2018 Certificate of Coverage for Platinum, Gold, Silver and Bronze Plans - BCBSVT

 
2018 Certificate of Coverage for Platinum, Gold, Silver and Bronze Plans - BCBSVT
2018 Certificate of Coverage for
Platinum, Gold, Silver and Bronze Plans
NOTICE: Discrimination is Against the Law
Blue Cross and Blue Shield of Vermont                 BCBSVT provides free language services to                You can file a grievance by mail, or email at the
(BCBSVT) and its affiliate The Vermont                people whose primary language is not English.            contacts above. If you need assistance, our civil
Health Plan (TVHP) comply with applicable             We provide, for example, qualified interpreters          rights coordinator is available to help you.
federal and state civil rights laws and do not        and information written in other languages.              You can also file a civil rights complaint with
discriminate, exclude people or treat them        If you need these services, please call                      the U.S. Department of Health and Human
differently on the basis of race, color, national (800) 247‑2583. If you would like to file a                  Services, Office for Civil Rights, electronically
origin, age, disability, gender identity or sex.  grievance because you believe that BCBSVT                    through the Office for Civil Rights Complaint
BCBSVT provides free aids and services to         has failed to provide services or discriminated              Portal, available at https://ocrportal.hhs.gov/
people with disabilities to communicate           on the basis of race, color, national origin, age,           ocr/portal/lobby.jsf, or by mail or phone at:
effectively with us. We provide, for example,     disability, gender identity or sex, contact:                   U.S. Department of
qualified sign language interpreters and              Civil Rights Coordinator                                   Health and Human Services
written information in other formats (e.g., large     Blue Cross and Blue Shield of Vermont                      Office for Civil Rights
print, audio or accessible electronic format).        PO Box 186                                                 200 Independence Avenue, SW
                                                      Montpelier, VT 05601                                       Room 509F, HHH Building
                                                      (802) 371‑3394                                             Washington, D.C. 20201
                                                      TDD/TTY: (800) 535‑2227                                    (800) 368‑1019
                                                      civilrightscoordinator@bcbsvt.com                          (800) 537‑7697 (TDD)

             For free language-assistance services, call (800) 247-2583.
ARABIC                                   GERMAN                                 PORTUGUESE                                   TAGALOG

    ‫ للحصول عىل خدمات المساعدة‬Kostenlose fremdsprachliche                       Para serviços gratuitos de                   Para sa libreng mga serbisyo
  ‫ اتصل عىل الرقم‬،‫ اللغوية المجانية‬Unterstützung erhalten Sie                   assistência linguística, ligue               ng tulong pangwika, tumawag
                   .(800) 247‑2583 unter (800) 247‑2583.                        para o (800) 247‑2583.                       sa (800) 247‑2583.
                                         ITALIAN                                RUSSIAN                                      THAI
CHINESE

如需免費語言協助服務,                              Per i servizi gratuiti di assistenza   Чтобы получить бесплатные                    สำ�หรับก�รให้บริก�รคว�ม
請致電(800) 247‑2583。                       linguistica, chiamare il               услуги переводчика,                          ช่วยเหลือด้�นภ�ษ�ฟรี โทร
                                         numero (800) 247‑2583.                 позвоните по телефону                        (800) 247‑2583
CUSHITE (OROMO)

Tajaajila gargaarsa afaan hiikuu         JAPANESE                               (800) 247‑2583.                              VIETNAMESE

kaffaltii malee argachuuf                無料の通訳サー                                SERBO-CROATIAN (SERBIAN)                     Để biết các dịch vụ hỗ trợ
(800) 247‑2583 bilbilaa.                 ビスのご利用                                 Za besplatnu uslugu prevođenja,              ngôn ngữ miễn phí, hãy
                                         は、(800) 247‑2583まで                     pozovite na broj (800) 247‑2583.             gọi số (800) 247‑2583.
FRENCH

Pour obtenir des services                お電話ください。                               SPANISH

d’assistance linguistique gratuits,      NEPALI                                 Para servicios gratuitos de
appelez le (800) 247‑2583.               नि:शुल्क भाषा सहायता                   asistencia con el idioma,
                                         सेवाहरूका लागि, (800) 247‑2583         llame al (800) 247‑2583.
                                         मा कल गर्नुहोस्।

