Blue Cross and Blue Shield of Kansas

 

Blue Cross and Blue Shield of Kansas is the PPO – preferred provider organization – insurance provider for the employees of Crawford County and their families.  A preferred provider organization is a group of doctors and/or businesses involved in health care services that have come together under a plan with specific guidelines and reimbursement amounts.  The name of the health plan is Blue Choice, with a $500 deductible per person, or $1000 deductible for two or more persons for covered services.

Crawford County pays 50% of allowed charges, after the deductible has been met.  Insured employees pay 50% of allowed charges to a maximum of $2000 per individual or $4000 for two or more person coverage.  After the $2000 or $4000 maximum has been reached, Crawford County pays 100% of allowed charges for the balance of the benefit period.  The benefit period is January 1 through December 31 each year.

Accident care is not subject to deductible and coinsurance, and 100% of the allowed charges are paid by Crawford County.  Accident care refers to the care for accidental injuries, which are defined as an injury to the body caused solely through external, violent, and accidental means.

Pre-Existing Conditions

 

Blue Cross and Blue Shield’s policy regarding pre-existing conditions is as follows.  You must have had coverage under this health plan for 90 continuous days before benefits are provided for pre-existing conditions.  A pre-existing condition is a condition, whether physical or mental, regardless of the cause of the condition for which medical advice, diagnosis, care, or treatment was recommended or received in the 90 days prior to the date this coverage becomes effective.

The waiting period for pre-existing conditions is 90 continuous days of coverage and applies to all employees and dependents enrolled under this coverage.  This means that there is a 90 day waiting period for pre-existing conditions beginning on the first day the health insurance plan becomes effective.  The exceptions to the pre-existing conditions waiting period are for pregnancies, newborns, or adopted children who, within 31 days of birth or the date of adoption, or placement of adoption, will not have the waiting period applied to them.

 

Benefits

 

Benefits for the Blue Choice plan include, but are not limited to, the following:

• In-hospital care

• Surgery and anesthesia
• Maternity
• Radiology and lab services
• Immunizations
• Ambulance
• Hearing tests
• Eye exams
• Allergy tests
• Newborn care
• Physical medicine
• Medical equipment
• Routine physicals
• Private duty nursing (limited)
• Unmarried dependents covered to age 23
• HMS – nervous and mental treatment precertification process
• Outpatient surgery
• Second surgical opinion
• Emergency services
• Outpatient nervous and mental services (limited)
• Inpatient nervous and mental services (limited)
• $2,000,000 lifetime maximum
• CAPplus – inpatient hospital pre-admission certification

 

Pre-Admission Certificate

 

All admissions to hospitals and medical care facilities for inpatient care – including nervous and mental conditions – require pre-admission certification by Blue Cross and Blue Shield of Kansas, unless the admission is for a medical emergency, a life-threatening condition, obstetrical care, or occurs outside of the 50 United States.  Should it become necessary for an individual to be admitted to a hospital, the individual’s doctor should obtain pre-admission certification for admission.  It is important to inform doctors that individuals are Blue Choice insured because, if no pre-admission request is made, the individual may be financially responsible for any medically unnecessary services.  The numbers to call for pre-certification will appear on the individual’s ID card.

 

Office Visit Copay

 

The copay, or individual’s share for each office visit is $20.  Individuals are responsible for the $20 office visit copay, regardless of whether or not they have met their deductible.  Outpatient immunizations and injections are paid by Crawford County for 100% of allowable charges.  Outpatient laboratory and radiology services are paid 100% of allowable charges up to $300 per person each benefit period.

 

Outpatient Prescription Drugs

Individuals are responsible for the following prescription copays:

• $15.00 generic
• $30.00 brand formulary
• $45.00 brand non-formulary

The brand formulary medicine is a list of preferred medications selected for consideration of safety, effectiveness, uniqueness, and cost.  All drugs on the brand formulary list have been reviewed by doctors and clinical pharmacists to ensure patients receive cost-effective pharmaceutical care emphasizing quality and safety.

The brand non-formulary medicines are those brand name drugs not found on the formulary list.

Individuals are responsible for the following mail order prescription copays.  The mail order prescriptions are for 90 consecutive day prescriptions.  To order prescriptions by mail, you need to fill the appropriate form, available at http://www.bcbsks.com/members/forms/PrimeMail_Order_Frm.pdf, and get a prescription from your doctor.  The savings that you will receive by using a mail prescription are as follows in Italics.  Theses savings are compared to filling a prescription three times at a pharmacy versus ordering a 90 consecutive day prescription by mail.

 

• $37.50   generic savings: $7.50
• $75.00   brand formulary savings: $15.00
• $112.50 brand non-formulary savings: $22.50

How to File a Claim

 

Contracting providers should file claims for covered services directly with the Blue Cross and Blue Shield Company that services the area in which they practice.  Should a provider choose not to file eligible claims for an individual, the individual should secure an itemized statement – including ID number, doctor’s name, and diagnosis – from that provider and send it along with a claim form within 90 days to the Blue Cross and Blue Shield Company that services the area in which they practice.

For fastest service, the following information should be available:

• Identification number
• Group number
• Employee’s name
• Patient’s name
• Date of service
• Type of service
• Doctor’s name or hospital’s name
• Total amount of claim

 

To obtain a claim form, or for any other questions, contact:

 

Blue Cross and Blue Shield of Kansas

1133 Topeka Boulevard

Topeka, KS 66629-0001

Telephone: toll free 1-800-432-3990 or (785) 291-4180

Web site: http://www.bcbsks.com

 

How Payment is Determined

 

Network Providers

 

Network providers refer to physicians, clinics, hospitals, etc. that have entered into a contract with Blue Cross and Blue Shield of Kansas to be part of a network.  Blue Cross and Blue Shield of Kansas negotiates the price of service rendered by the provider so there is a savings to the individual and Crawford County.

