Health Insurance Plans - Blue Cross of Idaho€¦ · New Ways to Get a Break on Costs There are new...

Health Insurance Plans

for Individuals and families from

Blue Cross of IdahoChoose coverage

that fits.

Form No. 3-1016 (11-13) Policy Form Numbers: 18-061-01/14 18-064-01/14 18-065-01/14

18-066-01/14 18-067-01/14 18-071-01/14

18-072-01/14 18-073-01/14 18-074-01/14

18-075-01/14 18-077-01/14 18-078-01/14

3-420-05/11

At Blue Cross of Idaho, we understand that a good health insurance company has to focus on a variety of things that affect its members.

In this guide, we’ll help you understand the complex health insurance and healthcare industries so that you can find the best coverage to meet your needs. You’ll learn how the Affordable Care Act will impact your wallet, your insurance, and your family. We will introduce you to our product portfolio, outline the services and resources we offer our members, and explain the Idaho Health Insurance Exchange and the financial assistance that may be available to you. We know you have options when you look for health insurance and we thank you for considering Blue Cross of Idaho. We’re confident you will find we offer:

• Coveragetomeetyourlifestyleandfinancialneeds

• Thelargestnetworkofhealthcareproviderstomeetyourhealthcareneeds

• Exceptionalcustomerservice

• Toolsandresourcestohelpyounavigateacomplexsystem

We look forward to serving you!

3Choose Coverage that fits – bcidaho.com.

3 What’s NeW?

9 hoW to Choose the Right PlaN

13 blue CRoss of idaho health iNsuRaNCe PlaNs

25 saVe MoNeY aNd PuRChase iNsuRaNCe

29 additioNal ResouRCes

4 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Individuals and Families

Visitbcidaho.com

formoreinformationaboutBlueCrossofIdaho,theAffordableCareActand

theIdahoHealthInsuranceExchange


The new healthcare law, called the Affordable Care Act (ACA), has brought many changes to health insurance for people who purchase individual or family insurance. There are changes to how we purchase and pay for insurance, new plan options and even financial assistance available to those who qualify.

Here’s a snapshot of the major changes: • ACA may provide financial assistance to

help you pay for your health insurance and healthcare costs.

• You can’t be denied coverage because of a pre-existing health condition.

• Insurance companies can’t drop your coverage if you get sick.

• All health insurance plans must cover standard essential health benefits.

• After your premium payments, the most in a year you will pay for covered healthcare services from in-network providers is $6,350 for individuals and $12,700 for families.

• Parents can keep their kids on their plans until they’re 26yearsold.

• There are no annual or lifetime coverage maximums on EHBs.

• Preventive care, such as annual doctor visits or regular screenings, is now covered with no out-of-pocket costs through your insurance plan.

• All Idahoans, with few exceptions, are required to have health insurance, or pay a taxpenalty.

• The Idaho Health Insurance Exchange is an online marketplace where individuals and families can compare and purchase plans and get financial help to pay premiums.

• Federal law requires dependents under age 19 to have dental insurance with their medical insurance. Blue Cross of Idaho offers dental products that provide the coverage you need and meet all ACA requirements.

WHAT’s NEW?


New Ways to Get a Break on CostsThere are new ways to get help paying for your insurance. Based on your income and family size, you may be eligible for financial assistance with your monthly health insurance costs—called a monthlypremiumtaxcredit. You might also receive cost-sharingsubsidiesthat help reduce your healthcare costs, such as your deductible.

This could also lower your out-of-pocket costs when you visit your doctor or go to the emergency room. see the Save Money and Purchase Insurance section of this booklet on page 29 to learn more about this new financial help.

To get this financial help, you’ll need to enroll in health coverage through Idaho’s Health Insurance Exchange. The next section will help you understand this new way to compare and enroll in insurance plans.

The Exchange is an online marketplace where insurance companies will offer their plans.

Idahoans can compare and select a coverage plan that best fits their healthcare needs and budget.

Open Enrollment is from October 1, 2013 through March 31, 2014.

idaho’s health insurance exchange

At a Glance


New Ways to Compare Health Insurance PlansYou and your family have new health insurance options and Idaho’s Health Insurance Exchange offers people a way to compare these new plans and find out

if you qualify for a monthly premium tax credit and a cost-sharing subsidy. The Exchange is particularly helpful if you:

• Have not been able to afford coverage

• Don’t have enough coverage

• Want a different plan that better meets your needs

WHAT’s NEW?

YoumAYBEElIgIBlEforsuBsIdIEsToHElpYoupAY

forHEAlTHInsurAnCEAndHEAlTHCArE

sErVICEs


WHATIsTHEExCHAngEAndHoWdoEsITWork?

Idaho’s Health Insurance Exchange is a website where you can compare insurance plans, apply for financial assistance, and buy a plan that best fits the needs of you and your family. When you fill out an application on the Idaho Health Insurance Exchange, you’ll learn if you qualify for financial assistance like lower monthly premiums, lower out-of-pocket costs (copayments, deductibles) or if you qualify for free or low-cost government programs like Medicaid or Medicare.

The Exchange will look and operate much like an online travel website, and show insurance plans from many different providers, including plans from Blue Cross of Idaho. You can compare all plans in one place so you can find the right option based on your health insurance needs and budget.

WHoCAnEnroll?

• Legal residents of Idaho who do not have qualified health insurance through their employer or another government program.

• Illegal aliens and incarcerated individuals are not eligible for the Exchange.


WHAT’s NEW?

Open EnrollmentCoveragerequirementMost Idahoans are required to have health insurance in 2014 or pay a penalty.

october2013throughmarch2014Idahoans can buy insurance at bcidaho.com or from the Idaho Health Insurance Exchange during Open Enrollment from October 2013 through March 2014.

december15,2013You will have until December 15, 2013 to apply for coverage starting on January 1, 2014.

• AfterDecember15,youwillstill be able to apply for the monthly premium credit and buy insurance on the Exchange, however, your coverage will not begin until February 1, 2014.

• Ifyouhaveachangeinyourlife, such as a new baby or marriage, or change in your health insurance, you may have a “special enrollment period” and be eligible to buy insurance, after the Open Enrollment period.


Key terms I should knowprEmIum

The amount you pay each month for your health insurance plan.

dEduCTIBlE

The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won’t have to pay any deductible for preventive care.

CoInsurAnCE

Your share of the costs you pay, calculated as a percentage. (for example, you pay 20 percent, insurance pays 80 percent).

CopAYmEnT

A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication.

nETWork

The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members.

ouT-of-poCkETExpEnsEs

Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions.

ouT-of-poCkETmAxImum

After your premium payments, the most in a year you will pay for covered healthcare services from in-network providers is $6,350 for individuals and $12,700 for families.

See the Glossary on page 34 for more key terms.

didYouknow?WestrivetoHelpYoumeetYourHealthcareneedsfrom our nurses in our health

management programs to our online health and wellness tools and more, we provide members with resources

to help them take control of their health.


