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January 2007 IFP Guaranteed Issue benefit changes and clarifications
Benefit Changes
The following benefit changes are effective January 1, 2007, or on the member’s first billing date thereafter:

What’s changing

Current benefit

New benefit

Shield Spectrum PPO Plans

1500 and 2000 Guaranteed Issue

Ambulatory surgery center (ASC) copayments

Out-of-network member coinsurance is 50% up to $500.

The out-of-network member coinsurance will be 50% up to $300 and all charges above $300.

X

Dialysis copayments (for facility services, not professional services)

Out-of-network member cost share is 50% up to $500.

The out-of-network member cost share will be 50% up to $300 and all charges above $300.

X

Out-of-network calendar-year copayment/coinsurance maximums

The calendar-year copayment/coinsurance maximums for non-preferred providers are as follows:

Shield Spectrum PPO Plan 1500 = $6500

Shield Spectrum PPO Plan 2000 = $7000

The calendar-year copayment/coinsurance maximum for non-preferred providers will be as follows:

Shield Spectrum PPO Plan 1500 = $9000

Shield Spectrum PPO Plan 2000 = $10,000

X

Emergency room

Emergency room coinsurance is 30%.

Emergency room cost sharing will be a $100 copayment, plus 30% coinsurance.

 

X

Hospital and mental health inpatient services and outpatient surgery coinsurance

 

Hospital and mental health inpatient and outpatient coinsurance is 30%.

Hospital and mental health inpatient and outpatient cost will be a $250 copay + 30%.

X

Durable medical equipment (DME) and prosthetics and orthotics

DME and prosthetics are covered with no limit per calendar year. Orthotics are covered up to $2000 per calendar year.

DME and prosthetic coverage will be limited to $2000 per calendar year each. Orthotics will be covered up to $1000 per calendar year.

Out-of-network DME, prosthetic and orthoses will not be covered for Shield Spectrum PPO Plan 1500.

X

Bariatric surgery network – Southern California

There isn’t a bariatric surgery network.

For PPO members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties, coverage will be provided only if:

1) consistent with Blue Shield’s medical policy; and,

2) pre-service review is obtained to determine whether services are medically necessary; and,

3) prior authorization is obtained, in writing, from Blue Shield’s Medical Director; and,

4) services are provided by a preferred bariatric facility and surgeon contracting with Blue Shield to provide the procedure.

A travel benefit is provided for members who live more than 50 miles from the nearest facility. There are no changes to either network or out-of-network coverage for other counties.

X

Certified registered nurse anesthetist (CRNA) network

CRNAs are not classified as participating or non-participating.

CRNAs will be designated as participating or non-participating providers.  If the CRNA is participating, payment for services will be sent to the CRNA. If the CRNA is non-participating, payment for services provided by a non-participating CRNA will be sent to the member.

X

 

Clarifications
The following are clarifications to existing plan benefit information for all Blue Shield of California and Blue Shield of California Life & Health Insurance Company (Blue Shield Life) plans. They are not benefit changes:

Home infusion therapy and home health care

 

Blue Shield and industry practices allow home infusion and home health services outside the home and also permit such services in the home for members who are not “homebound.”  Plan EOC and policy language will be modified to remove the "homebound" requirement.

 

Definitions of activities of daily living (ADL) and home medical equipment (HME)

 

To clarify benefit coverage plan EOC and policy language will be updated with a revised definition of ADL. Also the term “home medical equipment” will be changed to “durable medical equipment.”

 

Autologous chondrocytes transplantation (ACT)

 

Autologous chondrocytes transplantation (ACT), a type of knee surgery, is often performed on an outpatient basis. References to ACT will be removed from the special transplant benefits section.

 

Outpatient rehabilitation and speech therapy

EOC and policy language will be modified to clarify that outpatient rehabilitation and speech therapy provided in a hospital outpatient department are covered in the same manner as other hospital outpatient services.

Travel immunization

 

References to travel immunizations in Preventive Care Services and General Exclusions will be updated as follows: "...except for immunizations ‘and vaccinations by any mode of administration (oral, injection or otherwise)’ solely for the purpose of travel." Additionally, the Using Your Plan disclosure will be updated as follows: "...or immunizations 'and vaccinations by any mode or administration (oral, injection, or otherwise)’ solely for the purpose of travel...."

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