We’ll see you through.                    (800) 255‑4550 | www.bcbsvt.com
                                                                                             An independent licensee of the Blue Cross and Blue Shield Association.
TABLE OF CONTENTS
                                          CHAPTER ONE                                                                                                           CHAPTER FOUR
Guidelines for Coverage .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6                              Claims .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31
  General Guidelines............................................................................... 6                  Claim Submission................................................................................31
  Prior Approval Program..................................................................... 6                        Release of Information.....................................................................31
  Case Management Program.......................................................... 7                                  Cooperation...........................................................................................31
  Choosing a Provider............................................................................ 7                    Payment of Benefits...........................................................................31
  Primary Care Providers....................................................................... 8                      Payment in Error/Overpayments...............................................31
  Non-Network Providers..................................................................... 8                         How We Evaluate Technology ..................................................31
  Access to Care......................................................................................... 8            Complaints and Appeals................................................................31
  After-hours and Emergency Care................................................ 9
                                                                                                                                                                  CHAPTER FIVE
  Blue Cross Blue Shield Global Core™ Program .................10
  How We Determine Your Benefits............................................11                                       Other Party Liability .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34
  Payment Terms.....................................................................................11                 Coordination of Benefits.................................................................34
                                                                                                                       Subrogation............................................................................................35
                                         CHAPTER TWO                                                                   Cooperation...........................................................................................35
Covered Services .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13
                                                                                                                                                                   CHAPTER SIX
  Preventive Services............................................................................13
  Women’s Health...................................................................................13                Membership .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
  Office Visits..............................................................................................13        Coverage Effective Dates ..............................................................36
  Ambulance..............................................................................................13            Open Enrollment.................................................................................36
  Autism Spectrum Disorder ..........................................................14                                Special Enrollment Periods ..........................................................36
  Clinical Trials (Approved)................................................................14                         Cancellation of Coverage...............................................................36
  Chiropractic Services........................................................................14                      Medicare...................................................................................................38
  Cosmetic and                                                                                                         Our Pledge to You...............................................................................38
   Reconstructive Procedures........................................................15                                 Rules About Coverage for Domestic Partners...................39
  Dental Services.....................................................................................15               Right to Continuation of Coverage..........................................39
  Diabetes Services................................................................................16                  Continuation Rights under the Consolidated Omnibus
  Diagnostic Tests....................................................................................16                Budget Reconciliation Act (COBRA).....................................40
  Emergency Care...................................................................................16                                                          CHAPTER SEVEN
  Home Care...............................................................................................16         General Contract Provisions .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
  Hospice Care..........................................................................................17             Applicable Law.....................................................................................41
  Hospital Care..........................................................................................17            Entire Agreement................................................................................41
  Maternity..................................................................................................18        Severability Clause..............................................................................41
  Medical Equipment and Supplies.............................................18                                        Non-waiver of Our Rights...............................................................41
  Mental Health Care............................................................................19                     Term of Contract..................................................................................41
  National Preferred Formulary Prescription Drugs and                                                                  Subscriber Address.............................................................................41
   Biologics.................................................................................................20        Third Party Beneficiaries..................................................................41
  Nutritional Counseling.....................................................................22
  Outpatient Hospital Care................................................................22                                                                   CHAPTER EIGHT
  Outpatient Medical Services........................................................22                              More Information About Your Contract  .  .  .  .  .  . 42
  Rehabilitation/Habilitation............................................................23                            Notice of Privacy Practices for Protected Health
  Skilled Nursing Facility.....................................................................23                        Information..........................................................................................42
  Substance Abuse                                                                                                      Your Rights..............................................................................................44
   Treatment Services..........................................................................23                      Breach Notification.............................................................................45
  Surgery.......................................................................................................24     Non-public Personal Financial Information........................45
  Telemedicine Services......................................................................24                        Questions and Complaints............................................................46
  Transplant Services.............................................................................25                   Newborns’ and Mothers’ Health Protection Act...............46
  Vision Care...............................................................................................25         Women’s Health and Cancer Rights Act of 1998.............46
  Vision Services (Medical)................................................................27                          Our Quality Improvement Program........................................46
                                                                                                                       Information About Your Health Plan.......................................47
                                        CHAPTER THREE
General Exclusions .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28                                                                  CHAPTER NINE
                                                                                                                     Definitions .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 48
This is the Contract for your health plan.
Your Contract governs your Benefits.
These are the documents in your Contract:
 ƒƒ The Certificate of Coverage is this booklet, which describes your Benefits in detail.
    It explains requirements, limitations and exclusions for coverage.
 ƒƒ The Outline of Coverage, which shows what you must pay Providers.
 ƒƒ Any Riders or Endorsements that follow your Certificate, which describe
    additional coverage or changes to your Contract.
 ƒƒ Your ID card, which you should take with you when you need care. This will arrive in a separate mailing.
 ƒƒ Your Group Enrollment Form (your application) and any supplemental
    applications that you submitted and we approved.
This Contract is current until we update it. We sometimes replace just one part of your Contract.
If you are missing part of your Contract, please call customer service to request another copy.
If the Benefits described in your Contract differ from descriptions in our other materials, your Contract language prevails.
How to Use This Document
 ƒƒ Read Chapter One, “Guidelines for Coverage.” Information there applies to all Services.
    Pay special attention to the section on our “Prior Approval Program.”
 ƒƒ Find the Service you need in Chapter Two, “Covered Services.” You may use the
    Index or Table of Contents to find it. Read the section thoroughly.
 ƒƒ Check “General Exclusions” to see if the Service you need is on this list.
 ƒƒ Please remember that to know the full terms of your coverage, you should read your entire Contract.
 ƒƒ To find out what you must pay for care, check your Outline of Coverage.
 ƒƒ Some terms in your Certificate have special meanings. We capitalize these terms in the text. We define them in the last
    chapter of this booklet. We define the terms “We,” “Us,” “You” and “Your,” but we do not capitalize them in the text.
 ƒƒ If you need materials translated into a different language or would like to access an interpreter
    via the telephone, please call the customer service number on the back of your ID card.
 ƒƒ If you need translation services such as telecommunications devices for the deaf (TDD) or
    telephone typewriter teletypewriter (TTY), please call (800) 535-2227.
After we accept your application, we cover the health care Services in your Contract, subject to all Contract conditions.
Coverage continues from month to month until your Contract ends as allowed by its provisions. (See Chapters Six and
Seven.)
The service area for your health plan is the state of Vermont. We sell health plans to people who live in Vermont. We
sell plans to employer Groups located in the state of Vermont. Our plans are issued, renewed and delivered in Vermont
without respect to where any covered Dependent or employee resides. You may receive care both inside and outside of
the service area. Please read the Guidelines for Coverage chapter carefully to find out when you may receive care outside
the area.

                                                                 Charles P. Smith
                                                               Chair of the Board

                                                                  Don C. George
                                                                President & CEO

                                                               Rebecca C. Heintz
                                                      General Counsel & Secretary

                                     Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
                                                                                                                            5
Guidelines for Coverage

                          CHAPTER ONE                                               BCBSVT Network Providers should get Prior Approval
                                                                                    for you. If you use a Non-Network Provider it is your
Guidelines for Coverage                                                             responsibility to get Prior Approval. Failure to get
                                                                                    Prior Approval could lead to a denial of benefits.
This Certificate describes benefits for your Blue Cross and                         If you use a BCBSVT Network Provider and the
Blue Shield of Vermont (BCBSVT) Health Plan. Vermont                                Provider fails to get Prior Approval for services
Health Connect, Vermont’s health benefit exchange, has                              that require it, the Provider may not bill you.
selected this program as a “qualified health plan.” We will                         Our Prior Approval list can change. We inform you of
refer to this plan as “your Health Plan” in this document.                          changes using newsletters and other mailings. To get the
Chapter One explains what you must do to get                                        most up-to-date list, visit our website at www.bcbsvt.com
benefits through your Health Plan. Read this                                        or call our customer service team at (800) 310-5249.
entire chapter carefully, as it is your responsibility
to follow its guidelines. Your Outline of Coverage                                  How to Request Prior Approval
shows what you must pay (your cost-sharing).                                        To get Prior Approval, you or your Network Provider
                                                                                    must provide supporting clinical documentation
General Guidelines                                                                  to BCBSVT. When receiving care from a Non-
                                                                                    Network Provider it is your responsibility to get Prior
As you read your Contract, please keep these facts in mind:
                                                                                    Approval. Forms are available on our website at
 ƒƒ Capitalized words have special meanings.                                        www.bcbsvt.com. You may also get them by calling
    We define them in Chapter Nine. Read                                            our customer service team at (800) 310-5249.
    “Definitions” to understand your coverage.
                                                                                    Any Provider may help you fill out the form and give
 ƒƒ We only pay benefits for services we                                            you other information you need to submit your request.
    define as Covered by this Contract.                                             The medical staff at BCBSVT will review the form
 ƒƒ For most services, you must use Network                                         and respond in writing to you and your Provider.
    Providers (see Chapter Nine “Definitions”)                                      If the request for Prior Approval is denied,
    or get Prior Approval (see below).                                              you may appeal this decision by following the
 ƒƒ The provisions of this Contract only                                            steps outlined in Chapter Four, Claims.
    apply as provided by law.
 ƒƒ We exclude certain services from coverage under
                                                                                    Prior Approval List
    this Contract. You’ll find General Exclusions                                   You need Prior Approval for services outside of
    in Chapter Three. They apply to all services.                                   our Network. You also need Prior Approval for
    Exclusions that apply to specific services appear                               other services on our Prior Approval list, even if
    in applicable sections of your Contract.                                        you use a Network Provider. This list includes:
 ƒƒ We do not cover services we do not consider                                       ƒƒ Ambulance (non-emergency transport
    Medically Necessary. You may appeal our decisions.                                   including air or water transport);
 ƒƒ This is not a long-term care Policy as defined                                    ƒƒ anesthesia (monitored);
    by Vermont State law at 8 V.S.A. §8082 (5).                                       ƒƒ Autism Spectrum Disorder and
 ƒƒ You must follow the guidelines in this Certificate                                   intellectual disability treatment;
    even if this coverage is secondary to other health                                ƒƒ bilevel positive airway pressure (BIPAP) equipment:
    care coverage for you or one of your Dependents.
                                                                                      ƒƒ capsule endoscopy (wireless);
Prior Approval Program                                                                ƒƒ chiropractic care (after 12 visits in a Plan Year);
We require Prior Approval for all services from                                       ƒƒ chondrocyte transplants;
Non-Network Providers. We also require Prior                                          ƒƒ cochlear implants and aural rehabilitation;
Approval for certain services and drugs even when                                     ƒƒ continuous passive motion (CPM) equipment;
you use Network Providers. They appear on the
list later in this section. We do not require Prior                                   ƒƒ continuous positive airway pressure (CPAP) equipment;
Approval for Emergency Medical Services.                                              ƒƒ Cosmetic procedures except breast reconstruction
                                                                                         for patients with a diagnosis of breast cancer;

