More Information on Georgia Health Insurance Benefits

Hospice Care Services Hospice benefits cover Inpatient and outpatient services for patients certified by a Physician as terminally ill with a life expectancy of six months or less.

• Your Plan provides Covered Services for Inpatient and outpatient Hospice care under certain conditions as stated in the Summary of Benefits. The Hospice treatment program must:
• • Be recognized as an approved Hospice program by the Claims Administration;
  • Include support services to help covered family members deal with the patient's death; and
  • Be directed by a Physician and coordinated by an RN with a treatment plan that:
  • • provides an organized system of home care;
    • uses a Hospice team; and
    • has around-the-clock care available.

Hospital Services (Network)
For In-Network care, your Physician must arrange your admission. Your Plan provides Covered Services when the following services are Medically Necessary.

• In-Patient
  
  In-Patient Hospital Services
  • Inpatient room charges. Covered Services include Semiprivate Room and board, general nursing care and intensive or cardiac care. If you stay in a private room, Eligible Charges are based on the Hospital's prevalent semiprivate rate. If you are admitted to a Hospital that has only private rooms, Eligible Charges are based on the Hospital's prevalent room rate.
  Service and Supplies
  • Your benefits cover services and supplies provided and billed by the Hospital while you are an Inpatient, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, x-ray examinations, and radiation therapy, speech therapy and occupational therapy are also covered.
  • Convenience items (such as radios, TV's, record, tape or CD players, telephones, visitors' meals, etc.) will not be covered.
  Length of Stay
  • Determined by Medical Necessity.
  
  Outpatient
  
  Outpatient Services
  • Your Plan provides Covered Services when the following outpatient services are Medically Necessary: Pre-admission tests, surgery, diagnostic x-rays and laboratory services. Certain procedures require pre-certification from the Claims Administrator.

Hospital Visits
The Physician's visits to his or her patient in the Hospital.

Individual Case Management
The individual case management program is designed to ensure and provide payment of benefits to eligible Participants who, with their attending Physician, agree to treatment under an Alternative Benefit Plan intended to provide quality health care under lower cost alternatives. Such benefits will be determined on a case-by-case basis, and payment will be made only as agreed to under a written alternative benefit plan for each Plan Participant.

• The program includes:
• the identification of potential program participants through active casefinding and referral mechanisms;
• eligibility screening;
• preparation of alternative benefit plans;
• subsequent to the approval of the parties, transfer to alternative treatment settings in which quality care will be provided.

Eligibility
A Participant receiving benefits under an alternative benefit plan may, at any time, elect to discontinue the plan and revert to regular Plan benefits.

BCBSGA is responsible for determining eligibility for cases to be included in the program.

The Participant-or legal guardian or family member, if applicable-and the attending Physician must consent to explore with the Claims Administrator the possibilities of transfer to an alternative treatment setting and, prior to implementation, agree to the alternative benefit plan.

Benefits

Benefits will be determined on a case-specific basis, depending on the plan of treatment, and may include Covered Services under the applicable Plan.

Services will be covered and payable as long as the treatment is required as outlined in the alternative benefit plan, and is less expensive than the original treatment plan which otherwise would have been followed. The Plan Administrator will determine the maximum approved payments allowable under the Plan.

Benefits under the Plan are furnished as an alternative to other Plan benefits and are limited to the following:

• Services, equipment and supplies which are approved as Medically Necessary for the treatment and care of the Participant.
• Non-structural modifications to the home which are required to meet minimum standards for safe operation of equipment.
• When necessary for the long term care of the Participant in the home-setting, Respite Care to relieve family members or other persons caring for the Participant at home. (The Respite Care benefit can be credited at a rate of 24 hours for every month of care rendered in the home setting, and may be reimbursed for up to 6 consecutive days at a time. The Plan Claims may approve on an exception basis up to 5 days per month of Respite Care when medical review of the case indicates that such action is appropriate. Payments for Respite Care will be deducted from the Participant's remaining available benefits under the Plan.)

The Participant must obtain pre-certification from the Claims Administrator regarding the treatment plan and proposed setting to be utilized during the Respite Care period.

Potential cases include but are not limited to:

• spinal cord Injury;
• severe head trauma/coma;
• respiratory dependence;
• degenerative muscular/neurological disorders;
• long term IV antibiotics;
• premature birth;
• burns;
• cardiovascular accident;
• cancer;
• accidents;
• terminal illnesses;
• other cases at the Plan's discretion.

