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Comprehensive Plan Glossary
Better Beginnings Program
Better Beginnings helps babies get the best start in life by providing their parents with educational materials, such as popular books and CPR classes. We also cover skilled nursing and housekeeping visits to help parents after their babies leave the hospital. Throughout a pregnancy, our nurses keep in touch with a mom-to-be to ensure she's getting the best possible care and the benefits to cover it. To join the program, a member should call our customer service department during the first trimester of her pregnancy. Our Better Beginnings representative will then mail a starter kit to the member.
Your Contract
In addition to your Identification Card, your contract documents include:
Certificate of Coverage: Your Certificate of Coverage is the document that describes the services your plan covers, how to file claims, membership guidelines and other terms and conditions of your coverage. It also contains a list of excluded services and supplies.
Outline of Coverage: Your Outline of Coverage is the part of your contract that describes payment terms and benefit limitations. It also lists any riders or endorsements that apply to your contract.
Riders or Endorsements: Riders and endorsements, if any, listed on your Outline of Coverage, are documents that amend your Certificate or Outline of Coverage.
Deductible, Coinsurance and the Out-of-Pocket Limit
Most coverage types require members to share costs through deductible and coinsurance for some or all services. Under your Comprehensive plan, your coverage has a deductible you must meet each calendar year, then you and your health plan share expenses through coinsurance. To protect you and your family during serious illness or other lengthy treatment, your plan limits your potential share of deductible and coinsurance each year. This financial protection is called the out-of-pocket limit.
Your annual deductible plus your coinsurance amount equals your out of pocket limit. Step by step, here's how it works, using a plan with a $500 out-of-pocket limit as an example:
Let's say your annual deductible is $100. (Deductible amounts may vary. Read your Outline of Coverage to see your plan's deductible amount.) You must meet this deductible first before we pay benefits. We apply the first $100 in charges you or your provider submit to us each year to this deductible. You pay your provider for charges we've applied to your deductible.
Let's say you've met your deductible. Now we pay our share of the coinsurance, typically 80%, for covered charges submitted to us. (Coinsurance amounts vary. Read your Outline of Coverage to see what your coinsurance rate is.)You pay your share of the coinsurance, which is 20% of the next $2,000 in covered charges. That's $400.
When you've paid $500 in coinsurance, you've reached your out-of-pocket limit. (Out-of-pocket limits vary. Read your Outline of Coverage to see how much your out-of-pocket limit is.) Now your deductible and coinsurance payments, combined, total $500. We'll pay your covered charges in full for the rest of the calendar year.
Emergency Medical Condition
Our subscriber contracts define an emergency medical condition as the sudden and, at the time, unexpected onset of an illness or medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by the prudent layperson, who possesses an average knowledge of health and medicine, to result in:
| | | | | | • | placing the member's physical or mental health in serious jeopardy; or
| | • | serious impairment to bodily functions; or
| | • | serious dysfunction of any bodily organ or part.
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Managed Benefit Program
The Vermont Freedom Plan includes a Managed Benefit Program to help ensure that you receive the most appropriate medical care at the most reasonable costs. When you follow the Vermont Freedom Plan's managed benefit guidelines, you become more educated and knowledgeable about the cost of your health care. This, in turn, helps to keep the overall costs of health care lower for everyone enrolled in the program. Components of the Managed Benefit Program include Preadmission Review, Admission Review, Continued Stay Review and Individual Case Benefits Management, described below.
Preadmission Review
Preadmission Review You or your physician must call us and have your case reviewed by our Medical Services Department as soon as possible (preferably two weeks) before a scheduled, nonemergency inpatient admission. One of our nurse or physician reviewers will help determine if:
| | | | | | • | The admission meets our guidelines for medical necessity
| | • | The proposed length of stay is appropriate
| | • | Another setting for treatment is more appropriate
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Diversion to an alternate facility is possible If we approve your inpatient stay, we will send a confirmation letter to you, your physician and the facility where you will receive care. For Preadmission Review, call (800) 922-8778. If you don't call for approval, you may have to pay up to $100 in inpatient charges, in addition to any deductible and coinsurance you owe.
Admission Review
If you are admitted to the hospital for an emergency or maternity condition, you must contact us within 48 hours after admission, or as soon as reasonably possible. Call (800) 922-8778. If you don't call for approval, you may have to pay up to $100 in inpatient charges in addition to any deductible and coinsurance you owe.
Continued Stay Review
If you are admitted to the hospital for an emergency or maternity condition, you must contact us within 48 hours after admission, or as soon as reasonably possible. Call (800) 922-8778. If you don't call for approval, you may have to pay up to $100 in inpatient charges in addition to any deductible and coinsurance you owe.
Continued Stay Review
Continued Stay Review assures that continuation of inpatient care is medically necessary and best meets the treatment needs of the patient. Throughout your inpatient stay, our nurse reviewers gather information about your progress. They evaluate your need for continued hospitalization and stay in touch with both your physician and the hospital. They also participate at treatment team meetings, assisting with benefit coordination to facilitate quality case management. When hospitalization is no longer medically necessary, the nurse reviewers work with you, your doctor and the hospital to identify continued care issues after discharge. If you choose to stay in an inpatient facility longer than your attending physician and Blue Cross and Blue Shield of Vermont determine to be medically necessary, you may have to pay all charges for services you receive after you could have left the hospital.
Individual Case Benefits Management
Our trained professionals work with providers to ensure that patients who have catastrophic illnesses or injuries receive necessary care in a facility best suited for the diagnosis. We direct benefit dollars toward quality health care and treatment options that are cost-effective. We may, in certain circumstances, provide benefits for alternative care that is not normally covered.
Room and board includes:
| | | | | | • | Semi-private room (a room with two or more beds)
| | • | A bed in a special care unit if you are critically ill
| | • | Meals
| | • | General nursing
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