                                        Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
  6
Guidelines for Coverage

ƒƒ dental trauma, orthognathic Surgery, oral Surgery                                ƒƒ transplants (except corneal and kidney);
   except oral lesion excision and biopsy;                                          ƒƒ uvulopalatopharyngoplasty (UPPP)/somnoplasty;
ƒƒ Durable Medical Equipment (DME) and orthotics                                    ƒƒ wheelchairs.
   with a purchase price of $500 or more;
ƒƒ Electroconvulsive Therapy (ECT);                                               Case Management Program
ƒƒ gender reassignment services for gender dysphoria;                             Our case management program is a voluntary program.
ƒƒ genetic testing;                                                               Your case manager will work with you, your family and
                                                                                  your Provider to coordinate Medical Care for you.
ƒƒ hip resurfacing;
ƒƒ hospital beds;                                                                 Your case manager will help you manage your
                                                                                  benefits. He or she may also find programs, services
ƒƒ hyperbaric oxygen therapy;                                                     and support systems that can help. To find out if you
ƒƒ Investigational or Experimental services or procedures;                        are eligible for the program, call (800) 922-8778.
ƒƒ medical nutrition for inherited metabolic
   disease (medical supplies, pumps, enteral                                      Choosing a Provider
   formulae and parenteral nutrition);                                            If you want a list of BCBSVT Network Providers or want
ƒƒ Non-Network services;                                                          information about one, please visit our website at
ƒƒ oral appliances for sleep apnea;                                               www.bcbsvt.com/find-a-doctor. Use the Network
                                                                                  drop-down menu and select BCBSVT Network Providers
ƒƒ orthodontia for pediatric members up to age 21;                                to find a list of Providers. If you live or travel outside
ƒƒ orthotics with a purchase price of $500 or more;                               of the BCBSVT Provider network area please use the
ƒƒ osteochondral autograph transfer                                               three-letter prefix, located on your ID card, to find a
   system (OATS/mosaicplasty);                                                    network Provider using the Blue Cross and Blue Shield
                                                                                  Association National Doctor and Hospital Finder.
ƒƒ out-of-state inpatient and partial inpatient care;
                                                                                  You must verify Your Plan covers the Provider
ƒƒ percutaneous radiofrequency ablation of liver;
                                                                                  you choose outside of the BCBSVT network.
ƒƒ polysomnography (sleep studies) and
   multiple sleep latency testing (MSLT);                                         You may also call customer service at (800) 310-5249.
                                                                                  BCBSVT will send you a paper Provider Directory
ƒƒ certain Prescription Drugs and Biologics (please                               if you wish. Both electronic and paper directories
   see www.bcbsvt.com/pharmacy);
                                                                                  give you information on Provider qualifications,
ƒƒ prosthetics with a purchase price of $500 or more;                             such as training and board certification.
ƒƒ psychological testing;                                                         You may change Providers whenever you wish. Follow
ƒƒ radiation treatment and high-dose                                              the guidelines in this section when changing Providers.
   electronic brachytherapy;
                                                                                  You must use Network Providers or get Prior Approval to
ƒƒ radiology services (certain services including CT, CTA, MRI,                   get care outside of the Network. In Vermont, you must
   MRA, MRS, PET, echocardiogram and nuclear cardiology);                         use BCBSVT Network Providers. This Network includes
ƒƒ Rehabilitation (Skilled Nursing Facility, Inpatient                            a wide array of Primary Care Providers, Specialists and
   Rehabilitation treatment for medical conditions,                               Facilities in our state and in bordering communities
   intensive outpatient services or residential treatment                         in other states. Outside of this area, you will use our
   for mental health and substance abuse conditions);                             BlueCard Network (PPO/EPO). It includes Providers that
                                                                                  contract with other Blue Cross and/or Blue Shield Plans.
ƒƒ certain surgical procedures (examples include
   bariatric and gastric bypass Surgery, gastric electrical
   stimulation, percutaneous vertebroplasty, vertebral
                                                                                  Network Providers
   augmentation, temporomandibular joint manipulation/                            In most instances Network Providers will save
   Surgery and anesthesia and tumor embolization;                                 you money. Also, Network Providers will:
ƒƒ transcranial magnetic stimulation;                                               ƒƒ secure Prior Approval for you;
ƒƒ transcutaneous electrical nerve stimulation [TENS]                               ƒƒ bill us directly for your services, so you
   units/neuromuscular electrical stimulators [NMES];                                  don’t have to submit a claim;

                                      Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
                                                                                                                                                   7
Guidelines for Coverage

