Basic, Standard and Catastrophic
The Small Employer Health Insurance Availability Act
adopted by the state of Idaho mandates that all groups
of 2-50 "eligible employees" be able to purchase
health care coverage regardless of their health status.
An "eligible employee" is defined by the Act
as an employee that works at least 30 hours per week
on a regular basis. Employees that work 20-29 hours
per week on a regular basis (and their dependents) may
be accepted for coverage by agreement between Regence
BlueShield of Idaho and the employer. Current Regence
BlueShield of Idaho policy extends the protections of
the Act to these employees and their dependents.
Dependents
Dependent means a spouse, an unmarried child under the age of twenty-five (25) years who is financially dependent upon the parent, and an unmarried child of any age who is medically certified as disabled and dependent upon the parent.
Rates
Group initial premium rates are established based on
expected claims costs as determined by the underwriting
information provided by the group or individual. Renewal
rates may be adjusted for past or expected future utilization
by the group or individual. Rates will change for the
group or individual as age changes.
Member Card/Out of Network Coverage
The Regence BlueShield of Idaho member card
is an insured's direct link to care anywhere in the
country. Just show the member card to any Blue
Cross and/or Blue Shield Plan participating hospital
or physician across the USA and receive the same comforts
and conveniences as provided locally. The three letter
prefix on the member card indicates to participating
physicians, or hospitals that the employee is covered
under a Regence BlueShield of Idaho health insurance
plan.
Hospital Admission Review
All inpatient hospital skilled nursing facility and
home health/hospice care admissions must be reviewed
by Regence BlueShield of Idaho:
- Prior to admission
- Within 48 hours of admission, or
- On the first working day following an emergency
admission
If hospital admission review is not obtained, benefits
will be reduced by 25%, up to a maximum of $500.
Claim Forms
Claim forms are not required when providers bill Regence
BlueShield of Idaho directly. If the insured chooses
to submit a healthcare bill, Regence BlueShield of Idaho
requires a complete itemized statement with patient's
name, date of service, services rendered, charge per
service, and diagnosis.
Waiting Periods for Preexisting Conditions
Waiting periods for preexisting conditions will
be credited for employees or individuals and their dependents
who were enrolled under qualifying coverage. This is
contingent upon the qualifying coverage not ending more
than 63 days prior to the effective date under this
coverage. New enrollees without qualifying previous
coverage will be subject to a 12 month waiting period
for preexisting conditions.
Benefits for preexisting conditions may be denied until
the late enrollee has been enrolled for coverage on
the policy for a continuous 12 month period.
Benefits for surgically implantable and injectable
contraceptives will be subject to a 12 month waiting
period.
| Schedule
of Benefits |
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| Individual Benefit
Maximum per calendar year |
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| Deductible |
Individual |
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Family |
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Out of pocket
expense limit |
Individual |
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Family |
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Doctor visits |
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| Durable medical
equipment
Benefits shall be limited to
$15,000 per calendar year. |
50% |
80% |
50% |
50% |
| Emergency
ambulance service
Benefits shall be limited to $750 per calendar
year |
50% |
80% |
50% |
50% |
Inpatient hospital services |
|
|
|
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| Primary maternity
services provided by a physician*
|
100% subject
to a $15 copayment for initial visit Not subject
to deductible |
100% subject to
a $15 copayment for initial visit Not subject
to deductible |
50% |
50% |
| Other maternity services including
delivery room, hospital service, assistant surgeon,
and other services and supplies |
50% subject
to deductible |
50% subject
to deductible |
50% |
50% |
Organ Transplant
Available for medically necessary care.
Does not include care of an experimental or investigational
nature |
50% |
80% |
50% |
50% |
| Pharmacy
(including contraceptives) |
100% subject to a $10 copayment
per prescription |
100% subject to a $10 copayment
per prescription |
100% subject to a $10 copayment
per prescription |
100% subject to a $10 copayment
per prescription |
Preventive
Services*
(subject to deductible)
Copayment does not apply to the out of pocket
expense limit. Under 12 yrs of age, no copayment
|
100%
after a $15 copayment,
Calendar year limit: $500 |
100%
after a $15 copayment
Calendar year limit: $500 |
No copayment
Calendar year limit: $25
|
No copayment
Calendar year limit: $25
|
| Psychiatric/Substance
abuse services |
50%
Inpatient not covered
Outpatient
$2,500 per calendar year |
80%
Inpatient $5,000 per calendar
year
Outpatient combined with inpatient |
50%
Inpatient $5,000 per calendar
year
Outpatient combined with inpatient |
50%
Inpatient not covered
Outpatient $2,500 per calendar
year |
| Skilled nursing
in an approved extended care facility |
50% |
80% |
50% |
50% |
| Spinal manipulation
services Benefits shall be limited to $1,000
maximum per calendar year |
50% |
80% |
50% |
50% |
Surgically implantable
and injectable contraceptives
(subject to 12 months waiting period) |
50% |
80% |
50% |
50% |
*Benefits vary by age and several are available only
to high risk individuals. Benefits shall be limited
to one visit per calendar year up to the limitations
indicated per calendar year. The one visit per calendar
year shall not apply to children under the age of 2.
