choice of receiving covered services outside of regular
BlueAdvantage HMO Plan requirements. For services covered under this
rider, a member is not required to get a PCP referral, which is required
under the regular BlueAdvantage HMO Plan coverage. A member may
also choose to receive covered services from a provider who is not in the
BMOC network. In other words, the member chooses the level of coverage
received at the "point of service."
If a member obtains nonemergency services without first visiting his/her
PCP or obtaining a referral from his/her PCP, medically necessary services
may be available as "point-of-service" benefits under this rider, subject to
deductible and coinsurance. Note: Many point-of-service benefits require
prior authorization (see Section 2: How the Point-of-Service Rider Works).
Not all covered services that are described in the BlueAdvantage
HMO Plan Benefit Booklet are covered under this rider. See Sec-
tion 4: Point-of-Service Rider General Exclusions for a list of services that
are not covered.
When you have questions or concerns, customer service wants to
know. Your comments and suggestions are welcome. Listening to you
helps improve customer service. Your customer service representative is
knowledgeable about your point-of-service covered services, procedures,
and providers. (Please have your ID card handy when calling a customer
service representative)
Address: HMO Colorado Customer Service
700 Broadway
Denver, Colorado 80273
Hours: 7:30 A.M.to 5:30 P.M. (Monday—Friday)
Phone number: (800) 334-6557 or(303) 831-0161
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Section2.
ii f3,7,}t:,, ; ,, - Customer Service:(800)334-6557 or(303)831-0161 BwvmzM.RIC(BIM
Point-of-Service Rider Table of Contents
■ Table of Contents
Point-of-Service Rider to BlueAdvantage HMO 3 Point-of-Service Rider Covered Services . . . 9
Plan Benefit Booklet i Point-of-Service Benefits 9
Combined BlueAdvantage HMO Plan and Point-
Your Point-of-Service Rider at a Glance ii of-Service Limitations 9
Annual Gynecological Exam 10
1 How to Use This Point-of-Service Rider 1 Hospice Services 10
When Services Are Covered Under This Rider . 1 Preventive Child Care Services 10
Deadlines 1
Prior Authorization Required 1 4 Point-of-Service Rider General Exclusions . 11
Duplication 11
2 How the Point-of-Service Rider Works 2 Excluded Services 11
Services Not Covered Under This Rider 2 Prior Authorization 11
Provider Choices 2
Participating Providers 3 5 Point-of-Service Rider General Provisions . 12
Nonparticipating Providers 3 How and Where to Send Claims 12
Nonparticipating Facility Services 3 How Payments Are Made 12
Choosing a Provider— Provider Directories 4
Member's Payment Responsibility for Services . 4 Point-of-Service Rider Glossary 13
Benefit Period 4
Cost-Sharing Features 5
Calendar Year Deductible 5
Carryover Deductible Credit 5
Prior Deductible Credit 5
Coinsurance 6
Out-of-Pocket Limit 6
Maximum Lifetime Benefit 7
Prior Authorization 7
Obtaining Prior Authorization 8
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Section 2.
BLUP072M Ric(6/07) Customer Service:(800)334-6557 or(303)831-0161 X325 iii
■ Notes
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Steffan 2.
iv a.,� Customer Service:(800)334-6557 or(303)831-0161 6wPWZM.RIC(6/97)
Point-of-Service Rider Section 1: How to Use This Point-of-Service Rider
1 How to Use This Point-of-Service Rider
• When Services Are
Covered Under This Rider
This BlueAdvantage BCBSCO Plan Point-of-Service Rider provides
coverage for certain services that are not obtained in accordance with the
rules and procedures of the BlueAdvantage HMO Plan Benefit Booklet. All
provisions of your BlueAdvantage HMO Plan Benefit Booklet are used to
determine whether services are covered under this rider, except for provi-
sions that impose requirements for service or referral by your PCP, or
unless specifically addressed in this rider. A member will receive the most
comprehensive level of coverage by following the BlueAdvantage HMO
Plan procedures.
If the member receives services that are not provided by an HMOC
PCP or that are provided by an HMOC participating provider
without a PCP referral or that are provided by a non-participating
provider, these services may be eligible for coverage under this
rider. Covered services under this rider are subject to a calendar
year deductible and the member must pay a specified percentage
of the covered charges for covered services (coinsurance). Also, not
all services that are covered by the BlueAdvantage HMO Plan are
covered under this rider.