 ƒƒ not ask for payment at the time of service
    (except for Deductible, Co-insurance
                                                                                   Non-Network Providers
    or Co‑payments you owe); and                                                   You must get Prior Approval from us to use Non-
                                                                                   Network Providers. If you get Prior Approval to use a
 ƒƒ accept the Allowed Amount as full payment
                                                                                   Non-Network Provider, we pay the Allowed Amount
    (you do not have to pay the difference between
                                                                                   and you pay any balance between the Provider’s
    their total charges and the Allowed Amount).
                                                                                   charge and what we pay. You must also pay any
Although you receive services at a Network facility,                               Deductibles, Co-insurance and Co-payments that
the individual Providers there may not be Network                                  apply. (See your Outline of Coverage for details.)
Providers. Please make every effort to check the
status of all Providers prior to treatment.                                        If you are a new member and are seeing a Non-Network
                                                                                   Provider we shall allow you to keep going to that Provider
We have separate Networks for some types of                                        for up to 60 days after you join or until we find you a
Providers. You must use a separate Network                                         Network Provider, whichever is shorter. This can happen if:
Provider for the following Provider types:
                                                                                     ƒƒ you have a life-threatening illness; or
 ƒƒ dentists (for pediatric dental services);
                                                                                     ƒƒ you have an illness that is disabling or degenerative.
 ƒƒ Pharmacies; and
                                                                                   A woman in her second or third trimester of pregnancy
 ƒƒ Routine vision care Providers (if your coverage                                may continue to obtain care from her previous
    includes routine vision benefits).                                             Provider until the completion of postpartum care.

Primary Care Providers                                                             We only allow this if your Non-Network Provider will
                                                                                   accept the Health Plan’s rates and follow the Health Plan’s
When you join this Health Plan, you must select a Primary                          standards. The Health Plan’s medical staff must decide that
Care Provider (PCP) from our Network of Primary Care                               you qualify for the service. To find out, call (800) 922-8778.
Providers. You must receive services from your PCP
or another Network Provider to receive benefits. You                               Out-of-Area Providers
have the right to designate any PCP who is available
                                                                                   If you need care outside of Vermont, you may save money
to accept you or your family members. Each family
                                                                                   by using Providers that are Preferred Providers with their
member may select a different Primary Care Provider. For
                                                                                   local Blue Health Plan. See the BlueCard® Program section.
instance, you may select a pediatrician for your Child.
Your coverage does not require you to get referrals                                How We Choose Providers
from your Primary Care Provider. However, you must                                 When we choose Network Providers, we check their
get Prior Approval for certain services. (See page                                 backgrounds. We use standards of the National Committee
6.) You must get Prior Approval for any services                                   on Quality Assurance (NCQA). We choose Network
you receive from Providers outside our Network.                                    Providers who can provide the best care for our Members.
If you do not live in Vermont, you do not need to                                  We do not reward Providers or staff for denying services.
choose a Primary Care Provider (PCP). We encourage                                 We do not encourage Providers to withhold care.
you to do so, though, because it benefits your health                              Please understand that our Network Providers are not
to have one Provider coordinate your care. You only                                employees of BCBSVT; they just contract with us.
pay the PCP Co-payment listed on your Outline of
Coverage if you use a Provider who practices as a
PCP and is one of the following Provider types:
                                                                                   Access to Care
                                                                                   We require our Network Providers in the state
 ƒƒ family medicine;
                                                                                   of Vermont to provide care for you:
 ƒƒ general practice;
                                                                                     ƒƒ immediately when you have an
 ƒƒ internal medicine;                                                                  Emergency Medical Condition;
 ƒƒ naturopaths;                                                                     ƒƒ within 24 hours when you need Urgent Services;
 ƒƒ nurse practitioner;                                                              ƒƒ within two weeks when you need
 ƒƒ pediatrics.                                                                         non‑emergency, non-Urgent Services;
                                                                                     ƒƒ within 90 days when you need Preventive care
                                                                                        (including routine physical examinations);

                                       Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
  8
Guidelines for Coverage

 ƒƒ within 30 days when you need routine                                           you received those services from a Network Provider.
    laboratory services, imaging, general                                          These may include Deductibles, Co-insurance or Co-
    optometry, and all other routine services.                                     payments. If a Non-Network Provider requests any
If you live in the state of Vermont, you should find:                              payment from you other than your cost-sharing amounts,
                                                                                   please contact us at (800) 310-5249 so that we can work
 ƒƒ a Primary Care Provider (like a family                                         directly with the Provider to resolve the request.
    practitioner, pediatrician or internist) within
    a 30-minute drive from your home;                                              Care After Office Hours
 ƒƒ routine, office-based mental health and/or                                     In most non-emergency cases, call your Provider’s
    substance abuse treatment from a Network                                       office when you need care—even after office hours. He
    Provider within a 30-minute drive; and                                         or she (or a covering Provider) can help you 24 hours a
                                                                                   day, seven days a week. Do you have questions about
 ƒƒ a Network pharmacy within a 60-minute drive.
                                                                                   care after hours? Ask now before you have an urgent
You’ll find specialists for most common types of                                   problem. Then keep your doctor’s phone number
care within a 60-minute drive from your home. They                                 handy in case of late-night illnesses or injuries.
include optometry, laboratory, imaging and Inpatient
medical rehabilitation Providers, as well as intensive                             BlueCard® Program
Outpatient, partial hospital, residential or Inpatient                             In certain situations (as described elsewhere in this
mental health and substance abuse treatment services.                              Certificate) you may obtain health care services outside
You can find Network Providers for less common                                     of the Vermont service area. The claims for these services
specialty care within a 90-minute drive. This includes                             may be processed through the BlueCard® Program1.
kidney transplantation, major trauma treatment,                                    Typically, when accessing care outside of the service area,
neonatal intensive care and tertiary-level cardiac care.                           you will obtain care from health care Providers that have
Our Vermont Network Providers offer reasonable access                              a contractual agreement with the local Blue Cross and/or
for other complex specialty services, including major burn                         Blue Shield Licensee in that other geographic area (“Host
care, organ transplants and specialty pediatric care. We                           Blue”). In some instances, you may obtain care from health
may direct you to a “center of excellence” to ensure you                           care Providers that have contracts with Blue Cross and Blue
get quality care for less common medical procedures.                               Shield plans (e.g., Participating Providers). You must get
                                                                                   Prior Approval to get care from non-contracting providers.
After-hours and Emergency Care                                                     If you obtain care from a contracting Provider in
                                                                                   another geographic area, we will honor our contract
Emergency Medical Services                                                         with you, including all cost-sharing provisions and
In an emergency, you need care right away.                                         providing benefits for Covered services as long as you
Please read our definition of an Emergency                                         fulfill other requirements of this contract. The Host
Medical Condition in Chapter Nine.                                                 Blue will receive claims from its contracting Providers
Emergencies might include:                                                         for your care and submit those claims directly to us.