Limitations and Exclusions
- Any service not medically necessary or appropriate
unless specifically included within the coverage provisions.
- Custodial, convalescent or intermediate level care
or rest cures.
- Services which are experimental or investigational.
- Services eligible for coverage by Workers Compensation,
Medicare or CHAMPUS.
- Services for which no charges are made or for which
no charges would be made in the absence of insurance
or for which the Insured has no legal obligation to
pay.
- Services (including surgery), self-help and training
programs for weight control, nutrition, smoking cessation,
etc., as well as prescription drugs used in conjunction
with such programs and services.
- Cosmetic surgery and services, except for treatment
for congenital injury or surgery. Mastectomy reconstruction
is covered if within two (2) years of mastectomy.
- Artificial insemination and infertility treatment.
Treatment of sexual dysfunction not related to organic
disease.
- Services for reversal of elective, surgically or
pharmaceutically induced infertility.
- Vision therapy, tests, glasses, contact lenses and
other vision aids. Radial keratotomy, myopic keratomileusis
and any surgery involving corneal tissue to alter
or correct myopia, hyperopia or stigmatic error. Vision
tests and glasses will be covered for members under
the age of twelve (12).
- For treatment of weak, strained, or flat feet, including
orthopedic shoes or other supportive devices, or for
cutting, removal, or treatment of corns, calluses,
or nails other than corrective surgery, or for metabolic
or peripheral vascular disease.
- Spinal manipulation will be covered up to a maximum
of $1,000 per calendar year.
- Dental and orthodontic services, except those needed
for treatment of a medical condition or injury or
as specifically allowed in this policy for children
under the age of twelve (12).
- Hearing tests without illness being suspect.
- Hearing aids and supplies, tinnitus maskers, cochlear
implants and exams for the prescription or fitting
of hearing aids.
- Speech tests and therapy except as specifically
allowed in this policy for children under the age
of twelve (12).
- Private room accommodation charges in excess of
the institution's most common semiprivate room charge
except when prescribed as medically necessary.
- Services performed by a member of the insured's
family or of the insured's spouse's family. Family
includes parents or grandparents of the insured or
spouse and any descendants of such parents or grandparents.
- Care incurred before the effective date of the insured's
coverage.
- Immunizations and medical exams and tests of any
kind not related to treatment of covered injury or
disease, except as specifically stated in this policy.
- Injury or sickness caused by war or armed international
conflict.
- Sex change operations and treatment in connection
with transsexualism.
- Marriage and family and child counseling except
as specifically provided in this policy.
- Acupuncture except when used as anesthesia during
a covered surgical procedure.
- Private duty nursing except as specifically provided
in this policy.
- Services received from a medical or dental department
maintained by or on behalf of an employer, a mutual
benefit association, labor union, trust, or similar
person or group.
- Incurred after the date of termination of the insured's
coverage, except as allowed by any extension of benefits
provision in this policy.
- Expenses for personal hygiene and convenience items
such as air conditioners, humidifiers, and physical
fitness equipment.
- Charges for failure to keep a scheduled visit, charges
for completion of any form, and charges for medical
information.
- Charges for screening examinations except as otherwise
provided in this policy.
- Charges for wigs or cranial prostheses, hair analysis,
hair loss and baldness.
- Preexisting conditions, except as provided specifically
in this policy.
This is a summary of Regence BlueShield of Idaho's
Basic, Standard, and Catastrophic plans. This is not
a policy and only the actual group health plan policy
will determine payable benefits. Refer to your policy
or employee booklet to determine the exact terms and
conditions of coverage, which sets forth in detail the
rights and obligations of you and Regence BlueShield
of Idaho. |