■ Deadlines
Day
7 Li
You will see this symbol when you must take action within a specified mI
amount of time.
Prior = ■ Prior Authorization Required
Authorization
Required— For certain services covered under this rider and for all inpatient admis-
Call Customer sions, members are required to obtain prior authorization from HMOC.
�.. :.,. You will see this symbol next to covered services that require prior
authorization.
Some services covered under this rider require prior authorization or payment will be reduced,See
"Prim Authorization" in Section 2
BLUPo72M RIC(6/97) Customer Service:(800)334-6557 or(303)831-0161 Yb 1
Section 2: How the Point-of-Service Rider Works Point-of-Service Rider
2 How the Point-of-Service Rider Works
When you enroll in the BlueAdvantage HMO Plan, you must choose a
primary care provider (PCP) for each covered member of your family. If the
PCP provides care or refers the member to a specialist or hospital for
covered services, the member receives full BlueAdvantage HMO Plan
benefits, according to the terms of the BlueAdvantage HMO Plan Benefit
Booklet. Life-threatening emergency care received without a PCP referral
is covered under the BlueAdvantage HMO Plan.
A member receiving certain types of care without a referral from his/her
PCP will receive "point-of-service" coverage, subject to a calendar year
deductible and coinsurance.
Remember: Services for which a member has not obtained a referral
from his/her PCP are subject to the terms and conditions of this rider
and are not eligible for regular coverage under the BlueAdvantage HMO
Plan Benefit Booklet —regardless of whether or not such services are
received from an HMOC participating provider.
• Services Not Covered Under This Rider
Some services covered under the BlueAdvantage HMO Plan Benefit
Booklet are not covered under this rider. These services are covered
only if they are obtained in accordance with the procedures specified in
the BlueAdvantage HMO Plan Benefit Booklet. See Section 4: Point-of-
Service Rider General Exclusions for a list of services that are not covered.
■ Provider Choices
Providers (physicians, hospitals, and other health care facilities and
professionals) may have a participating provider agreement or no agree-
ment with BCBSCO. (Those with no agreement are referred to as non-
participating providers.)
With this BlueAdvantage BCBSCO Plan Point-of-Service Rider, members
have the flexibility to choose providers that are either inside or outside
BCBSCO's participating provider network. However, members can
reduce their out-of-pocket expenses by using participating providers.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Section 2.
.i
2 }�� Customer Service: (800)334-6557 or(303)831-0161 BLUP072M.RIC(6/97)
Point-of-Service Rider Section 2: How the Point-of-Service Rider Works
Participating Providers
Members can take advantage of participating provider agreements that
BCBSCO has with many providers throughout Colorado. When services
are covered under this rider and are received from a provider who partici-
pates with BCBSCO:
• The provider agrees to accept payment under this rider plus the mem-
ber's deductible, coinsurance, and penalty amounts, if any, as payment
in full for covered services. (The provider may request payment for
deductible, coinsurance, and penalty amounts at the time services are
delivered.)
• The member does not file claim forms; the participating provider files
for the member. In return, the provider will be paid directly for covered
services.
Nonparticipating Providers
A nonparticipating provider does not have a contractual agreement with
BCBSCO. When covered services are received from a nonparticipating
provider:
• The member is responsible for paying all billed charges to the provider,
which may include amounts greater than BCBSCO's maximum allow-
able fee. A member will always pay applicable deductibles, coinsur-
ance, and penalty amounts.
• Members may have to file their own claims. Payment for covered ser-
vices is usually made directly to the member. (See Section 6: Claims
Payments and Appeals in your BlueAduantage HMO Plan Benefit
Booklet.)
Nonparticipating Facility Services
For nonemergency services received in Colorado from a facility that does
not have a participating provider agreement with BCBSCO, covered
services are subject to the deductible and any penalty amounts but are not
subject to point-of-service coinsurance provisions. The maximum allowable
fee for services received from such providers are:
• for inpatient services, $500 per day or the billed charges for daily
room and ancillary expenses, whichever is less; and
• for outpatient services, 50 percent of the billed charges for covered
services.