 

Individual pays any deductible, coinsurance or shared payment amounts, amounts in excess of benefit limitations, and non-covered services.

 

Blue Cross and Blue Shield of Kansas covers hospital balance up to the maximum payment allowance.  The provider may not bill you for amounts in excess of that allowance.

 

To find a network provider in your area, visit the Blue Cross and Blue Shield provider directory at http://www.bcbsks.com/provider_dirc/index.htm

 

Non-Network Providers

 

Individual pays any deductible, coinsurance or shared payment amounts, amounts in excess of benefit limitations, and non-covered services.

 

Individuals pay an additional 20% coinsurance up to a maximum of $2000 per person or $4000 for two or more people for each benefit period and any remaining balance.

 

Blue Cross and Blue Shield of Kansas covers balance up to the maximum allowable payment.  The provider may not bill you for amounts in excess of the payment allowance.

Non-Contracting Provider

 

Individual pays any deductible, coinsurance or shared payment amounts, amount in excess of benefit limitations, and non-covered services.

 

Individuals pay an additional 20% of allowance, to a maximum of $2000 per person and $4000 for two or more people each benefit period and any remaining balance.

 

Individuals will also be responsible for the difference between the Blue Cross and Blue Shield of Kansas maximum non-contracting allowance, which is 80% of the maximum allowance to a contracting provider, and the provider’s charge.

 

Blue Cross and Blue Shield of Kansas covers balance up to the maximum allowable payment.

Out-of-Area Network Provider

 

In the Greater Kansas City Area, then Blue Choice Network will be the Blue Cross and Blue Shield of Kansas City Preferred-Care Blue Network.  If an individual seeks care in another state, and the care is provided by a PPO contracting provider in the plan area, the BlueCard arrangement will allow for the claim to be processed as a Blue Choice Network provider and the additional out-of-network coinsurance will not apply.  In Joplin, MO, the PPO contracting hospital is Freeman Health Systems, 1102 W. 32nd Street, Joplin, MO 64804.

 

Exceptions to Non-Network

 

• When the individual receives services from a provider that has not been given the opportunity to be a Blue Choice provider, there will be no reduction in payment.
• If the individual receives initial stabilizing treatment from any non-Blue Choice provider for an emergency condition.

 

Frequently Asked Questions

 

Q.  What providers participate in the Blue Choice Network?

 

A. Selected hospitals and all contracting professional providers participate in the Blue Choice Network.  There are currently, more than 150 Blue Choice health care facilities and more than 7,500 professional providers participating in the network in the Blue Cross and Blue Shield of Kansas company services – the entire state of Kansas, excluding Johnson and Wyandotte counties.  The Blue Choice provider directory will list the most current contracting providers.

 

Visit http://www.bcbsks.com/provider_dirc/index.htm

 

 

Q. Will I need to get a referral if I want to go to more than one doctor?

 

A. No.  You will have the freedom to access medical care without a referral.

 

 

Q. Who can enroll in Blue Choice?

 

A. If you can access a Blue Plan Network provider, you are eligible to enroll in Blue Choice.  You will receive maximum benefits when you receive health care services from a Blue Choice or Blue Plan Network provider.  See the back of your identification card for telephone numbers to call to learn if a provider is a network provider.

 

 

Q. Why did Blue Cross and Blue Shield of Kansas develop Blue Choice?

 

A. Our customers were telling us they want more freedom of choice and unrestricted access to health care providers.  Blue Choice is designed to respond to both our customers’ needs and the demands of the health care marketplace.

 

 

Q. What is the incentive to receive care from a Blue Choice PPO Network provider?

 

A. When you receive services from a Blue Choice Network provider, you will receive the highest benefit payment level, in turn reducing your out-of-pocket costs.  There will be a significant difference in benefit payment levels should you seek care from a non-Blue Choice provider.

 

 

Q. What if I receive care from a non-Blue Choice Network provider?

 

A. If you seek care from a non-Blue Choice Network provider, but a provider that is contracting with Blue Cross and Blue Shield of Kansas, you will be responsible for an additional 20% coinsurance to a maximum of $2000 for each covered person, $4000 for a family each benefit period.  This amount is in addition to any deductible, coinsurance or shared payment amounts, and any non-covered services of the program.

 

 

Q. What if I receive services from a non-contracting provider?

 

A. If you seek care from a non-contracting provider, you will be responsible for the difference between the Blue Cross and Blue Shield of Kansas non-contracting provider allowance and the provider’s charge.  You will also be responsible for an additional 20% coinsurance to a maximum of $2000 for each covered person, $4000 for a family each benefit period.  This amount is in addition to any deductible, coinsurance or shared payment amounts, and any non-covered services of the program.

 

 

Q. What if I have a medical emergency?

 

A. If you have a medical emergency, you may seek care from any provider for the initial treatment and receive maximum benefits.  Any follow-up care must be received from a Blue Choice Network provider in order for those services to be paid at the maximum payment level.

 

Contact Information

 

Please refer any remaining questions to the Plan Administrator:

 

Joane Cook

Director of Payroll, Insurance, and Human Resources

Crawford County Clerk’s Office

PO Box 249

Girard, KS 66743

Telephone: (620) 724-6117

E-Mail: joanes@ckt.net