MEMBER GUIDE - 4StudentHealth.com
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WELCOME TO BLUE KC By choosing Kansas City's health insurance leader, you've started on the path toward a healthier life. Besides giving you healthcare choices that fit the way you live, Blue Cross and Blue Shield of Kansas City (Blue KC) helps you navigate your healthcare process, and shows you how to get the greatest benefits from your plan. Let's get acquainted. The materials in this enrollment booklet were compiled for you, and represent your health plan. Please review the following pages thoroughly, and file this in a safe place for reference later. The information contained in this Member Guide is intended for summary purposes only. For full details regarding the terms and conditions of your specific health plan and benefits, please consult the Plan document for your plan which is available from Blue KC or your employer. 3
MyBlueKC.com YOUR BLUE KC MEMBER ID CARD The Blue Cross and Blue Shield of Kansas City 5 (Blue KC) member ID Card is your key to unlocking all the coverage and benefits your plan has to offer. 1 You can present your card anytime you visit your doctor, receive healthcare services or fill 2 6 a prescription. It contains information healthcare 3 professionals need to make sure your care 4 is covered. 7 Understand Your Member ID Card 1. Member ID Number – This is the number we use to identify You can quickly view, print or email a copy of your member ID card you and your policy. It’s also what providers use to file claims from your member portal at MyBlueKC.com. on your behalf. 2. Group Number – This number is used to classify our members into groups, usually by the employer they receive their plan from. 3. Plan Type – This describes what type of insurance plan you have (for example, a PPO plan). 4. Customer Service Phone Number – Call this number when you have a question about your Blue KC policy. Our Customer Service staff is available Monday through Friday from 8 a.m. to 8 p.m. Central Time. 5. Network Name – This is the network of hospitals, physicians and pharmacies that accept your Blue KC policy. It’s important that you see healthcare providers who are in your network to ensure you maximize the benefits of your policy. 6. Copayment – The amount you pay each time you receive a covered healthcare service. 7. Suitcase – Some Blue KC members have access to our “BlueCard” program, which extends the benefits of your Blue KC plan to all 50 states. Find a Doctor The Blue KC Doctor and Hospital Finder makes finding an in-network doctor, hospital or other healthcare provider quick and easy. In addition to viewing basic information, such as medical school attended, residency completed and board certification status, you can also read patient reviews, rate your doctor and view costs and treatment timelines for common procedures. To view the most accurate information related to your network, be sure to first log in to MyBlueKC.com. By doing so, the results from the Doctor and Hospital Finder will be tailored to your specific Blue KC network. 6
Important Resources YOUR MEMBER PORTAL ON MYBLUEKC.COM You deserve to enjoy all the benefits of being a Blue KC member, and our member portal can help you find just what you need. Simply register online at MyBlueKC.com to take advantage of the tools and information available to you. 5 2 1 3 4 1. Plan Benefits – View your medical contract, summary of 4. Find Care – This is where you can access the Blue KC Doctor benefits and coverage, and more. If your Blue KC policy and Hospital Finder. See which healthcare providers are includes pharmacy benefits, you'll have tools to help you covered by your network, and search for ones who can meet locate a pharmacy, learn about the differences between your specific needs. From this section you can also search for generic and brand name medications, save on prescriptions a pharmacy or dentist. and access the Blue KC Prescription Drug List. 5. Ask Us – Get answers to questions about your Blue KC policy 2. Claims & Usage – Check the status of your claims and export or health insurance in general. a list of past claims. You can view a copy of your Explanation of Benefits, which you receive after every visit to a healthcare provider. This section also includes graphs to illustrate your plan usage. 3. Health & Wellness – We’re proud to offer a variety of resources to help you stay healthy and live well. Learn more about our A Healthier YouTM wellness program and Healthy CompanionTM condition management program. 7
MyBlueKC.com HOW TO READ YOUR EXPLANATION OF BENEFITS (EOB) When you visit a doctor or hospital, they work with Blue KC to file a claim on your behalf. These claims are outlined on your EOB. It’s your go-to reference for important information like how much of your care was covered and how much you may still need to pay. 1 07/06/2016 08/14/2016 07/06/2016 08/14/2016 2 3 2016 5 6 8 11 12 7 9 10 4 07/06/2016 13 2016 8