The member is responsible for paying the remainder of all billed charges
beyond the maximum allowable fee described above.
When care is for a medical emergency (as defined in your BlueAdvantage
HMO Plan Benefit Booklet), these payment provisions do not apply.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" ir1 Section 2,
A
BLUPBl2M.RIC(6/97) Customer Service:(B00)334-6557 or(303)831-0161 990325 3
Section 2: How the Point-of-Service Rider Works Point-of-Service Rider
Choosing a Provider — Provider Directories
Your provider choice — participating or nonparticipating— can
make a difference in the amount you pay. Therefore, before choosing a
provider for health care services, you may want to check your BCBSCO
provider directory.
If you do not have a current directory, contact customer service or your
group administrator for a complete list of participating providers.
Although a directory is current as of the date published, it is sub-
ject to change without notice. To verify a provider's current status with
BCBSCO, or if you have any questions about how to use a directory,
contact a customer service representative.
• Member's Payment Responsibility for
Services
When you obtain most services under your BlueAduantage HMO Plan
Benefit Booklet, you pay only a copayment to your HMOC provider. When
you obtain services covered under this rider, however, the provider may
require that you pay in full for these services first, before filing your claim.
The contracts between HMOC and its providers include a "hold harmless"
clause which provides that a BlueAdvantage HMO Plan member cannot
be liable to the provider for moneys owed by HMOC for health care
services covered under the BlueAdvantage HMO Plan Benefit Book-
let. Services covered under this rider are not subject to this clause and the
provider may seek payment directly from the member.
• Benefit Period
The benefit period is the calendar year: January 1 through December 31 of
the same year. The initial benefit period is from a member's effective date
through December 31 of the same year. (A member's initial benefit period
may be less than 12 months.) Some benefits are limited to a specific dollar
amount or number of days or visits allowed during a benefit period. See
your Summary of Benefits and Copayments for benefit details.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization"In Section 2.
*. .', . .
k
4 r. •, ` >�' Customer Service:(800)334-6557 or(303)831-0161 BLUP072M Ric(6/97)
Point-of-Service Rider Section 2: How the Point-of-Service Rider Works
■ Cost-Sharing Features
This rider requires that the member share the cost of certain health care
expenses. This section describes the different cost-sharing methods.
Calendar Year Deductible
Each member must pay a deductible each calendar year before payment for
covered services begins under this rider. Your group's Summary of Benefits
and Copayments indicates the amount of your deductible. The deductible
requirements must be met before a member begins paying coinsurance for
point-of-service benefits. The deductible is waived for routine
immunizations and well-child care visits for children up to age 13. (Copay-
ments for BlueAdvantage HMO Plan covered services do not count toward
the calendar year deductible.)
Individual Deductible—Each member's calendar year deductible is the
amount specified on the group's Summary of Benefits and Copayments.
Family Deductible—All covered family members meet the deductible
when the combined deductible amounts for two or more family members
reach the amount specified as the family deductible on your group's Sum-
mary of Benefits and Copayments.
Once a family member has met his/her own deductible, that person
cannot contribute any more toward the family deductible. Only that one
person is eligible for benefits until one or more additional family members
meet the other half of the family deductible.
Carryover Deductible Credit—On January 1 of each calendar year,
HMOC will review the amounts applied to a member's point-of-service
deductible during the last three months of the previous calendar year. Any
amounts applied for services received from October 1 through December 31
of the previous year will be carried over and applied to the member's
deductible requirement for the new calendar year.
Prior Deductible Credit—When an employer group terminates other
coverage (including coverage through BCBSCO) and starts coverage with
HMOC under this Point-of-Service Rider, members may be eligible for
prior deductible credit. If an employer's Group Master Contract includes a
provision for prior deductible credit, a member's claims for covered services
which were applied to the deductible for the most recent benefit period
under other coverage will be applied to the current year's point-of-service
deductible. This provision only applies to members whose effective
date of coverage is the same as the group's effective date of
coverage.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Section 2
BLUPB]2M.RIC(6/97) Customer Service:(800)334-6557 or(303)831-0161 9913325 5
Section 2: How the Point-of-Service Rider Works Point-of-Service Rider
To receive prior deductible credit, the member must send HMOC written
documentation of deductible information from the other coverage no later
than 90 days following the member's effective date of coverage. If the
member is currently enrolled with BCBSCO, HMOC will get the documen-
tation of the member's deductible information directly from BCBSCO.