 ƒƒ broken bones;                                                                  We will base the amount you pay on these claims
                                                                                   processed through the BlueCard® Program on the lower of:
 ƒƒ heart attack; or
                                                                                     ƒƒ the billed Covered charges for your Covered services; or
 ƒƒ choking.
                                                                                     ƒƒ the price that the Host Blue makes available to us.
You will receive care right away in an emergency.
If you have an emergency at home or away, call 9-1-1 or
go to the nearest doctor or emergency room. You don’t
need Prior Approval for emergency care. If an out-of-area
hospital admits you, call us as soon as reasonably possible.
If you receive Medically Necessary, Covered Emergency
Medical Services from a Non-Network Provider, we                                   1 In order to receive Network Provider benefits as defined for ancillary
                                                                                     services, ancillary Providers such as independent clinical laboratories,
will cover your emergency care as if you had been                                    Durable Medical Equipment Suppliers and specialty pharmacies
treated by a Network Provider. You must pay any cost-                                must contract directly with the Blue Plan in the state where the
sharing amounts required under your Contract as if                                   services were ordered or delivered. To verify Provider participation
                                                                                     status, please call our customer service team at (800) 310-5249.

                                       Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
                                                                                                                                                                9
Guidelines for Coverage

Special Case: Value-Based Programs                                               If you need medical assistance services (including
If you receive Covered Services under a value-                                   locating a doctor or hospital) outside the BlueCard
based program inside a Host Blue’s service area, you                             service area, please call the Blue Cross Blue Shield
may be responsible for paying any of the Provider                                Global Core Service Center at (800) 810-BLUE (2583)
Incentives, risk sharing, and/or Care Coordinator                                or call collect at (804) 673-1177, 24 hours a day, seven
                                                                                 days a week. An assistance coordinator, working
Fees that are part of such an arrangement.
                                                                                 with a medical professional, can arrange a physician
Out-of-Area Services with non-contracting                                        appointment or hospitalization, if necessary.
Providers                                                                        Inpatient Services
In certain situations (as described elsewhere in this
                                                                                 In most cases, if you contact the Blue Cross Blue Shield
certificate), you may receive Covered health care services
                                                                                 Global Core Service Center for assistance, hospitals will not
from health care Providers outside of our service area
                                                                                 require you to pay for covered Inpatient services, except
that do not have a contract with the Host Blue. In
                                                                                 for your cost-sharing amounts. In such cases, the hospital
most cases, we will base the amount you pay for such
                                                                                 will submit your claims to the Blue Cross Blue Shield Global
services on either the Host Blue’s local payment or the
                                                                                 Core Service Center to begin claims processing. However,
pricing arrangements under applicable state law.
                                                                                 if you paid in full at the time of service, you must submit
In some cases, we may base the amount you pay for                                a claim to receive reimbursement for Covered Services.
such services on billed Covered charges, the payment
we would make if the services had been obtained within                           Outpatient Services
our service area or a special negotiated payment.                                Physicians, urgent care centers and other outpatient
                                                                                 providers located outside the BlueCard service
In these situations, you may owe the difference
                                                                                 area will typically require you to pay in full at
between the amount that the non-contracting
                                                                                 the time of service. You must submit a claim to
Provider bills and the payment we will make for
                                                                                 obtain reimbursement for Covered Services.
the Covered services as set forth above.
For contracting or non-contracting Providers, in                                 Submitting a Blue Cross Blue Shield Global
no event will you be entitled to benefits for health                             Core Claim
care services, wherever you received them, that are                              When you pay for Covered Services outside the
specifically excluded from, or in the excess of, the                             BlueCard service area, you must submit a claim to obtain
limits of coverage provided by your contract.                                    reimbursement. For institutional and professional claims,
                                                                                 you should complete a Blue Cross Blue Shield Global
Blue Cross Blue Shield Global                                                    Core International claim form and send the claim form
Core™ Program                                                                    with the Provider’s itemized bill(s) to the Blue Cross Blue
                                                                                 Shield Global Core Service Center (the address is on
If you are outside the United States, the Commonwealth                           the form) to initiate claims processing. Following the
of Puerto Rico, or the U.S. Virgin Islands, (which we will                       instructions on the claim form will help ensure timely
call the “BlueCard service area”), you may be able to                            processing of your claim. The claim form is available
take advantage of the Blue Cross Blue Shield Global                              from BCBSVT, the Blue Cross Blue Shield Global Core
Core™ Program when accessing Covered Services. The                               Service Center or online at www.bcbsglobalcore.com.
Blue Cross Blue Shield Global Core Program is unlike                             If you need assistance with your claim submission,
the BlueCard Program in certain ways. For instance,                              you should call the Blue Cross Blue Shield Global Core
although the Blue Cross Blue Shield Global Core Program                          Service Center at (800) 810-BLUE (2583) or call collect
helps you get care through a network of inpatient,                               at (804) 673-1177, 24 hours a day, seven days a week.
outpatient and professional Providers, the network is
not hosted by Blue plans. When you receive care from
Providers outside the BlueCard service area, you will
typically have to pay the Providers and submit the claims
yourself to obtain reimbursement for these services.
You must get Prior Approval from us for all non-
emergency services outside of the Preferred Network.

                                     Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
 10
Guidelines for Coverage

