Blue Cross Individual & Family HMO Plans

Blue Cross HMO Plans

Blue Cross Individual Select HMO

Blue Cross of California HMO Saver

Blue Cross of California Individual HMO

New Select HMO -No deductible

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Blue Cross of California plans

Individual / Family Brochure

HMO General Information

• Your Access to Healthcare
  
  
• HMO Plan Highlights
  
  
• Taking Care of Your Health With Blue Cross HMO Plans
  
  
• When You Need Care
  
  
• Emergency Care
  
  
• Mental Health Coverage
  
  
• Member and Blue Cross Rights and Obligations
  
  
• Exclusions and Limitations

Blue Cross of California Health Maintenance Organization (HMO) Plans cover more of the costs of your health care than any other plan type. With HMO plans, you choose a Participating Medical Group (PMG) or Independent Practice Association (IPA) from the Blue Cross HMO Network listed in your directory. You also choose a doctor within the group to serve as your Primary Care Physician (PCP), and you can select a different Primary Care Physician for each family member enrolled in your HMO Plan.

Your HMO plan coverage applies only when you receive health care services through your Primary Care Physician. He or she will coordinate all of your health care, either by treating you directly, or by referring you to a specialist.

For more information on accessing doctors and the referral process, be sure to read about the DirectAccess^SM and SpeedyReferral^SM  programs.

Blue Cross of California — HMO Quality

The Blue Cross HMO plans featured in this brochure were awarded a “Commendable” status from the National Committee for Quality Assurance (NCQA). The status of “Commendable” is granted to managed care organization plans that deliver high-quality care and service, and whose systems for consumer protection and quality improvement meet or exceed NCQA’s rigorous requirements.

NCQA is an independent, not-for-profit organization that evaluates managed care organizations. Its mission is to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, so they can make more informed decisions.

In a Blue Cross of California HMO, you get:

• Low out-of-pocket costs
• Comprehensive health care coverage
• Unlimited lifetime benefits for covered services
• Mimial copays for office visits
• Self-referral for OB/GYN (women's health specialists)
• Blue Cross DirectAccess
• Blue Cross SpeedyReferral

When you need care, simply call your Primary Care Physician for an appointment. He or she can help you when you are ill, either by treating you directly, or referring you to a specialist.

Programs for Quick Access to Specialists

Blue Cross provides you with additional options for accessing health care through the following special programs for our HMO members:

Blue Cross DirectAccess^SM

Blue Cross DirectAccess allows HMO plan members to select specialists for some services without authorization from their Primary Care Physicians. The speciality services include allergy, dermatology, and ear, nose and throat.

The program is available to HMO members who choose a medical group or IPA that participates in DirectAccess. Participation of a medical group or IPA is indicated in the provider directory. It is important that you check participation before utilizing DirectAccess.

Blue Cross SpeedyReferral^SM

With SpeedyReferral, HMO members can be referred by their Primary Care Physicians for specialist visits without prior authorization from the medical group or IPA. Specialty services include, cardiology, dermatology, ear, nose, and throat, endocrinology, gastroenterology, general surgery, hematology, neurology, oncology, ophthalmology, orthopedic surgery, podiatry, routine laboratory, routine x-ray and urology.

This program is available to HMO members who choose a medical group or IPA that participates in SpeedyReferral. Participation of a medical group or IPA is indicated in the provider directory. It is important that you check participation before utilizing SpeedyReferral.

Blue Cross MedCall – 24 Hour Medical Advice

Not sure how serious it is? HMO plan members can get professional, reliable health care information instantly by phone, toll-free, any time of the day or night, from the registered nurse at MedCall. They can answer questions from how to gauge your current symptoms to medication side effects, and more. MedCall also provides over 200 educational audiotapes on health related topics.

Blue Cross covers emergency services necessary to screen and stabilize your condition. No authorization or precertification is required if you reasonably believe an emergency medical condition exists. A medical emergency is an unexpected acute illness, injury or condition that could endanger your health if not treated immediately. Examples of medical emergencies include:

• Severe Pain
• Chest Pains
• Heavy Bleeding
• Difficulty breathing or shortness of breath
• Sudden loss of consciousness
• Active natal labor (childbirth)
• Sudden weakness or numbness of the face, arm or leg on one side of the body

When you consider a medical condition to be an emergency, immediately call 911 or go to the nearest hospital emergency room. If as a result of the medical emergency you are admitted into the hospital through the emergency room, you or a member of your family must notify your Primary Care Physician or medical group as soon as possible, but not later than 48 hours after the initial care has been provided.