Choosing the right coverage depends on knowing your healthcare needs, what you want from your coverage and what your budget will allow. Let’s say you don’t have any health coverage, or your current coverage is simply not right for you, now is the time to evaluate your options and find the coverage that fits you and your family.Blue Cross of Idaho has options to meet your medical needs. Our networks include 96 percent of all the doctors and 100 percent of all the hospitals in Idaho, so you can choose among many different plans. Herearesomeofthedifferencesamongplans:

1. Thetypeofhospitalanddoctornetwork:Blue Cross of Idaho offers plans with access to our robust PPO network, featuring 96 percent of doctors and all hospitals in the state, and our ConnectedCaresm networks which provide coordinated care through primary care and specialty physicians in select areas of the state. This gives you the freedom to choose from plans with the largest provider network in Idaho, or those with coordinated care that can lower your monthly premium. Look at the list of doctors and hospitals in each plan type to see if the healthcare providers you prefer are available in the plans you like.

2. Theamountofdeductible: Blue Cross of Idaho offers different deductible levels, including one plan with a $0deductible. The difference in deductible usually changes the amount of monthly premium you pay.

3. Howyoupayforyourcare:Many of our plans include deductibles, copayments and/or coinsurance. One more option is a high deductible health plan paired with a tax free Health savings Account (HsA) that allows you to set up a special bank account to save money to pay for your deductible and other medical expenses. When you put money in your HsA, you will keep that money forever, unless you decide to spend it on health costs. You will not pay tax on this money, and it will be in a savings account where it can earn interest.

HOW TO CHOOsE THE rIgHT PLAN



What are the new options?InTroduCIngmETAllEVElsforEAsYCompArIsonACrossplAns

Individual insurance plans are organized into four metal levels based on the amount of coverage provided. These levels are Bronze, silver, gold, and Platinum, and vary by the monthly premium cost and the percent of expected costs covered.

The metal level ranking system makes it easy to compare plans in the same category or across categories. This allows

you to make apples-to-apples comparisons among plans, see your expected costs more easily and get the coverage you need. It is important to know that all metal levels have the same essential health benefits, such as emergency room services, maternity and newborn care, annual doctor visits, and medical screenings.

As a general rule of thumb, you can choose to pay a higher monthly premium, so that when you need medical care, you pay less. Or you can choose a lower monthly premium so that when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.

didYouknow?You can get services from the best

doctors and hospitals all over the united states in blue networks,

from Johns hopkins and the Cleveland Clinic to the Mayo Clinic

and virtually every research and academic medical institution

in the country.


sImplYpuT:

• The Platinum plans have the most expensive monthly payments, but the insurance plan will cover more of the costs when you receive healthcare services.

• The Bronze plans have the lowest monthly payments, but you will be responsible for more of the costs when you receive healthcare services.

A deductible is the amount you pay each year for out-of-pocket expenses before your insurance covers the cost. You should consider the deductible when evaluating plans. generally speaking, the higher your monthly insurance costs, called premiums, the lower your deductible and vice versa. It’s also important to note that not all services are subject to deductible. some insurance plans pay for certain medical services (like trips to your doctor) before you meet the deductible.

An out-of-pocketmaximum is a fixed dollar amount – $6,350 for individuals, $12,700 for families – that is the most you will pay for covered services from in-network providers in an annual benefit period. Once you meet this maximum, your insurance will cover the total cost of covered services.


Check out Blue Cross of Idaho’s insurance products for each metal level to find the plan that’s right for you. See the Blue Cross of Idaho Health Insurance Plans section of this booklet.

BluECrossofIdAHoInsurAnCEplAns

monTHlYprEmIum

In-nETWorkdEduCTIBlE

rAngEIndividual/family


Individual/family

ElIgIBlEformonTHlYprEmIumTAxCrEdIT

ElIgIBlEforCosTsHArIngsuBsIdY

Bronzeplans $ $5,000-$6,350/ $10,000-$12,700 $6,350/$12,700

silverplans $$ $0-$4,000/$0-$8,000 $6,350/$12,700

goldplans $$$ $1,000/$2,000 $6,350/$12,700

platinumplan $$$$ $550/$1,100 $6,350/$12,700

minimumBenefitplans $ $6,350/$12,700 $6,350/$12,700

short-Termppo $ $500-$2,000 individual only

$2,500 - $4,000 individual only


Key considerations in choosing the right plan for youpleaseconsiderthesequestionsbeforeyouchooseacoverageplantohelpnarrowdownyourbestoptions:

doIquAlIfYforABrEAkonCosTsBAsEdonmYInComEAndfAmIlYsIzE?

Take a look at the Get a Break on Costs section of this booklet to learn if you may be able to get financial assistance.

WHATsorTofHEAlTHsErVICEsAndmEdICATIonsmIgHTmYfAmIlYAndInEEd?

Think about your current and future healthcare needs. How often do you need to go to the doctor? What is your family’s health history? Do you have a job or do activities through which you might get injured? Does your child play a sport in which they might get injured?

doEsTHEplAnInCludEmYCurrEnTdoCTors?

Each plan may include a different set of doctors and other health service providers, which is called being “in-network.” Look at the list of doctors and hospitals in each plan at bcidaho.com to see if the healthcare providers you prefer are in the network of the plans you are considering.

WHATIsTHEBEsTWAYformEToBAlAnCETHEdEduCTIBlEAndprEmIumopTIons?

In balancing your deductible and premium choices, ask yourself: Would I rather pay a higher monthly premium so that my insurance pays a greater portion of the costs if I get sick or injured, i.e. a lower deductible; Or would I rather have a lower monthly premium and pay a greater share of the cost if I get sick or injured, i.e., a higher deductible?

InAddITIon,mAkEsurEYouHAVEAllTHEInformATIonToComplETEYourApplICATIononTHEIdAHoHEAlTHInsurAnCEExCHAngETosEEIfYouquAlIfYforHElpInpAYIngYourmonTHlYprEmIums,InCludIng:

• Dates of birth for all family members

• social security numbers for all family members

• Employer information (Employer name, address, phone number and average hours worked each week)

• Income information (Adjusted gross Income from your previous year’s tax return)


BLuE CrOss OF IDAHO HEALTH INsurANCE PLANs We offer a variety of health insurance plans with the coverage you need at a price you can afford. Whether you buy directly from us, or through the Idaho Health Insurance Exchange, you will find affordable coverage for you and your family from Blue Cross of Idaho.Please take a look at the individual and family metallic plans we offer below. As we discussed in the How Do I Choose the Right Plan section of this booklet, all of our plans fit into four levels based on the amount of coverage they provide. These levels, known as metal levels, are Bronze, silver,

gold, and Platinum. In the following pages, we provide coverage details and plan information to help you find the insurance that best meets your needs. You can learn more about our products and the metal levels at bcidaho.com.

BlueCrossofIdahometallicplans

BronzE

BronzeChoice

BronzeConnect

BronzeHsAsaver

sIlVEr

silverChoice

silverConnect

silverChoice no deductible

silverConnect no deductible

gold

goldChoice

goldConnect

plATInum

platinumConnect


IndIVIduAlAndfAmIlYmEdICAlplAns

Now let’s dive into the health insurance plans you can choose from. Following these plan descriptions, you’ll also find a summary chart outlining the key cost information for each plan.

Please note: At this time the Connect plans in Bronze, Silver, Gold and Platinum are only available through the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Provider Network in eastern Idaho.

BronzEmEdICAlplAns

Our Bronze plans offer our lowest monthly payment options for slightly higher deductible amounts. If you want robust coverage for your routine, preventive care at lower monthly prices, our Bronze plans may be for you.