How We Determine Your Benefits                                                    Aggregate Deductible
When we receive your claim, we determine:                                         Your plan may have an Aggregate Deductible. Please see
                                                                                  your Outline of Coverage to see what type of Deductible
 ƒƒ if this Contract covers the medical                                           you have. If your plan has an Aggregate Deductible, and
    services you received; and                                                    you are on a two-person or family plan, you do not have
 ƒƒ your benefit amount.                                                          an individual Deductible. Your family members’ Covered
In general, we pay the Allowed Amount (explained                                  expenses must reach the family Deductible before any of
later in this section). We may subtract any:                                      your family members receive post-Deductible benefits.
                                                                                  When your family’s expenses reach this amount, all
 ƒƒ benefits paid by Medicare;                                                    family members receive post-Deductible benefits.
 ƒƒ Deductibles (explained below);                                                Stacked Deductible
 ƒƒ Co-payments (explained below);                                                Your plan may have a Stacked Deductible. Please see
 ƒƒ Co-insurance (explained below);                                               your Outline of Coverage to see what type of Deductible
                                                                                  you have. If your plan has a Stacked Deductible, and you
 ƒƒ amounts paid or due from other insurance carriers
    through coordination of benefits (see Chapter Five).                          are on a two-person or family plan, a Covered family
                                                                                  member may meet the individual Deductible and begin
Your Deductible, Co-insurance and Co-payment                                      receiving post-Deductible benefits. When your family
amounts appear on your Outline of Coverage. We                                    members’ Covered expenses reach the family Deductible,
may limit benefits to the Plan Year maximums                                      all family members receive post-Deductible benefits.
shown on your Outline of Coverage.
                                                                                  Co-payment
Payment Terms                                                                     You must pay Co-payments to Providers for specific
                                                                                  services shown on your Outline of Coverage. Your Provider
Allowed Amount                                                                    may require payment at the time of the service. We apply
The Allowed Amount is the amount we consider                                      Co-payments toward your Out-of-Pocket Limit. Check
reasonable for a Covered service or supply.                                       your Outline of Coverage for details on your Health Plan.
Note:                                                                             You may have different Co-payments
 ƒƒ Network Providers accept the Allowed Amount as                                depending on the Providers you see. Check
    full payment. You do not have to pay the difference                           your Outline of Coverage for details.
    between their total charges and the Allowed Amount.                           Co-insurance
 ƒƒ If you use a Non-Network Provider, we pay the                                 You must pay Co-insurance to Providers for specific
    Allowed Amount and you must pay any balance                                   services shown on your Outline of Coverage. We
    between the Provider’s charge and what we pay.                                calculate the Co-insurance amount by multiplying
                                                                                  the Co-insurance percentage by the Allowed Amount
Cost-Sharing                                                                      after you meet your Deductible (for services subject
Deductible                                                                        to a Deductible). We apply your Co-insurance toward
Your Deductible amounts are listed on your Outline of                             your Out-of-Pocket Limit for each Plan Year.
Coverage. You must meet your Deductibles each Plan Year
                                                                                  Out-of-Pocket Limit
before we make payment on certain services. We apply
your Deductible to your Out-of-Pocket Limit for each Plan                         Your Outline of Coverage lists your Out-of-Pocket
Year. You may have more than one Deductible. Deductibles                          Limit. We apply your Deductible, your Co-payments
can apply to certain services or certain Provider types.                          and your Co-insurance toward this limit. Check your
Please see your Outline of Coverage for details.                                  Outline of Coverage for details on your plan. After
                                                                                  you meet your Out-of-Pocket Limit, you pay no Co-
When your family meets the family                                                 insurance or Co-payments for the rest of that Plan Year.
Deductible, no one in the family needs to pay                                     Please check your Outline of Coverage for details.
Deductibles for the rest of the Plan Year.
                                                                                  When your family meets the family Out-of-Pocket
                                                                                  Limit, all family members are considered to have met
                                                                                  their individual Out-of-Pocket Limits. You may have
                                                                                  separate Out-of-Pocket Limits for certain services.

                                      Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
                                                                                                                                                11
Guidelines for Coverage

Aggregate Out-of-Pocket Limit                                                    Plan Year Benefit Maximums
Your plan may have an Aggregate Out-of-Pocket limit.                             Your Plan Year benefit maximums are listed on your
Please see your Outline of Coverage to see which kind                            Outline of Coverage or in this Certificate. After we have
of Out-of-Pocket limit you have. If your plan has an                             provided maximum benefits, you must pay all charges.
Aggregate Out-of-Pocket Limit and you are on a two-
person or family plan, you do not have an individual                             Self-Pay Allowed by HIPAA
Out-of-Pocket Limit. Your family members’ Covered                                Federal law gives you the right to keep your Provider
expenses must reach the family Out-of-Pocket Limit                               from telling us that you received a particular health
before we pay 100 percent of the Allowed Amount for                              care item or service. You must pay the Provider the
services. When your family’s expenses reach this amount,                         Allowed Amount directly. The amount you pay your
all family members receive 100 percent coverage.                                 Provider will not count toward your Deductible, other
                                                                                 cost-sharing obligations or your Out-of-Pocket Limits.
Stacked Out-of-Pocket Limit
Your plan may have a Stacked Out-of-Pocket limit. Please
see your Outline of Coverage to see which kind of Out-of-
Pocket limit you have. If your plan has a Stacked Out-of-
Pocket Limit, and you are on a family plan, a Covered family
member may meet the individual out-of-pocket limit and
we will begin to pay 100 percent of the Allowed Amount
for his or her services. Additionally, any combination
of Covered family members may meet the family Out-
of-Pocket limit and we will begin to pay 100 percent of
the Allowed Amount for all family members’ services.
Aggregate Prescription Drugs and
Biologics Out-of-Pocket Limit
Your plan may have an Aggregate Prescription Drugs and
Biologics Out-of-Pocket limit. Please see your Outline of
Coverage for details. Once any combination of Covered
family members meets the Prescription Drugs and
Biologics Out-of-Pocket limit, we begin to pay Prescription
Drugs and Biologics at 100 percent of the Allowed Amount.

                                     Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
 12
Covered Services

                     CHAPTER TWO                                                       ƒƒ generic female contraception methods
                                                                                          (or brand name methods if no generic is
Covered Services                                                                          available) and contraceptive counseling;1
                                                                                       ƒƒ breastfeeding support and counseling
This chapter describes covered services, guidelines                                       from Network Providers;
and Policy rules for obtaining benefits. Please see
your Outline of Coverage for benefit maximums and                                      ƒƒ breastfeeding supplies (you must get Prior
                                                                                          Approval for hospital-grade breast pumps); and
cost-sharing such as Co-insurance and Deductibles.
                                                                                       ƒƒ domestic violence screening.
Preventive Services
We provide benefits for Preventive Services. We
                                                                                   Office Visits
encourage you to get Preventive Services that are                                  When you receive care in an office setting, you must
appropriate for you. Examples of preventive care                                   pay the amount listed on your Outline of Coverage.
include colonoscopies for people age 50 and over,                                  Please read this entire section carefully. Some office visit
mammograms for women age 40 and over and Coverage                                  benefits have special requirements or limits. We cover
for women’s reproductive health as required by law.                                Professional services such as these in an office setting:
We pay for some Preventive Services with no Cost-                                      ƒƒ examination, diagnosis and treatment
Sharing (like Co-payments, Deductibles and Co-                                            of an injury or illness;
insurance). We provide such Coverage for services                                      ƒƒ injections;
rated A or B by the United States Preventive Services                                  ƒƒ Diagnostic Services, such as X-rays;
Task Force. You can find this list on our website at
www.bcbsvt.com/preventive. Or you can call our                                         ƒƒ nutritional counseling (See page 22);
customer service team at (800) 310-5249 to get a list.                                 ƒƒ Surgery; and
Note that the list includes many Preventive Services, but                              ƒƒ therapy services (See page 24).
not all. Coverage for other preventive, diagnostic and                             Some office visits may fall under your
treatment services may be subject to cost-sharing. The                             preventive services benefit.
list also includes some services that are appropriate for
individuals at increased risk for certain conditions.                              Exclusions
Please note that if your Provider finds or treats                                  We do not cover immunizations that the law
a condition while performing Preventive                                            mandates an employer to provide. General
Services, cost-sharing may apply.                                                  exclusions in Chapter Three also apply.
                                                                                   Notes:
Women’s Health                                                                         ƒƒ We describe office visits for mental health
We pay benefits for certain services and supplies that                                    services, substance abuse treatment services,
support women’s health with no cost-sharing (like                                         and chiropractic services elsewhere in this
Co-payments, Deductibles and Co-insurance).                                               Chapter. Please see those sections for benefits.
This benefit covers the following Services if they are                                 ƒƒ You must get Prior Approval for certain services in order
appropriate for the Member (for a detailed list, visit                                    to receive benefits. See page 6 for a description of
our website at www.bcbsvt.com/preventive or call                                          the Prior Approval program. Visit our website or call
our customer service team at (800) 310-5249):                                             our customer service team at (800) 310-5249 for the
                                                                                          newest list of services that require Prior Approval.
 ƒƒ well-women visits;
 ƒƒ gestational diabetes screening;                                                Ambulance
 ƒƒ human papillomavirus testing;                                                  We cover Ambulance services as long as your condition
 ƒƒ sexually transmitted infections counseling;                                    meets our definition of an Emergency Medical Condition.
                                                                                   Coverage for Emergency Medical Services outside of the
 ƒƒ human immunodeficiency virus
    counseling and screening;                                                      service area is the same as coverage within the service
                                                                                   area. If a Non-Network Provider bills you for a balance
                                                                                   1
                                                                                        Please note if you use brand-name contraceptives, we
                                                                                        will cover them at the applicable Co-payment.