Blue Cross provides the same level of coverage as other medical diagnoses for the medically necessary treatment of severe mental illnesses in persons of any age. Severe mental illness, as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM), includes the following diagnoses:

• Schizophrenia
• Schizoaffective disorder
• Bipolar disorder (manic-depressive illness)
• Major depressive disorders
• Panic disorder
• Obsessive-compulsive disorder
• Pervasive developmental disorder or autism
• Anorexia nervosa
• Bulimia nervosa

Blue Cross also provides the same level of coverage as other medical diagnoses for serious emotional disturbances in children that result in behavior inappropriate to the child’s age, according to expected development norms. More limited benefits are provided for other mental disorders such as primary substance use disorder and developmental disorder. For more details regarding these benefits, refer to the Evidence of Coverage (EOC).

No-Obligation Review Period

After you enroll in a Blue Cross health plan, you will receive an Evidence of Coverage policy booklet that explains the exact terms and conditions of coverage, including the plan’s exclusions and limitations. You have 10 full days to examine your plan’s features. During that time, if you are not fully satisfied, you may decline by returning your Evidence of Coverage booklet along with a letter notifying us that you wish to discontinue coverage. Evidence of Coverage booklets are available for you to examine prior to enrolling. Ask your agent or Blue Cross.

Your Right to Privacy

We do not release information that identifies your diagnosis or medical condition without your consent, except as permitted by law. Your treating physician also has rules about your medical information. Physicians customarily ask their patients to sign a release form before they give their patients medical information to anyone, even Blue Cross. You may request to see a copy of your physicians confidentiality policy, and you should talk to your physician about how your privacy is protected.

Requirement for Binding Arbitration

If you are applying for coverage, please note that Blue Cross requires binding arbitration to settle all disputes, including claims of medical malpractice. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: “It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will by California law, and not by lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Both parties also agree to give up any right to pursue on a class basis any claim or controversy against the other.

Grievances

All complaints and disputes relating to your coverage must be resolved in accordance with Blue Cross’ grievance procedure. Grievances may be made by telephone or in writing; the phone number and address are located on your Blue Cross ID card. All grievances received by Blue Cross will be answered in writing, together with a description of how Blue Cross proposes to resolve the grievance.

Department of Managed Health Care

The California Department of Managed Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 333-0912 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions on-line.

Third-Party Liability

Blue Cross of California is entitled to reimbursement of benefits paid if you recover damages from a legally liable third party. Examples of third-party liability include car accidents and work-related injuries. For complete information about third-party liability, refer to the plan Evidence of Coverage booklet.

Loss Ratio

As required by law, we are advising you that Blue Cross of California’s incurred loss ratio for 2001 was 80.28 percent. This loss ratio was calculated after provider discounts were applied.