• BronzeChoice:Combining the low cost and robust benefits of our Bronze plans with our PPO provider network, featuring all of the hospitals in Idaho and 96 percent of doctors and physicians.

• BronzeConnect:Our lowest cost plan brings the benefit package of other Bronze plans together with our ConnectedCare networks in southwestern and southeastern Idaho to meet your coverage and cost needs.

• BronzeHsAsaver:A health plan that you can pair with a Health savings Account (HsA) you set up at your financial institution, like a bank. You can use the tax-free money you deposit into your HsA to cover a wide range of medical costs like your deductible and any other medical costs. If you don’t use the money, you can keep it in your account to earn interest and use when you need it at any time in the future.

Remember… if you purchase insurance through the Idaho Health Insurance Exchange, you

may be eligible for financial help to cover your monthly insurance costs (your premium) and

your additional healthcare costs. Check out the Get a Break on Costs section of this booklet to learn more.


sIlVErmEdICAlplAns

Our silver plans provide a variety of coverage options and pricing structures to meet your health insurance needs. You can choose from a $0deductible option to a higher deductible with low copayment and rich pharmaceutical benefits. Your monthly insurance costs, or premiums, will be slightly higher than those of the Bronze plans but your coverage will pay more of the costs of the services you receive.

• silverChoice: Low out-of-pocket costs for trips to the doctor and prescription drugs combine with the variety and strength of our PPO provider network.

• silverChoicenodeductible: A $0deductible allows you to avoid having to meet a deductible before your insurance kicks in, while providing the strength of our PPO network.

• silverConnect:Low out-of-pocket costs for trips to the doctor and prescription drugs meets the value of a primary care physician of your choice coordinating your care through the ConnectedCare network.

• silverConnectnodeductible: Coordinated medical care without a deductible ensures you get the care you need without huge out-of-pocket costs after your monthly premiums.

BLuE CrOss OF IDAHO HEALTH INsurANCE PLANs

didYouknow?silverplansofferreductions

in deductible, copayment and monthly premium payments for people who qualify. Check out the save Money

and Purchase insurance tab on page 29 of this book

to learn more.


goldmEdICAlplAns

We offer gold plans on our PPO and ConnectedCare networks. With low deductible and copayment amounts, our gold plans combine some of our richest benefit packages with affordability to give you and your family peace of mind in your health insurance.

• goldChoice:Low out-of-pocket costs for trips to the doctor and prescription drugs and a $1,000 deductible make this an easy Choice. The variety and strength of our PPO network is icing on the cake.

• goldConnect: This connects low costs and deductible with coordinated care offering proactive, quality care to meet your needs and budget through our ConnectedCare networks in southwest or eastern Idaho.


plATInummEdICAlplAns

Our Platinum plan is available on our ConnectedCare network in southwestern Idaho. Platinum Connect is a low deductible plan with the highest level of coverage. This plan brings you, your medical providers and health insurance together to offer proactive, quality care at an affordable price. Among all the metal levels, Platinum plans will have the highest predictable monthly premiums, but you’ll have the lowest out-of-pocket costs when you get medical care.

• platinumConnect: Our most comprehensive coverage plan combines a low deductible with our most robust benefit structure. This plan offers the value of having your primary care doctor from the saint Alphonsus Health Alliance Network in southwest Idaho coordinate your care with other healthcare providers, such as specialists.

mInImumBEnEfITplAns

We also offer a pair of high-deductible, low payment plans available to people under the age of 30, and for people who qualify through the Exchange on a hardship exemption. These “catastrophic” plans provide coverage for the essential health benefits but only after a member has met the deductible levels in out-of-pocket expenses. If you are under the age of 30, or if you meet certain criteria through the Exchange, these plans may be a good choice for you. Members on the catastrophic plans are not eligible for the monthly premium tax credit or cost sharing subsidy available through the Idaho Health Insurance Exchange.

• CoveredChoice: Combines our largest provider network with a high-deductible, lower-premium plan design.

• CoveredConnect:The same benefit design as our Covered Choice plan at a slightly lowered price. Available only to buyers in southwestern and eastern Idaho, through our ConnectedCare networks in those areas of the state.

sHorT-TErmppoplAn

Do you need coverage for a short period of time? Blue Cross of Idaho’s short Term PPO offers a limited benefit program for temporary coverage. You can protect yourself and eligible dependents during those times between coverage and choose from non-renewable coverage for one to 10 months. Our short-term plans are only available directly from Blue Cross of Idaho and are not subject to the rules set forth by the ACA, including the pre-existing condition coverage requirement.

Dental insurance must be included in your coverage if you or a dependent are under the age of 19.



The size of our provider networks

allows us to negotiate pricing to help keep your

costs low.

Our Provider NetworksYou’ll get the best choice of doctors and hospitals with Blue Cross of Idaho. As you read the descriptions of each of the plans, you’ll notice that Choice plans use our PPO network, whereas the Connect plans use our new ConnectedCare network. As you consider which plan is right for you, check to make sure the healthcare providers and facilities, such as hospitals, you like are in the plan’s provider network. You can look for specific doctors and hospitals through our Find a Provider link on our homepage at bcidaho.com.

preferredproviderorganization(ppo)network:If you choose a plan with the PPO network, you’ll get access to 96 percent of all physicians in the state. Additionally, you can visit any acute care hospital in Idaho, i.e., those hospitals that provide services for short-term illnesses or injuries. With this vast group of in-network providers, you can be sure to find a provider you want, pay the in-network costs and avoid the higher costs that come when you use a provider or health services facility that is out-of-network. Plus, you won’t need referrals to visit specialists or other care providers. It’s your choice who you see.

ConnectedCarenetwork: Our ConnectedCare products are supported by the saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Health Network in eastern Idaho. When you choose managed care through ConnectedCare networks, you’ll receive high quality care, close to home from highly skilled healthcare providers dedicated to delivering effective, efficient care.

Our Connect plans, in combination with ConnectedCare networks in southwestern and eastern Idaho, are designed to improve the quality of care and control costs by coordinating your services through a primary care physician (PCP). You’ll need to select a PCP to serve as your care coordinator. What does that mean? Your PCP will act as a central point for your care, coordinating your treatment by providing your care when it is appropriate or referring you to other in-network specialists for other healthcare services as needed. With more coordinated care, we believe your receive higher quality care for your overall wellbeing. Please note: at this time the ConnectedCare network is only available in southwestern and eastern Idaho.


didYouknow?WeofferWide,qualityprovidernetworks

96% of idaho doctors and 100% of idaho hospitals are in our network. Plus, thousands of doctors and hospitals all over the united states

are in the blueCard® network. outside of the united states, members have access to

doctors and hospitals in more than 200 countries and territories

around the world.



mETAllEVEl CATAsTropHICplAns (Minimum Benefit) BronzE mETAllEVEl BronzEplans CoVErEdCHoICEAndCoVErEdConnECT

In-network out-of-networkBronzEHsAsAVEr

In-network out-of-networkplans BronzECHoICE

In-network out-of-networkBronzEConnECT

In-network out-of-network

deductible Individual – $6,350 Family – $12,700

Individual – $6,350 Family – $12,700







Annualout-of-pocket

maximumCosts


CoveredChoice $8,350 / $16,700CoveredConnect $10,000 / $20,000



Annualout-of-pocket

maximumCosts





Coinsurance Youpaynothing.(services may be subject to deductible.)