Check with your group administrator to find out if this provision applies to
your group.
Coinsurance
Under this rider, the member is responsible for paying a percentage of the
covered charges, called "coinsurance," after the calendar year deductible is
met. Please refer to your Summary of Benefits and Copayments for copay-
ment and coinsurance information. (Note: No coinsurance is required for
nonemergency services received from a nonparticipating facility, but
payment may be reduced; see "Nonparticipating Facility Services," earlier
in this section, for details.)
Out-of-Pocket Limit
This rider also includes an out-of-pocket limit designed to protect you from
catastrophic health care expenses. After the out-of-pocket limit is reached,
payment will be made which will satisfy the remaining payment obliga-
tions up to the maximum allowable fee for the remainder of that calendar
year.
The out-of-pocket limit includes only the point-of-service coinsur-
ance. It does not include copayments for prescription drugs or regular
BlueAdvantage HMO Plan benefits, penalty amounts (see "Prior Authori-
zation" in this section), deductible amounts, expenses in excess of the
maximum allowable fee, or expenses for noncovered services.
Individual Out-of-Pocket Limit—Each member meets his/her annual out-
of-pocket limit after coinsurance amounts for his/her covered services
equal the individual "point-of-service" out-of-pocket limit shown on the
group's Summary of Benefits and Copayments.
Family Out-of-Pocket Limit—All covered family members meet the
annual out-of-pocket limit when the combined coinsurance amounts for
two or more family members reach the amount specified as the family
"point-of-service" out-of-pocket limit on the group Summary of Benefits and
Copayments.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Section 2.
6 ;*r . ., '; _ Customer Service:(800)334-6557 or(303)831-0161 BLUP072M AIC(6197)
Point-of-Service Rider Section 2: How the Point-of-Service Rider Works
If any one family member's out-of-pocket reaches the individual limit, the
out-of-pocket for that member is met and no additional amounts may be
applied to the family out-of-pocket by that member for the remainder of
the calendar year.
• Maximum Lifetime Benefit
The maximum amount that will be paid for all services covered under this
rider is $1,000,000 per member per lifetime. The maximum lifetime
benefit includes all covered charges less deductible, coinsurance, and
penalty amounts, if any. Any payments made by HMOC under the
BlueAduantage HMO Plan Benefit Booklet do not contribute to the
$1,000,000 point-of-service maximum lifetime benefit.
■ Prior Authorization
Members must obtain prior authorization before certain services are re-
ceived, or payment for covered services will be reduced as explained below.
There is no coverage or payment for any service, procedure,
admission, or portion of an admission that is not medically neces-
sary.
Prior Nonemergency Admissions---Members are responsible for obtaining
Authorization _• prior authorization before being admitted as an inpatient to a hospital or
Required— other treatment facility in these nonemergency situations:
Call Customer • a provider recommends that a member be admitted as an inpatient
I 7"
• a member is transferred from one inpatient facility to another
• a member is readmitted as an inpatient for any reason (other than an
emergency)
Routine newborn care admissions do not require prior authorization if the
newborn is discharged before or on the same date as the mother. If the
newborn remains in the hospital after the mother is discharged, the
member must call HMOC within 48 hours of the mother's discharge to
notify HMOC of the newborn's continued inpatient stay.
Outpatient Services and Surgical Procedures—Members must also
obtain prior authorization before treatment begins for the outpatient
services and surgical procedures listed below, or payment will be reduced
or denied as explained under "Obtaining Prior Authorization," below.
• physical rehabilitation (physical, occupational, or speech therapy)
• home health services
• hospice services
• durable medical equipment purchase or rental
• ambulatory or outpatient surgery
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in ectIon 2.