                                      Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
                                                                                                                                                           13
Covered Services

between the charges and what we pay, please notify us by                          We cover Acute and Supportive chiropractic
calling our customer service team at (800) 310-5249. We                           care (only for services that require constant
will defend against and resolve any request or claim by a                         attendance of a Chiropractor), including:
Non-Network Provider of Emergency Medical Services.
                                                                                    ƒƒ office visits, spinal and extraspinal
We cover transportation of the sick and injured:                                       manipulations and associated modalities;
 ƒƒ to the nearest Facility from the scene of an                                    ƒƒ home, hospital or nursing home visits; or
    accident or medical emergency; or                                               ƒƒ Diagnostic Services (e.g., labs and X-rays).
 ƒƒ between Facilities or between a Facility                                      Requirements and conditions that apply to
    and home (but not solely according to the                                     coverage for services by Providers other than
    patient's or the Provider's preference).                                      Chiropractors also apply to this coverage.
Limitations                                                                       If you use more than 12 chiropractic visits in one
 ƒƒ You must get Prior Approval for non-emergency                                 Plan Year, you must get Prior Approval from us for
    transport including air or water transport.                                   any visits after the 12th. See page 6 for more
                                                                                  information about the Prior Approval program.
 ƒƒ We cover transportation only to the closest
    Facility that can provide services appropriate                                Exclusions
    for the treatment of your condition.
                                                                                  We provide no chiropractic benefits for:
 ƒƒ We do not cover Ambulance services when the
    patient can be safely transported by any other                                  ƒƒ treatment after the 12th visit if you
    form of transportation. This applies whether                                       don’t get Prior Approval;
    or not the transportation is available.                                         ƒƒ services by a Provider who is not in our Network;
 ƒƒ We do not cover Ambulance transportation                                        ƒƒ services, including modalities, that do not require
    when it is solely for the convenience of                                           the constant attendance of a Chiropractor;
    the Provider, family or member.                                                 ƒƒ treatment of any “visceral condition,”
                                                                                       that is a dysfunction of the abdominal or
Autism Spectrum Disorder                                                               thoracic organs, or other condition that is
We cover Medically Necessary services related to Autism                                not neuromusculoskeletal in nature;
Spectrum Disorder (ASD), which includes Asperger’s                                  ƒƒ acupuncture;
Syndrome, moderate or severe Intellectual Disorder,
                                                                                    ƒƒ hot and cold packs;
Rett Syndrome, Childhood Disintegrative Disorder (CDD)
and Pervasive Developmental Disorder—Not Otherwise                                  ƒƒ massage therapy;
Specified (PDD-NOS) for members up to age 21.                                       ƒƒ care provided but not documented with clear,
                                                                                       legible notes indicating the patient’s symptoms,
You must get Prior Approval for services.
                                                                                       physical findings, the Chiropractor’s assessment,
Please remember General Exclusions                                                     and treatment modalities used (billed);
in Chapter Three also apply.
                                                                                    ƒƒ low-level laser therapy, which is
                                                                                       considered Investigational;
Clinical Trials (Approved)                                                          ƒƒ vertebral axial decompression
We cover Medically Necessary, routine                                                  (i.e. DRS System, DRX 9000, VAX-D Table,
patient care services for members enrolled in                                          alpha spina system, lordex lumbar spine
Approved Clinical Trials as required by law.                                           system, internal disc decompression [IDD]),
                                                                                       which is considered Investigational;
General Exclusions in Chapter Three apply.
                                                                                    ƒƒ supplies or Durable Medical Equipment;
Chiropractic Services                                                               ƒƒ treatment of a mental health condition;
We cover services by our Network Chiropractors who are:                             ƒƒ prescription or administration of drugs;

 ƒƒ working within the scope of their licenses; and                                 ƒƒ obstetrical procedures including
                                                                                       prenatal and post-natal care;
 ƒƒ treating you for a neuromusculoskeletal condition.