Youpay30%.(services may be subject to deductible.)

Youpaynothing.(services may be subject to deductible.)

Youpay30%(services may be subject to deductible.)





WHATYou’llpAYupToYourAnnuAlouT-of-poCkETmAxImum WHATYou’llpAYupToYourAnnuAlouT-of-poCkETmAxImum

preventiveCareservices

Youpaynothingfor covered preventive care services.

Youpaycostsup to your deductible and then 30%.








doctor’sofficeVisit

CoveredChoice:Youpay$30 each for first 3 office visits, then costs up to your deductible.


Youpaycosts up to your deductible and then you pay nothing.



Youpay$30copayment(up to 4 non-preventive office visits, then you pay costs up to your deductible.)


Youpay$30copayment(up to 5 PCP office visits, then you pay costs up to your deductible.) Youpaycosts up to your deductible for non-PCP visits with referral.


CoveredConnect:Youpay$10copayment(each for first 3 PCP office visits, then costs up to your deductible.) Youpaycostsup to your deductible for non-PCP visits with referral.

Immunizations Youpaynothingfor covered immunizations.

Youpaynothingfor covered immunizations.







InpatientHospitalservices

Youpaycosts up to your deductible.


Youpaycosts up to your deductible and then nothing.

Youpaycosts up to your deductible and then 30%.






EmergencyroomVisit


Youpaycostsup to your deductible and then 30%. *

Youpaycosts up to your deductible and $150copayment.

Youpaycosts up to your deductible, 30% and $150copayment.*

EmergencyroomVisit


Youpaycostsup to your deductible and then 30%.*



prescriptiondrugs

Youpaycosts up to your deductible

and then nothing.

Youpaynothing for covered generic and brand-name preventive drugs. Youpaycosts up to your deductible and

$10copaymentfor non-preventive generic drugs, and 50% for non-preventive brand-name drugs.

prescriptiondrugs


and then nothing.


and then nothing.

pregnancy Youpaycosts up to your deductible.




pregnancy Youpaycosts up to your deductible and then nothing.




outpatientmentalHealthservices






Youpay$30copaymentfor outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible.




physician,surgical&medicalservices










diabetesEducationservices



Youpaycosts up to your deductible and then $30 copayment.



Youpay$30copayment. Youpaycosts up to your deductible and then 30%.


ChiropracticCare Youpaycosts up to your deductible.




ChiropracticCare Youpaycosts up to your deductible and then nothing.




up to a combined in and out-of-network total of 18 visits per member, per benefit period.

up to a combined total of 18 visits per member, per benefit period.



outpatientrehabilitation

services






services





Physical Therapy (PT) Occupational Therapy (OT) Speech Therapy (ST)

PT, sT, OT limited to a combined total of 20 visits per member, per benefit period

PT,OT,sT limited to a combined total of 20 visits per member, per benefit period.




diagnosticx-rayandlabservices



Youpaycosts up to your deductible, then nothing.







benefit grid outlines coverage for in-network and out-of-network services. Not a comprehensive list of benefits.

* For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.



mETAllEVEl CATAsTropHICplAns (Minimum Benefit) BronzE mETAllEVEl BronzEplans CoVErEdCHoICEAndCoVErEdConnECT

In-network out-of-networkBronzEHsAsAVEr

In-network out-of-networkplans BronzECHoICE

In-network out-of-networkBronzEConnECT










Annualout-of-pocket

maximumCosts


CoveredChoice $8,350 / $16,700CoveredConnect $10,000 / $20,000



Annualout-of-pocket

maximumCosts






Youpay30%.(services may be subject to deductible.)



















CoveredChoice:Youpay$30 each for first 3 office visits, then costs up to your deductible.


Youpaycosts up to your deductible and then you pay nothing.



Youpay$30copayment(up to 4 non-preventive office visits, then you pay costs up to your deductible.)


Youpay$30copayment(up to 5 PCP office visits, then you pay costs up to your deductible.) Youpaycosts up to your deductible for non-PCP visits with referral.


CoveredConnect:Youpay$10copayment(each for first 3 PCP office visits, then costs up to your deductible.) Youpaycostsup to your deductible for non-PCP visits with referral.



















EmergencyroomVisit


Youpaycostsup to your deductible and then 30%. *

Youpaycosts up to your deductible and $150copayment.


EmergencyroomVisit





prescriptiondrugs


and then nothing.

Youpaynothing for covered generic and brand-name preventive drugs. Youpaycosts up to your deductible and

$10copaymentfor non-preventive generic drugs, and 50% for non-preventive brand-name drugs.

prescriptiondrugs


and then nothing.


and then nothing.

pregnancy Youpaycosts up to your deductible.




pregnancy Youpaycosts up to your deductible and then nothing.



























Youpaycosts up to your deductible and then $30 copayment.









ChiropracticCare Youpaycosts up to your deductible and then nothing.




up to a combined in and out-of-network total of 18 visits per member, per benefit period.





services






services






PT, sT, OT limited to a combined total of 20 visits per member, per benefit period








Youpaycosts up to your deductible, then nothing.







Visit bcidaho.com for a summary of benefits and Coverage.



mETAllEVEl sIlVEr mETAllEVEl sIlVErplans sIlVErCHoICE

In-network out-of-networksIlVErConnECT

In-network out-of-networkplans sIlVErCHoICEnodEduCTIBlE

In-network out-of-networksIlVErConnECTnodEduCTIBlE






deductible Individual – $0 Family – $0


Individual – $0 Family – $0


Annualout-of-pocket

maximumCosts





Annualout-of-pocket

maximumCosts





Coinsurance Youpay30% of the cost of your care. (services may be subject to your deductible.)

Youpay50% of the cost of your care. (services may be subject to your deductible.)



Coinsurance Youpay50% of the cost of your care.


Youpay50% of the cost of your care.














Youpay$10copayment(up to 4 non-preventive office visits, then you pay costs up to your deductible and 30%.)


Youpay$10copayment(up to 5 PCP office visits, then you pay costs up to your deductible and 30%.) Youpaycosts up to your deductible and 30% for non-PCP visits with referral.



Youpay50%. Youpaycosts up to your deductible and then 75%.


















EmergencyroomVisit

Youpaycosts up to your deductible, 30% and $150copayment.




EmergencyroomVisit

Youpay$150copayment and then 50%.




prescriptiondrugs

Youpay$10copaymentfor generic drugs.


prescriptiondrugs Youpay50%

of the cost of your prescription.Youpay50%

of the cost of your prescription.Youpaycostsup to a separate $2,350 deductible for brand-name and specialty drugs and then: $30for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs.

Youpaycostsup to a separate $2,350 deductible for brand-name and specialty drugs and then: $30for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs.

pregnancy Youpaycostsup to your deductible and then 30%.




pregnancy Youpay50%. Youpaycosts up to your deductible and then 75%.



Youpay$10copaymentfor outpatient psychotherapy services. For facility and other professional services, you pay costs up to deductible and 30%.
















Youpay$10copaymentper visit.







ChiropracticCare Youpaycosts up to your deductible and then 30%.




