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Frequently Asked Questions General Benefit Questions Managed Care Questions Membership Questions General Questions About BCBSVT and Health Coverage General Benefit Questions What is a deductible? What is coinsurance? What is a co-payment? A deductible is an amount you must pay each calendar year before your Plan begins to pay for a particular service. Some programs (such as the Vermont Freedom Plan) have deductibles that apply to all services combined. For some services, we require you to share the cost of your services. The Plan may pay 80%, for example, while you pay 20%. This arrangement is called "coinsurance." We refer to your share (the 20% in our example) as your coinsurance amount. A co-payment is a per-service fee you pay. You pay co-payments when you receive prescription drugs, for example. We call co-payments for office visits and other professional care "visit fees." You pay a visit fee each time you visit a provider's office. Is there a difference between a Participating Provider and a PPO Provider? Yes and no. In the state of Vermont, we use our Participating network as our Preferred Provider network for PPO programs. So if you have a Vermont Freedom Plan PPO program, you may use Participating providers in Vermont and still get the highest level of benefits. If you travel outside the state for services, however, make sure that your provider is "Preferred" with the local BCBS plan. Some Blue Cross and Blue Shield Plans have two networks-one consisting of "Participating" providers and one of "Preferred" providers. How do I get Blue Cross and Blue Shield of Vermont coverage if I do not have insurance available through an employer? If you have no other group coverage available to you, you may be eligible for coverage through our "direct-pay" products. We designed these products specifically for individuals and families like you. Visit our Nongroup Coverage in the Contact Us section of the site. You'll find the name and phone number of a representative who can tell you more about our coverage. What's the difference between preadmission review, prior approval and prior authorization? Preadmission review (sometimes called "precertification") is our review to determine whether your inpatient admission is appropriate for your condition and/or the procedure you need. It is part of the Managed Benefit program. If your program includes managed benefits, you must call to initiate the review before you enter the hospital (preferably at least two weeks before your admission). For emergency and maternity admissions, we ask that you call within 24 hours after you are admitted. (In this case, it's called an "admission review.") If you do not get the appropriate reviews for an admission, you may have to pay a penalty. With most managed care programs, you do not need a preadmission review if you have a referral from your primary care physician. Prior approval (sometimes called prior authorization) happens after we review your service and determine it medically necessary. We require you to get prior approval for certain services. For example, most members must get prior approval before they receive mental health services or oral surgery. For other services, we merely recommend prior approval to ensure that our members do not receive services we don't consider medically necessary. For example, we encourage you to get prior approval for all reconstructive surgery to be sure we don't consider it cosmetic. Am I covered if I travel out of state? If you have a fee-for-service plan, like the Vermont Freedom Plan or the Comprehensive or JY plan, you may use any out-of-state provider. If the provider participates with his or her local BCBS plan, you should have your provider file the claim with the local plan. If the provider does not participate, you may have to pay up front for your services and submit the claim to us. If you have a Vermont Freedom Plan PPO plan, you should make sure your provider is "preferred" with the local plan in order to make sure you will get the highest level of benefits available under your program. If you have a managed care plan, like the Vermont Health Partnership or a TVHP BlueCare or BlueCare Options plan, you are covered only for emergency or urgent care when you are out of state. You should arrange for routine care or care for chronic conditions before you leave the state. What does the little suitcase on my card mean? That tells you and the providers you see that you are a member of the BlueCard program. When you are traveling out of state, you can go to providers who participate with us or with another Blue Cross and Blue Shield plan and they will accept the Allowed Price or other contractual allowance of the local plan. This saves you from paying any balances for which you might otherwise be billed. Also, you won't have to pay up front. The provider will bill the local plan for you and then we will reimburse that plan. If the suitcase on your card contains the initials "PPO" inside it, your must use "Preferred Providers" in order to get the best out of your benefits. In Vermont, we use our network of Participating Providers for our PPO plans, but in other states, you may be limited to a smaller provider network. Managed Care Questions What is a referral? A referral is a written authorization from a primary care physician. A managed care member must obtain a referral before seeking care with another provider. We must receive a copy of the referral and we must approve it or the managed care member will not receive the highest level (the Preferred level) of benefits under his or her program. BlueCare (HMO) members must receive referrals for most services to receive any benefits at all. How do I know if I need a referral to see a specialist? Check your contract documents for specifics about referrals. In general, managed care plans require you to get a referral for all specialty care except mental health and substance abuse treatment, routine vision care (if your coverage includes it) and oral surgery. For these services, you must get prior approval and use network providers. You may not need a referral for chiropractic benefits either. If you're not sure whether you need a referral, get one just to be sure. Some programs provide a lower level of benefits for some services if you don't get a referral. (The Vermont Health Partnership and BlueCare Options work this way.) Other plans (like BlueCare) don't pay any benefits at all if you don't follow referral guidelines. What do I do if I'm not comfortable with my Primary Care Physician? You can change your Primary Care Physician at any time. Do so by calling our customer service department at the number on the back of your I.D. card. Or fill out a new application form and forward it to us. Your change becomes effective on the first of the month after we receive your request. I have a child who is a student at an out-of-state institution. I have a managed care plan. How can I be sure she'll be covered? She's covered in emergency circumstances. You may want to check into what the university offers through its infirmary for urgent, but less serious, care – sore throats, infections, etc. Please be sure your daughter gets any care that can be scheduled while she's home on break. Membership Questions My daughter just turned 18. How long may she stay on my family membership? She