How Georgia Health Insurance Benefits Work

Note: Capitalized terms such as Covered Services, Medical Necessity, Network Hospitals and Out-of-Pocket Limit are defined in the "Definitions" section.

Introduction

BlueChoice Healthcare Plan is a comprehensive plan that provides Primary and Referral health care services. All In-Network Care must be received from or coordinated through your Primary Care Physician. Direct Access In-Network is available for a gynecologist for obstetrical or gynecological-related conditions, a dermatologist, a chiropractor, and an optometrist or ophthalmologist for medical conditions only. All Covered Services must be Medically Necessary, and coverage or certification of services that are not Medically Necessary may be denied.

Physicians and Hospitals participating in BCBSHP's networks are compensated using a variety of payment arrangements, including capitation, fee for service, per diem, discounted fees, and global reimbursement.

Eligible Charges
For In-Network services, Eligible Charges are determined by: (a) BCBSHP's negotiated arrangements; (b) pre-determined fee schedules; and (c) the applicable Reimbursement Rate. For Out-of-Network services, Eligible Charges are determined by : (a) BCBSHP's Usual, Customary and Reasonable (UCR) Fees; (b) a Provider's contracted fee schedule; (c) the applicable Reimbursement Rate; or (d) negotiated fees. Reimbursement for Out-of-Network, Participating and Non-Participating Providers is based on Eligible Charges for the type of service a Participant receives, for example, Hospital or Physician services.

Copayment
A Participant will be charged a Copayment amount for certain services; the Copayment amount is a flat-dollar amount. Copayment amounts are shown in the Summary of Benefits. The emergency room Copayment is waived if a Participant is admitted to the Hospital through the emergency room.

Calendar Year Deductible
Before your program begins to pay benefits, you must meet any Deductible required. Deductible requirements are stated in the Summary of Benefits.

Coinsurance and Out-of-Pocket Limit
The percentage payable by the Claims Administrator is stated in the Summary of Benefits. The portion which you must pay (the Coinsurance) is stated in the Summary of Benefits. After you reach your Out-of-Pocket Limit, (including any required Deductible), your Plan pays 100% of Eligible Charges for the remainder of the Calendar Year. Copayments do not apply to the Out-of-Pocket Limit.

Mental Health Care and Substance Abuse Treatment
The percentage payable for Mental Health Care and Substance Abuse Treatment is stated in the Summary of Benefits. Limitations, if any, are stated in the Summary of Benefits.

Pre-Admission Certification (PAC)

Hospital Pre-certification

The Pre-Admission Certification Process

• Length-of-Stay Assignment indicates the number of Inpatient days usually Medically Necessary to treat a condition;
• Continued Stay Review/Concurrent Review determines whether a continued Inpatient stay is Medically Necessary;

If your stay exceeds the number of days assigned under this Plan, the Hospital's charge for additional days beyond the assigned length of stay will not be paid. If all Primary Care Physician or Referral Specialist guidelines are followed, you will not be responsible for any eligible Hospital charge in excess of any applicable Deductible, Copayment or Coinsurance amounts.

• Admission Review determines whether an unscheduled Inpatient admission or an admission not subject to pre-certification was Medically Necessary;
• Discharge Planning assesses the Participant's need for additional treatment after Hospital discharge.

In-Network Care

• If you are hospitalized other than in a Medical Emergency and pre-admission certification was not obtained, all charges will be denied. You will be held harmless if all Network guidelines are followed. This means you will not be responsible for any bill in excess of the Deductible, Copayments or Coinsurance that apply.
• Ineligible Charges and Non-Covered Services are always the Participant's responsibility.
• PAC is the responsibility of the admitting Physician.

Pre-Admission Certification is a guarantee of payment Admissions are approved only when the appropriateness of the Inpatient setting can be substantiated. Actual payment is based upon eligibility for coverage and the Effective Date for any Participant, and also will be dependent on, but not limited to, specific Group coverage and the status of the coverage on the date services are rendered. The Plan will not cover services related to specific Plan exclusions and limitations, including but not limited to, Custodial Care, Experimental and Investigational procedures and services determined not Medically Necessary.