ChiropracticCare Youpay50%. Youpaycosts up to your deductible and then 75%.






outpatientrehabservices


























mETAllEVEl sIlVEr mETAllEVEl sIlVErplans sIlVErCHoICE

In-network out-of-networksIlVErConnECT

In-network out-of-networkplans sIlVErCHoICEnodEduCTIBlE

In-network out-of-networksIlVErConnECTnodEduCTIBlE






deductible Individual – $0 Family – $0


Individual – $0 Family – $0


Annualout-of-pocket

maximumCosts





Annualout-of-pocket

maximumCosts





Coinsurance Youpay30% of the cost of your care. (services may be subject to your deductible.)




Coinsurance Youpay50% of the cost of your care.


Youpay50% of the cost of your care.














Youpay$10copayment(up to 4 non-preventive office visits, then you pay costs up to your deductible and 30%.)


Youpay$10copayment(up to 5 PCP office visits, then you pay costs up to your deductible and 30%.) Youpaycosts up to your deductible and 30% for non-PCP visits with referral.





















EmergencyroomVisit





EmergencyroomVisit





prescriptiondrugs



prescriptiondrugs Youpay50%

of the cost of your prescription.Youpay50%

of the cost of your prescription.Youpaycostsup to a separate $2,350 deductible for brand-name and specialty drugs and then: $30for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs.

Youpaycostsup to a separate $2,350 deductible for brand-name and specialty drugs and then: $30for preferred brand-name, $50 for non-preferred brand-name, $100 for specialty drugs.

pregnancy Youpaycostsup to your deductible and then 30%.




pregnancy Youpay50%. Youpaycosts up to your deductible and then 75%.






























ChiropracticCare Youpay50%. Youpaycosts up to your deductible and then 75%.































mETAllEVEl gold mETAllEVEl plATInumplans goldCHoICE

In-network out-of-networkgoldConnECT

In-network out-of-networkplans plATInumConnECT






deductible Individual – $550 Family – $1,100

Individual – $550 Family – $1,100

Annualout-of-pocket

maximumCosts





Annualout-of-pocket

maximumCosts



Coinsurance Youpay15%of the cost of your care. (services may be subject to deductible.)

Youpay50%of the cost of your care. (services may be subject to deductible.)





WHATYou’llpAYupToYour AnnuAlouT-of-poCkETmAxImum

WHATYou’llpAYupToYourAnnuAlouT-of-poCkETmAxImum


Youpaynothingfor covered preventive care visits.








Youpay$10copayment(up to 4 office visits, then you pay costs up to your deductible and coinsurance.)


Youpay$10pCpcopaymentand $40non-pCpcopayment (up to 5 office visits, then you pay costs up to your deductible and coinsurance.) Youpaycosts up to your deductible and 15% for non-PCP visits with referral.



Youpay$10pCpcopaymentand$40non-pCpcopayment(up to 5 office visits, then costs up to your deductible.) Youpaycosts up to your deductible for non-PCP visits with referral.














Youpaycostsup to your deductible and then nothing.


EmergencyroomVisit





EmergencyroomVisit

Youpay$150copayment(Not subject to deductible.)

Youpay$150copaymentand then 50% (Not subject to deductible.)*

prescriptiondrugs Youpay$10copaymentfor generic prescription drugs.

Youpay$10copaymentfor generic prescription drugs.



Youpaycostsup to your deductible for brand-name and specialty drugs and then: $30for preferred brand-name,

$50 for non-preferred brand-name, $100 for specialty drugs.



Youpay$30copaymentfor preferred brand-name, $50copayment for non-preferred brand-name,

$100copayment for specialty drugs.pregnancy Youpaycosts up to your

deductible and then 15%.Youpaycosts up to your deductible and then 50%.



pregnancy Youpay$200copaymentfor facility services and costs up to your deductible for physician’s care.












































PT,OT,sT limited to a combined total of 20 visits per member, per benefit period

















mETAllEVEl gold mETAllEVEl plATInumplans goldCHoICE

In-network out-of-networkgoldConnECT

In-network out-of-networkplans plATInumConnECT






deductible Individual – $550 Family – $1,100

Individual – $550 Family – $1,100

Annualout-of-pocket

maximumCosts





Annualout-of-pocket

maximumCosts



Coinsurance Youpay15%of the cost of your care. (services may be subject to deductible.)






WHATYou’llpAYupToYour AnnuAlouT-of-poCkETmAxImum

WHATYou’llpAYupToYourAnnuAlouT-of-poCkETmAxImum










Youpay$10copayment(up to 4 office visits, then you pay costs up to your deductible and coinsurance.)


Youpay$10pCpcopaymentand $40non-pCpcopayment (up to 5 office visits, then you pay costs up to your deductible and coinsurance.) Youpaycosts up to your deductible and 15% for non-PCP visits with referral.



Youpay$10pCpcopaymentand$40non-pCpcopayment(up to 5 office visits, then costs up to your deductible.) Youpaycosts up to your deductible for non-PCP visits with referral.














Youpaycostsup to your deductible and then nothing.


EmergencyroomVisit





EmergencyroomVisit

Youpay$150copayment(Not subject to deductible.)

Youpay$150copaymentand then 50% (Not subject to deductible.)*









Youpay$30copaymentfor preferred brand-name, $50copayment for non-preferred brand-name,

$100copayment for specialty drugs.pregnancy Youpaycosts up to your

deductible and then 15%.Youpaycosts up to your deductible and then 50%.



pregnancy Youpay$200copaymentfor facility services and costs up to your deductible for physician’s care.
























































Key terms I should knowprEmIum

The amount you pay each month for your health insurance plan.

dEduCTIBlE

The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won’t have to pay any deductible for preventive care.

CoInsurAnCE

Your share of the costs you pay, calculated as a percentage. (for example, you pay 20 percent, insurance pays 80 percent).

CopAYmEnT

A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication.

nETWork

The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members.

ouT-of-poCkETExpEnsEs

Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions.


After your premium payments, the most in a year you will pay for covered healthcare services from in-network providers is $6,350 for individuals and $12,700 for families.

THECosTofYourCArE

When you use in-network providers, your cost of care is lower because even when you are paying your deductible, you only pay Blue Cross of Idaho’s discounted fee.



Why Blue Cross of Idaho? From our beginnings at a meeting in Boise in 1945, through the current evolving health insurance landscape and beyond, Blue Cross of Idaho has remained committed to a healthier Idaho.

Today, Blue Cross of Idaho Health service, Inc. is a tax-paying, not-for-profit mutual insurance company with more than 700,000 members enrolled in our medical and dental insurance programs. We employ nearly 900 employees at our headquarters in Meridian, Idaho, with additional staff in offices in Coeur d’Alene, Lewiston, Twin Falls, Pocatello and Idaho Falls.

BEsTVAluE

Our mission is to provide our members the best value in health insurance and the tools for maintaining, and improving, their health. By providing the best value in health insurance, we meet our member needs. We do this by offering members a variety

of insurance options, extensive provider networks that let you get care from the doctors you want, award winning customer service and by giving you access to the healthcare programs you need to achieve your best health. And even as healthcare costs continue to rise, we work to minimize the administrative costs, so that we can keep your premiums as low as possible.

sTrongproVIdErnETWorks

No insurance company has a more complete network of doctors and hospitals in the state than Blue Cross of Idaho. We contract with every hospital in Idaho and 96 percent of all Idaho physicians and healthcare providers.

If you’re traveling outside of Idaho, doctors and hospitals all over the united states are in our BlueCard network, from Johns Hopkins and the Cleveland Clinic to the Mayo Clinic and virtually every research and academic medical institution in the country. Outside of the united states, you’ll have access to doctors and hospitals in more than 200 countries and territories around the world through the BlueCard Worldwide® Program.