BLUP072M.RIC(6)97) Customer Service:(800)334-6557 or(303)831-0161 990325 7
Section 2: How the Point-of-Service Rider Works Point-of-Service Rider
• cochlear implantation of a hearing device (such as an electromagnetic
bone conductor) to facilitate communication for the profoundly hearing
impaired, including any necessary training required to use the device
• reconstructive surgery (such as septoplasty or the surgical reconstruc-
tion of the nasal septum)
• surgery for obesity, including the surgical treatment of morbid obesity
(morbid obesity means the state of being either twice the ideal body
weight or 100 pounds over ideal body weight)
Obtaining Prior Authorization
Prior o To obtain prior authorization, you must call the HMOC health services
Authorization • department (1-800-526-4662 or 303-831-4115, Monday through Friday,
Required— - 8 A.M. to 4:30 P.M., Mountain Time) before receiving the service. The
Call Customer health services representative will explain prior authorization require-
ments and ask for information about your provider and the proposed
services or admission. If the provider has not already requested authoriza-
tion for the proposed services, a representative will call his/her office for
more information. The member and his/her provider will be notified by
mail of authorization decisions. The member's treatment may be reviewed
at periodic intervals to ensure services continue to be covered.
Penalty for Not Obtaining Prior Authorization—If authorization is not
obtained in advance, but the member chooses to receive the services any-
way, payment may be reduced:
• If there has been no prior authorization for services that would have
been authorized if a request had been received, coinsurance for covered
services will be increased by an additional 20 percent. For example,
if the point-of-service coinsurance (the percent of covered charges that
the member pays) is 30 percent, it will be increased to 50 percent. This
penalty amount is in addition to all deductible and coinsurance re-
quirements. If the member's out-of-pocket limit is reached, the penalty
amount for covered services received without prior authorization will
be 20 percent coinsurance.
• If prior authorization is denied or if the services would not have been
authorized if a request had been received, all related claims will be
denied.
Any penalty amounts the member pays do not contribute to the member's
out-of-pocket limit.
Prior authorization does not guarantee benefits or validate
eligibility—it determines only the medical necessity of a service or an
admission and an allowable length of stay. If a member loses coverage
under this rider, no payments will be made for services received or admis-
sions beginning after coverage ends —even if prior authorization was
obtained.
Some services covered under this rider require prior authorization or payment will be reduced See
"Prior Authorization" in Section 2.
8 Customer Service:(800)334-6557 or(303)831-0161 6LUP072M.RIC(6/97)
Point-of-Service Rider Section 3: Point-of-Service Rider Covered Services
3 Point-of-Service Rider Covered Services
• Point-of-Service Benefits
Members receive point-of-service benefits for covered services that are not
provided by an HMOC PCP or are provided without PCP referral. Point-of-
service benefits are available under this rider for all covered services under
the BlueAdvantage HMO Plan Benefit Booklet, except for specified ser-
vices listed as excluded (see Section 4: Point-of-Service Rider General
Exclusions).
Point-of-service benefits are subject to deductible and coinsurance, and the
prior authorization procedures described in Section 2: How the Point-of-
Service Rider Works. Some covered services are limited to a certain num-
ber of visits or a certain maximum payment limit. For specific deductible
and coinsurance amounts, and benefit limitations, see your Summary of
Benefits and Copayments.
All services are also subject to Section 4: General Exclusions in
your BlueAdvantage HMO Plan Benefit Booklet, which explains the
services, situations, and related expenses that are not covered.
• Combined BlueAdvantage HMO Plan and
Point-of-Service Limitations
Certain covered services have a limited number of visits and/or maximum
benefit payment limit (see your Summary of Benefits and Copayments). A
member may receive these covered services as follows:
• all of these covered services under the BlueAdvantage HMO Plan
Benefit Booklet, or
• all of these covered services under the Point-of-Service Rider, or
• part of these covered services under the BlueAdvantage HMO Plan
Benefit Booklet, and part under the Point-of-Service Rider, until the
combined number of visits or payments reach the specified limit.
For example, if a member receives prior authorization for a covered service
that has a 10-visit maximum, the member may visit his or her PCP six
times for the services and visit a provider without a PCP referral for the
remaining four visits. The member may use any such combination of
BlueAdvantage HMO Plan Benefit Booklet and BlueAdvantage BCBSCO
Plan Point-of-Service Rider benefits, up to the limit.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization"in Section 2.