                                      Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
 14
Covered Services

 ƒƒ Custodial Care (see Definitions), as                                                            • 12 years of age or younger with phobias or
    noted in General Exclusions;                                                                      a mental illness documented by a licensed
 ƒƒ Surgery;                                                                                          physician or mental health professional; and
                                                                                                    • members with severe disabilities that preclude
 ƒƒ unattended services or modalities that do not require
                                                                                                      office-based dental care due to safety consideration
    one-on-one patient contact by the Provider; or
                                                                                                      (examples include, but are not limited to, severe
 ƒƒ any other procedure not listed as a                                                               autism, cerebral palsy, hemorrhagic disorders,
    Covered chiropractic service.                                                                     and severe congestive heart failure).
General Exclusions in Chapter Three also apply.                                              Note: the professional charges for the
                                                                                             dental services may not be covered.
Cosmetic and                                                                                 For individuals up to age 21 (and through the
Reconstructive Procedures                                                                    end of the Plan year in which a member turns
We exclude Cosmetic procedures (see General                                                  21) we provide the services above and also
Exclusions in Chapter Three). Your benefits cover                                            the following pediatric dental services:
Reconstructive procedures that are not Cosmetic.                                               ƒƒ Class I services including semiannual examinations,
(Please see the definitions of Reconstructive                                                     semiannual cleaning, X-rays and diagnosis.
and Cosmetic.) For example, we cover:
                                                                                               ƒƒ Class II (basic) services including simple
 ƒƒ Reconstruction of a breast after breast Surgery                                               restoration (fillings), crowns and jackets,
    and Reconstruction of the other breast to                                                     repair of crowns, wisdom tooth removal,
    produce a symmetrical appearance;                                                             extractions and endodontics (root canal).
 ƒƒ prostheses (which we cover under Medical                                                   ƒƒ Class III (major) services including dentures,
    Equipment and Supplies on page 19); and                                                       bridges, replacement of bridges and dentures
 ƒƒ treatment of physical complications                                                           and Medically Necessary orthodontia.
    resulting from breast Surgery.                                                           For pediatric dental services you must use a Provider in our
You must get Prior Approval for these services.                                              pediatric dental network. For a list of dentists please visit
                                                                                             www.bcbsvt.com/find-a-doctor or call (800) 310-5249.
Dental Services                                                                              Please see your Outline of Coverage to see how
We cover only the following dental services for individuals                                  much you must pay for each level of service.
over age 21; you may use any Network Provider:                                               You must get Prior Approval for the services beginning
 ƒƒ treatment for, or in connection with, an accidental                                      on page 6, including some dental services, or
    injury to jaws, sound natural teeth, mouth or face,                                      your care may not be Covered. In the event of an
    provided a continuous course of dental treatment                                         emergency, you must contact us as soon as possible
    begins within six months of the accident.1                                               afterward for approval of continued treatment.
 ƒƒ Surgery to correct gross deformity resulting from major                                  Exclusions
    disease or Surgery (Surgery must take place within six                                   Unless expressly Covered in other parts of this Contract or
    months of the onset of disease or within six months                                      required by law, we do not cover the following services:
    after Surgery, except as otherwise required by law).
                                                                                               ƒƒ Surgical removal of teeth, including
 ƒƒ Surgery related to head and neck cancer                                                       removal of wisdom teeth;
    where sound natural teeth may be affected
    primarily or as a result of the chemotherapy                                               ƒƒ gingivectomy;
    or radiation treatment of that cancer.                                                     ƒƒ tooth implants;
 ƒƒ Facility and anesthesia charges for members who are:                                       ƒƒ care for periodontitis;
     • 7 years of age or younger;                                                              ƒƒ injury to teeth or gums as a result of chewing or biting;
1 Note: A sound, natural tooth is a tooth that is whole or properly
  restored using direct restorative dental materials (i.e. amalgams,                           ƒƒ pre- and post-operative dental care;
  composites, glass ionomers or resin ionomers); is without impairment,
  untreated periodontal conditions or other conditions; and is not in
                                                                                               ƒƒ orthodontics (including orthodontics
  need of the treatment provided for any reason other than accidental                             performed as an adjunct to orthognathic or
  injury. A tooth previously restored with a dental implant, crown, inlay,                        in connection with an accidental injury);
  onlay, or treated by endodontics, is not a sound natural tooth.

                                                 Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
                                                                                                                                                            15
Covered Services

 ƒƒ procedures designed primarily to prepare
    the mouth for dentures (including alveolar
                                                                                   Emergency Care
    augmentation, bone grafting, frame implants                                    We cover services you receive in the emergency room
    and ramus mandibular stapling);                                                of a General Hospital. Coverage for Emergency Medical
                                                                                   Services outside of the service area will be the same as for
 ƒƒ charges related to non-Covered dental procedures
                                                                                   those within the service area. If a Non-Network Provider
    or anesthesia (for example, facility charges, except
                                                                                   bills you for a balance between the charges and what
    when Medically Necessary as noted above).
                                                                                   we pay, please notify us. Call us at (800) 310-5249. We
General Exclusions in Chapter Three also apply.                                    will defend against and resolve any request or claim by a
                                                                                   Non-Network Provider of Emergency Medical Services.
Diabetes Services
                                                                                   Requirements
We cover treatment of diabetes. For example, we cover
syringes, insulin, nutritional counseling, Outpatient self-                        We provide benefits only if you require Emergency
management training and education for people with                                  Medical Services as defined in this Certificate.
diabetes. We pay benefits subject to the same terms and
conditions we use for other medical treatments. You                                Home Care
must get nutritional counseling from one of the following                          We cover the Acute services of a Home Health
Network Providers or we will not cover your care:                                  Agency or Visiting Nurse Association that:
 ƒƒ medical doctor (M.D.);                                                           ƒƒ performs Medically Necessary skilled
 ƒƒ doctor of osteopathy (D.O.);                                                        nursing procedures in the home;
 ƒƒ registered dietitian (R.D.);                                                     ƒƒ trains your family or other caregivers to perform
                                                                                        necessary procedures in the home; or
 ƒƒ certified dietitian (C.D.);
                                                                                     ƒƒ performs Physical, Occupational or Speech Therapy.
 ƒƒ naturopathic doctor (N.D.);
                                                                                   We also cover:
 ƒƒ advanced practice registered nurse (A.P.R.N.); or
 ƒƒ certified diabetic educator (C.D.E.).                                            ƒƒ services of a home health aide (for personal
                                                                                        care only) when you are receiving skilled
Diagnostic Tests                                                                        nursing or therapy services;

We cover these Diagnostic Tests to help                                              ƒƒ other necessary services (except drugs and
                                                                                        medications) furnished and billed by a Home
find or treat a condition, including:
                                                                                        Health Agency or Visiting Nurse Association; and
 ƒƒ imaging (radiology, X-rays, ultrasound
                                                                                     ƒƒ home infusion therapy.
    and nuclear imaging);
                                                                                   For more information about therapy
 ƒƒ studies of the nature and cause of disease
                                                                                   services, see page 24.
    (laboratory and pathology tests);
 ƒƒ medical procedures (ECG and EEG);                                              Private Duty Nursing
 ƒƒ allergy testing (percutaneous, intracutaneous,                                 We cover skilled nursing services by a private-duty nurse
    patch and RAST testing);                                                       outside of a hospital, subject to these limitations:
 ƒƒ mammograms; and                                                                  ƒƒ We limit benefits for private duty nursing.
 ƒƒ hearing tests by an audiologist only if your                                        Check your Outline of Coverage.
    doctor suspects you have a disease condition.                                    ƒƒ We provide benefits only if you receive services
You must get Prior Approval for special radiology                                       from a registered or licensed practical nurse.
procedures (including CT, MRI, MRA, MRS and PET                                    Requirements
scans) and polysomnography (sleep studies). See page
                                                                                   We cover home care services only when your Provider:
6 for more information regarding Prior Approval.
                                                                                     ƒƒ approves a plan of treatment for a
                                                                                        reasonable period of time;
                                                                                     ƒƒ includes the treatment plan in your medical record;
                                                                                     ƒƒ certifies that the services are not for Custodial Care; and

                                       Certificate of Coverage for BCBSVT Platinum, Gold, Silver and Bronze Plans (280.318)
 16
You can also read
Next slide ... Cancel