ExCEllEnTCusTomErsErVICE

Blue Cross of Idaho takes pride in providing exceptional service to all our members in an experienced, consistent and accountable manner. At Blue Cross of Idaho, we go to great lengths to make sure important information is always at your fingertips by providing support through our website at bcidaho.com and over the phone. Whether you prefer researching your question on our website or contacting one of our specially trained customer advocates on the phone, we’re here for you.


HErEWHEnYounEEdus

Members can connect with one of our many experienced customer advocates specifically trained to handle your needs. Our Customer Advocates are available from 8 a.m. to 6 p.m. MT Monday through Friday. Blue Cross of Idaho also provides services to our members 24 hours a day online or through our automatic phone system that offers self-service options such as claims history, eligibility or deductible information.

HEAlTHmAnAgEmEnTprogrAms

We help our members succeed in creating and sustaining healthy behaviors. By crafting programs that focus on supporting our members’ goals, they have access to the critical information and tools to help them live healthier, happier lives. You can too!

If you participate in one of our Health Management Programs, our nurse health coaches will work with you one-on-one over the phone, helping you learn how to take the best care of yourself, realize your goals, and take confident steps toward better health.

BEHAVIorAlHEAlTHmAnAgEmEnTInTEgrATIon

Behavioral health focuses on improving the quality of life for people with mental illness or substance abuse because mental

health is a key aspect of overall health and wellbeing. Having a department dedicated to behavioral health allows us to help coordinate overall member care, and provide an integrated approach to your entire physical and mental health picture.

HElpfulonlInETools

At bcidaho.com/members as a member you can get information on your coverage, claims, and the cost of services, take an online health risk assessment and find a doctor or hospital – all available 24 x 7 on our website. Here are some of the details of what you can find on our easy-to-use site:

• Health plan specifics

• Claims history, coverage descriptions and the explanation of benefits for all claims

• Individual and family deductible information

• searchable benefit information for your specific plan

• Hospital admissions and prior authorization history

• Provider and hospital finders

• Pharmacy benefits information and a prescription drug formulary

• Medical forms

BluECrossofIdAHoHAsprogrAmsforAsTHmA,

CongEsTIVEHEArTfAIlurE,dEprEssIon,

dIABETEs,AndCHronICoBsTruCTIVEpulmonArYdIsEAsE,

AmongoTHErs.



Additionally, members who complete a personal health assessment have access to online health coaching programs that give them personalized action plans, tools and resources to help them meet their health goals. These programs include:

• rElAx® – stress management

• moVE® – fitness/physical activity

• nourIsH® – nutrition

• BrEATHE® – smoking cessation

• BAlAnCE® – weight management

Members can also visit our online health library to access tools and information like:

• Interactive tools and quizzes

• symptom checker

• A variety of health topics

• Information on medical tests and medications

Personal health coaching is a value added program and is not health insurance.

Blue Extras!BlueExtrasisavalueaddedprogramandnothealthinsurance.

We know that maintaining good health is important to our members and that there are many different approaches to achieving good health. Whether you follow a formal workout routine or rely on evening walks in the neighborhood – take a daily multi-vitamin or follow a strict naturopathic medicine, acupuncture and massage therapy program, our Blue Extras! program can help you succeed.

Blue Extras! offers a variety of value-add services, programs and products to help our members achieve their personal health, wellness and fitness goals. The Blue Extras! program offers discounted rates to members for the following services:

• Babyhealthandsafety

• Complementaryandalternativehealth

• Fitnessclubs

• Hearingservices

• Medicalalertservices

• Orthodontiaservices

• Visionservices

Blue Extras! is available to most Blue Cross of Idaho members and is not dependent on your specific benefit plan. However, if your plan includes coverage for a service included in the Blue Extras! value-added program, the service provider will apply the discount before submitting the claim for payment under your benefit plan. For more information about Blue Extras! and for a list of specific clubs and services providers, visit bcidaho.com.

We are dedicated to providing the highest quality

member service, whether through

our website at bcidaho.com,

over the phone, in person at our

district offices and through e-mail.


Visitoursubsidycalculatoratbcidaho.comtogetanestimateonhowmuchmoneyyoumightbeabletosave.

fAmIlYsIzE

InComErAngE

ElIgIBlEformonTHlYprEmIumTAxCrEdIT

Individual $11,490–$45,960 Yesfamilyof4 $23,550–$94,200 Yes

SAVeMOneyAnD PurCHAsE INsurANCE

Worried that health insurance is too expensive? Well, it may now be within reach.Not only does Blue Cross of Idaho offer plans to meet your budget and coverage needs, but depending on your income and family size, you may qualify for help paying your health insurance and healthcare costs. You may even be eligible for a low cost or $0 insurance plan. remember, you’ll need to apply for financial assistance on the Exchange.

monTHlYprEmIumTAxCrEdITs

starting in 2014, there is a new credit you may be able to use right away to lower your monthly insurance premium costs.

• The Federal government will send that money directly to your insurance company.

• You will be able to calculate if you are eligible for a credit before you enroll in a plan. Financial assistance depends on your income and family size.

forExAmplE:

– Individuals: A single person earning between $11,490 and $45,960 will qualify.

– families: The amount of income you can have and still qualify varies according to the size of your family. As an example, a family of four with household income between $23,550 and $94,200 will qualify.

You may be eligible for financial assistance that will help you right away.

gET A BrEAk ON COsTs


opTIonsforfAmIlIEs

There is also help for working families through already existing programs like the Children’s Health Insurance Program (CHIP) and Medicaid.

• CHIP provides coverage for children so that they will be able to get routine checkups, dental care, and immunizations to keep them healthy.

They will also get physician visits, prescription. For more information, visit: insurekidsnow.gov/state/idaho

• Medicaid offers $0 or low cost coverage for your healthcare needs based on income level and family size. For more information, visit: healthandwelfare.idaho.gov

loWErYourouT-of-poCkETCosTs

If your household income is in a certain range – between 100 percent and 250 percent of the federal poverty level – you may be able to get extra help paying

out-of-pocket costs, such as deductibles and coinsurance. This assistance is known as cost sharing reduction or subsidies, and is only available if you choose the silver plan.

To learn more about what determines health insurance

costs, go to bcidaho.com

fAmIlYsIzE

InComErAngE

ElIgIBlEforCosTsHArIngrEduCTIon

Individual $11,490–$28,725 Yesfamilyof4 $23,550–$58,875 Yes


SAVeMOneyAnDpurCHASeInSurAnCe

You can purchase insurance directly from Blue Cross of Idaho, through your insurance agent, or from the Idaho Health Insurance Exchange.purCHAsIngInsurAnCETHrougHBluECrossofIdAHo

If you’d like to purchase Blue Cross of Idaho health insurance, you can:

• VisittheBlueCrossofIdahowebsitebcidaho.com.

• Contact Blue Cross of Idaho sales at 1888goCross(1888-462-7677)to help choose a plan that is right for you.

• Visitadistrictoffice–youcanfindlocations on the back of this booklet or on our website at shoppers.bcidaho.com under the Contact Us tab.

InsurAnCEBrokErs

An insurance broker can help you understand, compare and evaluate plans, including those from Blue Cross of Idaho, based on your specific needs.