BLUP072M.RIC(6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 9
Section 3: Point-of-Service Rider Covered Services Point-of-Service Rider
Covered services with limits include:
• durable medical equipment (outpatient)
• home health care
• physical rehabilitation (physical, occupational, and speech therapy)
When a member calls HMOC for prior authorization, he/she may ask about
visit or maximum payment limitations.
The member is responsible for charges for services that exceed the maxi-
mum number of visits or maximum payment limitations.
• Annual Gynecological Exam
A member may receive her annual gynecological exam under this Point-of-
Service Rider. Contraceptive devices that can be purchased at a physician's
office are also covered under this rider. (Birth control pills and devices can
be purchased through the BlueAdvantage HMO Plan Retail Pharmacy and
Managed Prescription Mail Services Programs.)
• Hospice Services
A member may receive hospice care under this Point-of-Service Rider. In
addition to the benefits provided in your BlueAdvantage HMO Plan
Benefit Booklet, bereavement support services for the family during the
three month period following the death of the member are covered up to a
total payment of$1,077.
• Preventive Child Care Services
Services are covered for age-appropriate routine immunizations and well-
child care visits up to age 13. Benefits are not subject to the deductible, but
are subject to the coinsurance.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization"in Section
10 .yy., Customer Service:(800)334-6557 or(303)831-0161 BLUP072M RIC(6197)
:
Point-of-Service Rider Section 4: Point-of-Service Rider General Exclusions
4 Point-of-Service Rider General Exclusions
Section 4: General Exclusions in your BlueAdvantage HMO Plan Benefit
Booklet applies to this Point-of-Service Rider. In addition, this Point-of-
Seruice Rider includes the following exclusions:
Duplication— If a member receives services that are covered under the
BlueAduantage HMO Plan Benefit Booklet, those services will not be cov-
ered under this rider.
Excluded Services—The following services and supplies are not covered
under this rider, but may be covered under your BlueAdvantage HMO
Plan Benefit Booklet when provided by your PCP or with a PCP referral:
• Ambulance Services (emergency ambulance services are covered
under your BlueAduantage HMO Plan Benefit Booklet)
• Chemical Dependency Treatments
• Infertility Services
• Major Organ Transplants
• Mental Illness Treatments
• Preventive Care Services for members over the age of 13, with
the exception of annual gynecological examinations (i.e., routine
physical examinations for adults, screening mammography, routine
hearing examinations, and adult immunizations)
• Skilled Nursing Facility Care
Prior o Prior Authorization— Certain services require prior authorization in
Authorization advance. If the member chooses to receive the services without obtaining
Required— prior authorization, payment may be reduced. Reminder: All nonemer-
Call Customer gency inpatient admissions, physical rehabilitation (physical,
occupational, and speech therapy), durable medical equipment,
and home health care require prior authorization. See "Prior Autho-
rization" in Section 2: How the Point-of-Service Rider Works for a list of
services requiring prior authorization and details on how to obtain
authorization and for information on the penalty amounts for not obtaining
prior authorization.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in melon 2.
BLUPW2M Rio(6/97) Customer Service:(800)334-6557 or(303)831-0161 990325 11
Section 5: Point-of-Service Rider General Provisions Point-of-Service Rider
5 Point-of-Service Rider General Provisions
All provisions of your BlueAdvantage HMO Plan Benefit Booklet are used
to determine whether services are covered under this rider, except for
those provisions that impose requirements for service or referral by your
PCP, or unless specifically addressed in this rider.
■ How and Where to Send Claims
Reminder: If you go to a participating provider, the provider will
file your claims.
HMOC or its designee administers claims under this rider as the agent for
BCBSCO. Submit claims to:
HMO Colorado, Inc.
700 Broadway, Suite 612
Denver, CO 80273
in accordance with the provisions of Section 6: Claims Payment and Appeals
in your BlueAdvantage HMO Plan Benefit Booklet. If a member assigns his or
her right to payment for covered services to a nonparticipating provider,a
copy of the executed assignment of benefits agreement must be submitted
with the claim.
• How Payments Are Made
After a claim has been processed,the member will receive an explanation of
benefits (EOB). (When the member is a dependent child of divorced parents,
the custodial parent may receive the EOB.) Payments for covered services
usually are sent directly to participating providers and the member receives
an EOB that explains the payment. If payment for covered services is sent to
the member,the check is attached to the EOB.The EOB indicates what services
were covered and what services,if any,were not.