may stay on your membership until her 19th birthday unless she is a full-time student. If she is a full-time student (taking 12 credit hours or more per semester), she may stay on until she's 25. To continue her coverage past her 19th birthday, you must provide us with the following information: · written notice of your daughter's student status on our Student Certification form; and · written proof of student status. If your daughter is still a full-time student on her 19th birthday and we receive the request to continue her coverage before the first of the month after her 19th birthday, she stays on your membership and won't have to meet any waiting periods for pre-existing conditions. My 21-year-old son has just become a full-time student. Can I get him back on my family membership? Yes, but waiting periods may apply for pre-existing conditions. (Check your contract materials or check with your group benefits manager to see if you have waiting periods.) If we receive your request for student status for your son within 60 days after he became a student, his coverage can be effective the first of the month after we receive your request. If we don't receive the request within the 60 days, you may have to wait until an open enrollment date to add the student to your membership. Do all BCBSVT contracts include coverage for domestic partners? No. Some larger groups may choose not to offer this type of coverage. All programs contain benefits for parties to a civil union, however. Is there a difference between domestic partner coverage and civil union benefits? Yes. Civil unions are treated just like marriages in our contracts. Domestic partners do not have the same rights as parties to a civil union. For example, if your group has an open enrollment, you may only add domestic partners to your membership at open enrollment time. You may add dependents that become eligible because of a civil union at any time within 60 days after the civil union. (If we receive your request within 31 days after the civil union, dependents receive coverage on the first of the month after the civil union. If we receive your request within 32 to 60 days after the civil union, coverage becomes effective the first of the month after we receive your request.) Neither domestic partners nor parties to a civil union qualify for COBRA coverage (due to Federal law). Parties to a civil union qualify for coverage under the Vermont continuation of coverage statute. Domestic partners do not. How do I add a dependent (or newborn child) to my policy? If you are a group subscriber-that is you get your coverage through an employer or other group-you must change your coverage through your group. You may be able to do so through an on-line service, but your group must be enrolled in this service. If you are a direct-pay, or "nongroup" subscriber, you should fill out an application and change form. You may find this form on our Publications site. Be sure to add dependents as soon as they become eligible. Your contract lists deadlines for additions to coverage after qualifying events such as birth, marriage, etc. What should I do if I am getting a divorce and need to update my membership? If you get your coverage through your employer, you must let your group benefits manager know that your spouse must be removed from the group membership. If you are a direct-pay subscriber, please fill out an application and change form and forward it to the Plan. You can download this form from the Publications section of this site. What do I need to do if I have another medical plan in addition to my BCBS plan? If you are covered by more than one health plan, you need to contact our Customer Service Department with this information so medical benefits can be coordinated. How soon after I begin a new job does my health coverage start? Your employer determines how soon after your employment date your coverage may start. Many employers have a three-month or six-month probationary period before they offer group coverage. (Check with your group benefits manager to find out your employer's policy.) Your coverage will likely start the first day of the month after your employer's probationary period ends. If your group has no probationary period, your coverage begins the first of the month after your date of hire. Blue Cross and Blue Shield of Vermont cannot start coverage in the middle of a month. General Questions About BCBSVT and Health Coverage What is Blue Cross and Blue Shield of Vermont (BCBSVT)? Blue Cross and Blue Shield of Vermont is a non-profit health service organization. We operate under guidelines set up by the state of Vermont to provide health coverage for Vermonters. For more information about the plan, visit our corporate information site. What is the address of Blue Cross and Blue Shield of Vermont? Our mailing address is P.O. Box 186, Montpelier, VT 05601-0186. Our office is at 445 Industrial Lane in Berlin, Vermont. What are your regular business (customer service) hours? We are generally open from 8 a.m. to 4:30 p.m., although some business units and individuals may work slightly different hours under flex-time arrangements. Our service units stop taking new calls at 4:15 p.m. What is your Customer Service Center telephone number if I have a question? We have several different customer service numbers. You may find the one that applies to your group or contract on the back of your I.D. card. In general, fee-for-service customers (Vermont Freedom Plan, Basic and Comprehensive members) should call (800) 247-2583. Managed care subscribers should call (800) 344-6690. TVHP (BlueCare and BlueCare Options) members should call (888) 882-3600. What is an HMO? A health maintenance organization is a type of managed care program where you get all of your care from a network of doctors and hospitals. One doctor manages your care and helps you get preventive services and specialty care when you need it. Why choose an HMO? HMOs can be very affordable-especially for preventive care and other primary care services. In fact, The Vermont Health Plan's BlueCare and BlueCare Options programs provide preventive care with no co-payments for members. How does an HMO work? HMOs all work in slightly different ways. But, in very general terms, the health plan pays your "primary care physician," whom you select when you join the plan, a certain amount of money with the understanding that this physician will provide you with most of the care you need and manage any of your care that he or she cannot provide. This sum is called a "capitation." The Vermont Health Plan's BlueCare HMO arranges for some specialty care in its capitation, since TVHP contracts with physician-hospital organizations to provide care for its members. This differs from a fee-for-service arrangement, where doctors and hospitals receive fees for each visit or procedure you need. What is a Point -of-Service (POS) plan? A Point-of-Service plan has two levels of benefits-one that applies when you follow the Plan's managed care guidelines and one that applies when you choose not to follow these guidelines. (We call these levels "Preferred Benefits" and "Standard Benefits.") You may decide before each episode of care whether you want to follow guidelines or accept the Standard level of benefits. You decide at the "point of service." |
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