Check out our broker locator at shoppers.bcidaho.com under the Tools and Resources tab.

THEIdAHoHEAlTHInsurAnCEExCHAngE

The Exchange at YourHealthIdaho.org allows you to apply for the new financial help and make side-by-side comparisons of the insurance plans available from a variety of insurance providers, including Blue Cross of Idaho. You must purchase insurance through the Exchange to qualify for the new monthly premium credit.

HOW CAN I PurCHAsE INsurANCE?


didYouknow?our website, bcidaho.com, provides

our members access to a variety of information about their health

plan and health history, from health plan specifics to

medical forms.


ADDITIONAL rEsOurCEsTo learn more about the changes to health insurance following healthcare reform and learn more about Blue Cross of Idaho products, visit:BCIdaHo.CoM

Check out Blue Cross of Idaho plans that are available to you.

BluECrossofIdAHosAlEs1888goCross(1888-462-7677)

GETCovEREdIdaHo.CoM

This educational website will help Idahoans understand the changes coming to health insurance in 2014, including information on the Idaho Health Insurance Exchange, the financial assistance that may be available to you, as well as a calculator to estimate if you are eligible for those cost breaks.

HEAlTHInsurAnCEBrokErs

Visitourbrokerlocatoratshoppers.bcidaho.com under the Tools and Resources tab.

YoURHEalTHIdaHo.oRG

allows you to apply for the new financial help and make side-by-side comparisons of the insurance plans available from a variety of insurance providers.

HEalTHCaRE.Gov

This website was created by the Federal government to help you understand more about healthcare reform and the new state health insurance exchanges that will be offering new insurance options across the country.


gLOssArYHere are simple and straightforward explanations of common terms you’re bound to come across as you scan plan options. knowing these definitions can help you find the best options are for you and your family.premium:The amount you pay each month for your health insurance plan.

deductible:The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won’t have to pay any deductible for preventive care.

Coinsurance:Your share of the costs you pay, calculated as a percentage. (for example, you pay 20 percent, insurance pays 80 percent)

Copayment:A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication.

network:The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members.

out-of-pocketExpenses:Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions.

maximumout-of-pocket:A fixed dollar amount that is the most you will pay for covered services in a benefit period. Once you meet the out-of-pocket maximum, covered services are paid at 100 percent of the allowed amount.

monthlypremiumCredits(also:AdvancepremiumTaxCredit):When enrollment through the Health Insurance Exchange starts in October 2013, individuals and families may be eligible for a new kind of monthly premium credit to lower what they pay for their monthly health plan premiums. The government will pay your premium credit in advance to your insurance company to help cover the cost of premiums, helping make insurance more affordable. You’ll be able to buy insurance through Idaho’s Health Insurance Exchange or from an insurance company, but the credits to help pay for insurance will be available only if you purchase the Idaho Health Insurance Exchange.

AmountCharged/AmountAllowed: A provider can charge you any amount for a service, but a health insurer may establish the maximum it will pay for a given covered service. This amount will often be less than the charged amount. Contracting or “in-network” providers agree to accept the allowed amount (called the maximum allowance in your policy) as payment in full for a covered service and, as part of their contract, agree not to bill you the difference between the allowed amount and charged amount.


ADDITIONAL rEsOurCEs

EssentialHealthBenefits(EHBs): Basic health benefits that most health insurance plans will have to cover starting in 2014 with no coverage limit. They include: office visits, emergency services, hospitalization, rehab care, mental health and substance abuse treatment, prescriptions, lab tests, prevention, maternal and newborn care, and pediatric care.

ExplanationofBenefits(EoB): An explanation of benefits (EOB) form lists the services for which you or your providers have sent claims for coverage. These forms are not bills.

federalpovertylevel(fpl): The Federal Poverty Level is a measure of income level issued annually by the Department of Health and Human services. Federal poverty levels are used to determine your eligibility for certain programs and benefits. Incomes between 100 and 400 percent of the FPL ($11,490 – $45,960 for an individual) are eligible for the monthly premium tax credit and those with incomes from 100 through 250 percent of FPL may be eligible for cost sharing subsidies.

Idaho’sHealthInsuranceExchange:The Idaho Health Insurance Exchange is designed to make buying health coverage easier and more affordable. Idaho’s new Health Insurance Exchange is an online portal where a variety of insurance providers will offer their products for you to consider and select a coverage plan that best fits your healthcare needs and your budget. starting in 2014, the Exchange will allow individuals to compare health plans, get answers to questions, find out if they are eligible for credits, and enroll in a health plan that meets their needs.

Insuranceproviders:The private companies selling health insurance plans.

Individualmandate(AlsoTaxpenalty):starting in 2014, you must be enrolled in a health insurance plan that meets basic minimum standards. If you aren’t, you may be required to pay a tax penalty. This penalty will be either 1 percent of your taxable income Or a flat dollar amount – whichever amount is greater. The flat dollar amount will increase every year you are without health insurance. It starts at $95 in 2014, $325 in 2015 and $695 in 2016. You won’t have to pay a penalty if you have very low income and coverage is unaffordable to you or for other reasons, including your religious beliefs. You will also be able to apply for a waiver asking not to pay an assessment if you don’t qualify automatically.

metallevels:There are four levels of individual coverage available through Exchange plans, called bronze, silver, gold and platinum. All plans will cover the essential benefits. Bronze plans feature the lowest monthly premiums, but cover only 60 percent of average costs. Platinum plans cover 90 percent of expected costs, but have the highest premiums.

non-Coveredservice:A service or type of service that is specifically excluded from coverage in your policy. read your policy for a full list, but non-covered services often include those considered experimental or convenience items.

Note: These definitions are general descriptions. Please refer to your policy for specific definitions related to your benefits.


ExCLusIONs & LIMITATIONsIn addition to the exclusions and limitations listed elsewhere in this booklet, the following exclusions and limitations apply to the entire Policy, unless otherwise specified:THErEArEnoBEnEfITsforsErVICEs,supplIEs,drugs,oroTHErCHArgEsTHATArE:• notMedicallynecessary.Ifservices

requiring Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Insured. However, the Insured could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider.

• InexcessoftheMaximumAllowance.

• ForHospitalInpatientorOutpatientcarefor extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Insured has a non-dental, life-endangering condition that makes hospitalization necessary to safeguard the Insured’s health and life.

• notprescribedbyoruponthedirectionofa Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed general Hospitals, Physicians, and other Providers.

• Investigationalinnature.

• providedforanycondition,Disease,Illness,or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers’ Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related Injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party.

• providedorpaidforbyanyfederalgovernmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefore would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Medicare Part B or would have been made if an Insured had applied for such payment except when payment under this Policy is expressly required by federal law.

• providedforanycondition,AccidentalInjury,Disease or Illness suffered as a result of any act of war or any war, declared or undeclared.

• Furnishedbyaproviderwhoisrelatedtothe Insured by blood or marriage and who ordinarily dwells in the Insured’s household.

• receivedfromadental,vision,ormedicaldepartment maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group.

• ForSurgeryintendedmainlytoimproveappearance or for complications arising from surgery intended mainly to improve appearance, except for:

prEExIsTIngCondITIonWAITIngpErIodsThere is no preexisting condition waiting period for benefits.