BCBSCO's payment to providers is based upon provider agreements and the
covered charges as determined by BCBSCO.The member is responsible for
paying all deductible amounts,coinsurance, penalty amounts, and expenses for
noncovered services. Payments for covered services received from a non-
participating provider are usually made to the member,who is also respon-
sible for paying the provider,including any amounts greater than BCBSCO's
maximum allowable fee. If payment is assigned to a nonparticipating provider,
payment will be made to the nonparticipating provider.
Benefit payments for members who are eligible for Medicaid are paid to the
Colorado Department of Health Care Policy and Finance or providers when
required by law.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization" in Section 2.
12 "�• .o Customer Service:(800)334-6557 or(303)831-0161 BLUPW2M.RIC(B/9])
Point-of-Service Rider Point-of-Service Rider Glossary
■ Point-of-Service Rider Glossary
This section defines certain words used in this rider that are either not defined
in the Glossary of your BlueAdvantage HMO Plan Benefit Booklet or are
used in a different way in your BlueAdvantage HMO Plan Benefit Booklet.
Please see the Glossary of your BlueAdvantage HMO Plan.Benefit Booklet
for additional definitions.
Blue Cross and Blue Shield of Colorado(BCBSCO)—A nonprofit health
service corporation organized under the laws of Colorado.
Coinsurance—An arrangement by which a member pays a certain percent-
age of covered charges for covered services under this rider, after the deduct-
ible is satisfied.
Covered charges— For some facilities and/or pharmacies,the billed
charges. For all other providers,the lesser of billed charges or the maximum
allowable fee.
Deductible—A specified amount of covered charges that each member must
pay for covered services provided under this rider within a calendar year
before any payments will be made by BCBSCO.
Maximum allowable fee—The amount determined by BCBSCO to be a
reasonable and adequate allowance for a covered service. BCBSCO's determi-
nation of a maximum allowable fee is the maximum amount BCBSCO ap-
proves for any particular service.
Nonparticipating provider— An appropriately licensed health care provider
who has not entered into an agreement with BCBSCO. The member is respon-
sible to the nonparticipating provider for all charges,regardless of BCBSCO's
maximum allowable fee or the amount of the benefit payment. The provider's
charge may exceed the BCBSCO maximum allowable fee.
Participating provider— This term means either:
• A facility provider, such as a hospital, that has entered into an agreement
with BCBSCO or another Blue Cross Plan to bill BCBSCO directly for
covered services and to accept the plan's payment plus the member's
share of covered charges (deductible, coinsurance, and penalty amounts,if
any) as payment in full for such covered services; or
• A professional provider, such as a physician,who has entered into an
agreement with BCBSCO for direct billing of covered services,and who
agrees to accept the BCBSCO maximum allowable fee as payment in full
for such covered services.
Some services covered under this rider require prior authorization or payment will be reduced.See
"Prior Authorization"in Section 2.
BLUP072M.RIC(6/9]) Customer Service:(800 334-6557 or(303)831-0161 990325 13
Point-of-Service Rider Glossary Point-of-Service Rider
For covered services received from a BCBSCO participating provider,the
member pays only the deductible and coinsurance amounts. A participating
provider may request payment for deductible and coinsurance amounts at the
time services are rendered. This plan will pay participating providers directly.
Pay—For the purposes of this rider, "pay"means to satisfy a debt or obliga-
tion. BCBSCO reimburses providers by first calculating the member's share of
covered charges. The member's share of the cost of covered services includes
deductible, coinsurance, any penalty amounts, and other cost-sharing amounts.
BCBSCO will then satisfy the difference between the covered charges and the
member's share. This difference may be satisfied by an actual dollar payment
to the provider, discounts negotiated with the provider, or by combining these
two methods of payment. If the provider is not a BCBSCO participating
provider,any amount over the maximum allowable fee must also be paid by
the member.
Some services covered under this rider require prior authorization or payment will be reduce!.See
"Prior Authorization" in Section 2.
14 Customer Service:(800)334-6557 or(303)831-0161 B W P072M RIC(6/97)
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