Covered Services

• Services covered under individual case management will be determined by the Plan on a case-by-case basis. Benefits may be provided for the rehabilitation of a Participant on an Inpatient, outpatient, or out-of-Hospital basis, as long as they are Medically Necessary, support the plan of treatment, and ensure quality of care.
• The program may provide or coordinate any of the types of Covered Services provided pursuant to this SPD Booklet.
• At its sole discretion, in the context of an individual case management program, the Plan may also provide or arrange for alternative services or extra-contractual benefits which are either (i) excluded by this SPD Booklet; (ii) neither excluded nor defined as Covered Services under this SPD Booklet, or (iii) exceeding the maximum for any Covered Service under this SPD Booklet.

Utilization

• Benefits will be provided only when and for as long as the Plan deems they are Medically Necessary. The approved alternative benefit plan of treatment will establish which benefits will be provided and for how long, and shall be subject to pre-certification and continuing review for Medical Necessity as set forth in such plan for treatment.
• The total benefits that may be paid will not exceed those which the Participant would have otherwise have received in the absence of individual case management benefits.

Exclusions

• Rehabilitation or Custodial Care for chronic (recurring) conditions that do not, in BCBSHP sole discretion, significantly improve in an observable way within a reasonable period of time will not be a covered benefit under the individual case management program.

Individual Case Management Definitions

Case Manager
The person designated by the Claims Administrator to manage and coordinate the Participant's medical benefits under the individual case management program.

Provider
A Provider may be any facility or practitioner including, but not limited to Ineligible Providers, licensed or certified to give services or supplies consistent with the Plan of Treatment and approved by the Claims Administrator.

Termination of Individual Case Management
Services in the alternative benefit plan approved by the Claims Administrator under individual case management will cease to be Covered Services under this Plan when:

• Extra-contractual benefits or alternative services are no longer Medically Necessary, as determined by the Plan Sponsor, due to a change in the patient's condition, or
• The total amount of benefits paid for such services and for all other Covered Services equals the Lifetime Maximum Benefit.

Licensed Speech Therapist Services
The Participant must obtain pre-certification from the Claims Administrator. Services must be ordered and supervised by a Physician as outlined in the Summary of Benefits. Developmental Delay will be covered when it is more than two standard deviations from the norm as defined by standardized, validated developmental screening tests such as the Denver Developmental Screening Test. Services will be covered only to treat or promote recovery of the specific functional deficits identified.

Maternity Care
Covered Services include Maternity Care on the same basis as for any other type of care, subject to your Plan's Copayment and/or percentage payable provisions.

Maternity benefits are provider for a female employee or for the Spouse of a male employee. Maternity benefits are NOT provided for Dependent children.

Routine newborn nursery care is part of the mother's maternity benefits. The newborn pediatrician visit in the Hospital is covered In-Network.

Should the newborn require other than routine nursery care, the baby will be admitted to the Hospital in his or her own name (see "Changing Coverage" to add coverage for a newborn).

Under federal law, the Plan may not restrict the length of stay to less than the 48/96 hour periods or require prior certification for either length of stay. The length of hospitalization which is Medically Necessary will be determined by the mother's attending Physician in consultation with the mother. Should the mother or infant be discharged before 48 hours following a normal delivery or 96 hours following a cesarean section delivery, the mother will have access to two post-discharge follow-up visits within the 48- or 96-hour period. These visits may be provided either in the Physician's office or in the mother's home by a Home Health Care Agency. The determination of the medically appropriate place of service and the type of provider rendering the service will be made by the mother's attending Physician.

Prenatal care visits: only one (1) Copayment for all visits combined will be charged.

Medical and Surgical Care
General care and treatment of illness or Injury, and surgical diagnostic procedures including the usual pre- and post-operative care.

Non-Contracted Freestanding Ambulatory Facility
Any Covered Services rendered or supplies provided while you are a patient or receive services at or from a Non-Contracted Freestanding Ambulatory Facility will be payable at 50% of Eligible Charges.

Nutritional Counseling
Nutritional counseling related to the medical management of certain disease states (subject to pre-certification by the Claims Administrator).

Nutritional Counseling for Obesity
Covered Services for obesity include up to two nutritional counseling visits when referred by your Primary Care Physician. Prescription Drugs and any other services or supplies for the treatment of obesity are not covered.