•reconstructiveSurgerynecessarytotreatan Accidental Injury, infection, or other Disease of the involved part; or

•reconstructiveSurgerytocorrectCongenital Anomalies in an Insured who is a dependent child.

• renderedpriortotheInsured’seffectiveDate.

• Forpersonalhygiene,comfort,beautification(including non-surgical services, drugs, and supplies intended to enhance the appearance), or convenience items, even if prescribed by a Physician, including, but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, massage therapy, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, homeopathic or naturopathic, massage, or music.

• Fortelephoneconsultations,andallcomputer or Internet communications; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider.

• ForInpatientadmissionsthatareprimarilyfor Diagnostic services, Therapy services, or Physical rehabilitation, except as specifically provided in this Policy; or for Inpatient admissions when the Insured is ambulatory and/or confined primarily for bed rest, special diet, behavioral problems, environmental change or for treatment not requiring continuous bed care.

• ForInpatientorOutpatientCustodialCare;or for Inpatient or Outpatient services consisting mainly of educational therapy,

behavioral modification, self care or self help training, except as specified as a Covered service in this Policy.

• Foranycosmeticfootcare,includingbutnotlimited to, treatment of corns, calluses and toenails (except for surgical care of ingrown or Diseased toenails).

• Foranyofthefollowing:

•Forappliances,splintsorrestorationsnecessary to increase vertical tooth dimensions or restore the occlusion, except as specified as a Covered service in this Policy;

•FororthognathicSurgery,includingservices and supplies to augment or reduce the upper or lower jaw;

•Forimplantsinthejaw;forpain,treatment,or diagnostic testing or evaluation related to the misalignment or discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies;

•Foralveolectomyoralveoloplastywhenrelated to tooth extraction.

• Forhearingaidsorexaminationsfortheprescription or fitting of hearing aids.

• Fororthoptics,eyeglassesorcontactlensesor the vision examination for prescribing or fitting eyeglasses or contact lenses, unless specifically provided as a Covered service in this Policy.

• Foranytreatmentofeithergenderleadingto or in connection with transsexual surgery, gender transformation, sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition.

• MadebyaLicensedGeneralHospitalforthe Insured’s failure to vacate a room on or before the Licensed general Hospital’s established discharge hour.


• notrelateddirectlytothecareandtreatmentof an actual condition, Illness, Disease, or Accidental Injury.

• Furnishedbyafacilitywhichisprimarilyaplacefor treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home.

• ForAcuteCare,rehabilitativecare,diagnostictesting, except as specified as a Covered service in this Policy; for Mental or Nervous Conditions and substance Abuse or Addiction services not recognized by the American Psychiatric and American Psychological Association.

• Forweightcontrolortreatmentofobesityor morbid obesity, including but not limited to surgery for obesity, except when surgery for obesity is Medically Necessary to control other medical conditions that are eligible for Covered services under the Policy, and nonsurgical methods have been unsuccessful in treating the obesity. For reversals or revisions of surgery for obesity, except when required to correct an immediately life-endangering condition.

• Foranelectiveabortion,unlessitistherecommendation of one consulting Physician that an abortion is necessary to save the life of the mother, or if the pregnancy is a result of rape as defined by Idaho law, or incest as determined by the court.

• Foruseofoperating,cast,examination,ortreatment rooms, or for equipment located in a Contracting or Noncontracting Provider’s office or facility, except for emergency room facility charges in a Licensed general Hospital, unless specified as a Covered service in this Policy.

• Forthereversalofsterilizationprocedures,including, but not limited to, vasovasostomies or salpingoplasties.

• Treatmentforinfertilityandfertilizationprocedures, including, but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance an Insured’s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures.

• ForTransplantservicesandArtificialOrgans,except as specified as a Covered service under this Policy.

• Foracupuncture.



• Forsurgicalproceduresthataltertherefractive character of the eye, including, but not limited to, radial keratotomy, myopic keratomileusis, Laser-in-situ keratomileusis (LAsIk), and other surgical procedures of the refractive-keratoplasty type, to cure or reduce myopia or astigmatism, even if Medically Necessary. Additionally, reversals, revisions and/or complications of such surgical procedures are excluded, except when required to correct an immediately life-endangering condition.

• ForHospice,exceptasspecifiedasaCoveredservice in this Policy.

• Forpastoral,spiritual,bereavementormarriage counseling.

• Forhomemakerandhousekeepingservicesor home-delivered meals.

• Forthetreatmentofinjuriessustainedwhilecommitting a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence.

• AnyservicesorsuppliesforwhichanInsuredwould have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party.

• Foraroutineorperiodicphysicalexaminationthat is not connected with the care and treatment of an actual Illness, Disease or Accidental Injury, or for an examination required on account of employment; or related to an occupational injury; for a marriage license; or for insurance, school or camp application; or for sports participation physical; or a screening examination including routine hearing examinations, except as specified as a Covered service under this Policy.

• Forimmunizations,exceptasspecifiedasaCovered service in this Policy.

• ForbreastreductionSurgeryorSurgeryforgynecomastia.

• Fornutritionalsupplements.

• Forreplacementsornutritionalformulas,except when administered enterally due to impairment in digestion and absorption of an oral diet and is the sole source of caloric need or nutrition in an Insured.

• Forvitaminsandminerals,unlessrequiredthrough a written prescription and cannot be purchased over the counter.

• Foralterationsormodificationstothehomeor vehicle.

• Forspecialclothing,includingshoes(unlesspermanently attached to a brace).

• providedtoapersonenrolledasaneligibleDependent, but who no longer qualifies as an Eligible Dependent due to a change in eligibility status which occurred after enrollment.

• providedoutsidetheunitedStates,whichifhad been provided in the united states would not be Covered services under this Policy.

• Furnishedbyaproviderorcaregiverthatisnot listed as a Covered Provider, including but not limited to, naturopaths and homeopaths.

• ForOutpatientpulmonaryand/orcardiacrehabilitation.

• Forcomplicationsarisingfromtheacceptance or utilization of noncovered services.

• FortheuseofHypnosis,asanesthesiaorother treatment, except as specified as a Covered service.

• Forarchsupports,orthopedicshoes,andother foot devices.

• Anyservicesorsuppliesfurnishedbyafacility that is primarily a health resort, sanatorium, residential treatment facility, transitional living center, or primarily a place for Outpatient treatment or residential facility care of Mental or Nervous Conditions.

• Forwigs.

• Forcranialmoldinghelmets,unlessusedtoprotect post cranial vault surgery.

• Forsurgicalremovalofexcessskinthatisthe result of weight loss or gain, including but not limited to association with prior weight reduction (obesity) surgery.

• ForthepurchaseofTherapyorServiceDogs/Animals and the cost of training/maintaining said animals.

• Fordentalimplants,appliances(withtheexception of sleep apnea devices), and/or prosthetics, and/or treatment related to Orthodontia, even when Medically Necessary, unless specified as a Covered service in this Policy.

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© 2013 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue shield Association.

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275 south 5th Avenue suite 150

Pocatello, ID 83201

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Twin Falls, ID 83301

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P.O. Box 5025 Twin Falls, ID 83303-5025 208-733-7258

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3000 East Pine Avenue Meridian, ID 83642-5995

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P.O. Box 7408 Boise, ID 83707 208-387-6683 800-365-2345

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Coeur d’Alene, ID 83814 208-666-1495

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