Exclusions and Limitations Common to All Individual Medical Plans

• Conditions covered by workers’ compensationor similar laws.
• Experimental or investigative care or therapy.
• Any services provided by a local, state, county or federal government agency, including any  foreign government.
• Services or supplies not specifically listed as covered under the plan agreement.
• Services received before your Effective Date or during an inpatient stay that began before your Effective Date.
• Services rendered before coverage begins or after coverage ends.
• Services or supplies for which no charge is made, or for which no charge would be made if you  had no insurance coverage or services for which you are not legally obligated to pay.
• Services provided by relatives, and professional services received from a person who lives in  your home or who is related to you by blood, marriage or adoption.
• Any services to the extent you are entitled to receive Medicare benefits for those services without payment of additional premium for Medicare coverage. For parts of Medicare requiring additional premium payment, service are excluded for those parts of Medicare the member enrolled in.
• Services or supplies that are not medically necessary, as determined by Blue Cross of California or BC Life & Health.
• Routine physical exams, except for preventive care services (e.g., physical exams for insurance, employment, licenses or school are not covered) except as specifically stated for PPO Share 500/1000 plans.
• Services furnished through outdoor treatment programs.
• Outpatient speech therapy, except following surgery, injury or otherwise as medically necessary
• Benefits for Hospice services are limited to a lifetime maximum of $10,000 per member for participating and non-participating providers combined (BC Life PPO Share 500, BC Life PPO Share 100, BC Life PPO Share 5000, PPO Saver, PPO Basic only).
• Any amounts in excess of the maximum amounts stated in the Maximum Comprehensive and Copayment/Coinsurance Lists sections of your agreement.
• Sex change operations or related treatment and study.
• Cosmetic surgery or other services for beautification, including any complications arising from or the result of cosmetic surgery, except for reconstructive surgery.*
• Services primarily for weight reduction or treatment of obesity, or any care which involves weight reduction as the main method of treatment, except medically necessary treatment of morbid  obesity with our prior authorization.
• Dental care and treatment or treatment on or to the teeth and gums — unless covered under accidental injury.
• Dental implants.
• Hearing aids.
• Contraceptive drugs or devices including Norplant and Norplant kits, except injectable  contraceptives when administered by a physician. (Contraceptives are covered under all plans’  prescription benefits except the Basic Plan.)
• All services related to the evaluation or treatment of infertility, including all tests, consultations, medications, surgical, medical or lab procedures, and reversal of sterilization.
• Private duty nursing, including inpatient or outpatient services of a private duty nurse.
• Eyeglasses or contact lenses, unless specified in your plan agreement.
• Certain eye surgeries, including those solely for the purpose of correcting refractive defects of the  eye such as nearsightedness (myopia) and astigmatism.
• Diagnostic admissions, including inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests that could have been safely performed on an outpatient basis, and inpatient admissions primarily for diagnostic studies when inpatient bed care is not medically necessary.
• Mental and nervous disorders, substance abuse, and learning disabilities, except as specifically stated under the benefits sections of the plan agreement.
• Orthopedic shoes (except when joined to braces) or shoe inserts, except for limited benefits as  stated in the Evidence of Coverage.
• Orthodontic services, braces, and other orthodontic appliances.
• No payment will be made for services or supplies for the treatment of a preexisting condition during a period of six months following your effective date. This limitation does not apply to a child  born or newly adopted by an enrolled subscriber or spouse. Also, if you were covered under  qualifying prior coverage within 63 days of becoming covered under this Agreement, the time  spent under the qualifying prior coverage will be used to satisfy, or partially satisfy, the six-month period.
• Consultations provided by telephone or facsimile machines.
• Educational services except as specifically provided or arranged by Blue Cross.
• Nutritional counseling and food supplements except as stated in your plan agreement.
• No benefits are provided for care and treatment furnished in a non-contracting hospital, except for medical emergencies as specified in your agreement.
• Items which are furnished primarily for your personal comfort or convenience: air purifiers, air  conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for  comfort, hygiene or beautification.
• Custodial care. Custodial care is care that does not require the services of trained medical or  health professionals, such as, but not limited to, help in walking, getting in and out of bed,  bathing, dressing, preparation and feeding of special diets, and supervision of medications that  are ordinarily self-administered. Domiciliary, or rest cures for which facilities and/or services of a general acute hospital are not medically required, including resident treatment centers are also  excluded.

* Does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or medically necessary reconstructive surgery performed to restore symmetry incident to mastectomy.

Exclusions and Limitations Common to All Individual Medical Plans

• Care not authorized by your Primary Care Physician at your participating medical group (PMG) or  IPA.
• Growth hormone treatment.
• Amounts in excess of customary and reasonable charges for out-of-area emergency services.
• Eyeglasses or contact lenses unless specified in your plan agreement.
• Acupuncture/Acupressure
• Chiropractic Services
• Immunizations for foreign travel not specifically listed as covered.
• Treatment for chronic alcoholism or other substance abuse unless specified in the plan agreement.
• Inpatient mental care, including acute alcoholism and drug addiction benefits except detoxification.
• Treatment of mental and nervous disorders except as stated in the plan agreement.
• Rehabilitative care except as stated in the plan agreement.
• Private room, unless specified in the plan agreement.
• Reconstructive surgery, purchase or replacement of artificial limbs or prosthesis unless the  medical condition creating the need for the limb or prosthesis occurred while you were covered  under the plan.
• Medical, surgical and/or psychological treatment of a sexual dysfunction except when a sexual dysfunction is a result of a physical abnormality, defect or disease.
• Medical, surgical services, supplies or treatment to the joint of the jaw (temporomandibular joint), upper jaw (maxilla) or lower jaw (mandible), unless related to a tumor or accident occurring while covered.
• Routine physical examinations or tests that do not directly treat an acute illness, injury or condition unless authorized by your Primary Care Physician, except in no event will any physical examination or test required by employment or government authority, or at the request of a third  party, such as a school, camp or sports-affiliated organization, be covered unless medically necessary.
• Care or treatment of a pregnancy, or any condition related to pregnancy (except treatment of complications of pregnancy or Cesarean section deliveries) when conception has occurred before the effective date of the plan agreement. However, if you were covered under Creditable Coverage within 62 days of becoming covered, the time spent under Creditable Coverage will be used to satisfy, or partially satisfy, the six (6) month period.