Important Resources 1. Member Information Section – Information about you and 8. Allowable Charges – This is the total of the claim after all your recent claim. discounts and other reductions. Deductible and coinsurance amounts are calculated from this figure. 2. This Is Not A Bill – Your EOB is just a documentation of how Blue KC has processed your claim. If you do receive a bill from 9. Copay – The amount a member must pay each time a your provider, you can use your EOB to ensure the amount specific covered service is received, if your policy includes billed is correct based on your Blue KC coverage. copayments. 3. Narrative – A brief overview of how your claim was 10. Deductible – The portion of the claim being applied to your processed. plan deductible. This amount must be paid by you before benefits become payable by Blue KC. 4. Claim-at-a-Glance – A simple equation to show how your claim is paid. Please review the Detailed Explanation section 11. Coinsurance – The percentage of an allowable charge you for further details. must pay for a covered service. Generally, the deductible must be met before your coinsurance applies. 5. Detailed Explanation of this Claim – This area combines critical payment information into one convenient summary. 12. Plan Payment – This is the amount that Blue KC will pay to Please review this carefully as it clearly outlines the Blue KC the provider or member for the claim. negotiated savings as well as any fees and services for which 13. Deductible Information – This area documents what your you are responsible. deductible status was at the time the claim was processed. 6. Blue KC Member Savings – Blue KC has negotiated these Many times, this information will be outdated by the time you savings with providers on your behalf. This is one of the most receive an EOB. You can get your most recent and up-to-date valuable aspects of having coverage with Blue KC. deductible information in your member portal at MyBlueKC.com under the Benefits section. 7. Other – Amounts deducted from the Billed Charges for a variety of reasons. Amounts in this column may reduce your out-of-pocket expenses. Your Explanation of Benefits (EOB) online Your EOBs are always available in your member portal on MyBlueKC.com, under the Claims & Usage section. WANT YOUR EOB ELECTRONICALLY INSTEAD OF VIA MAIL? If you want to opt-out of receiving paper copies of your EOB, simply manage the communication preferences in the profile section of your member portal on MyBlueKC.com. 9
MyBlueKC.com THE BLUECARD PROGRAM Across the Country and Around the Globe With your Blue KC member ID card, you can stay covered no matter where life takes you. Available for Blue KC PPO & EPO plans only Your Blue Cross and Blue Shield of Kansas City (Blue KC) membership gives you a world of healthcare choices across the country and around the globe. Follow these simple steps to put the power of Blue KC coverage to work for you. Locate doctors and hospitals With your Blue KC member ID card handy, follow these steps: • Visit the Blue National Doctor & Hospital Finder at BCBS.com • Call BlueCard Access at 1-800-810-BLUE (2583) to get info about doctors and hospitals in your area If you’re a PPO member, always use a BlueCard PPO doctor or hospital to make sure you receive the highest level of benefits. HMO members only have out-of-network benefits in the case of an emergency or when prior authorized by Blue KC. 10
In the United States Around the World 1. Always carry your current Blue KC ID card. 1. Verify your international benefits with Blue KC before leaving the United States as coverage may be different 2. Find a nearby doctor or hospital using the methods listed on outside the country. previous page. 2. Always carry your current Blue KC member ID card. 3. Call Blue KC for precertification or prior authorization, if necessary. The phone number is located on your Blue KC 3. Call the Blue Cross Blue Shield Global Core (BCBS member ID card. Global Core) at 1-800-810- BLUE (2583) or call collect at 1-804-673-1177 to locate a doctor. An assistance 4. When you arrive at the participating doctor’s office or hospital, coordinator will arrange a physician appointment or show the provider your ID card. The provider will identify your hospitalization if necessary. This line is available 24/7. benefits through one of these symbols: 4. Please see below for steps that should be taken for inpatient and professional services. Inpatient claim: In most cases, you should not need to pay upfront After you receive care, you should: for inpatient care at participating BCBS Global Core hospitals except for the out-of-pocket expenses (non-covered services, deductible, • Not have to complete any claim forms copay and coinsurance) you normally pay. The hospital should • Not have to pay upfront for medical services, except for submit the claim on your behalf. In addition to contacting the the usual out-of-pocket expenses (non-covered services, BCBS Global Core Service Center, call Blue KC for precertification deductible, copay and coinsurance) or preauthorization. Refer to the phone number on your Blue KC • Receive an explanation of benefits from Blue KC member ID card. Note: This number is different from the phone number listed above. PPO Benefits Professional claim: You pay upfront for care received from a doctor and/or non-participating hospital. Complete a BCBS Global Core BCKC NAME PPO International claim form and send it with the bill(s) to the BCBS ® ID#: YBW08T600050 SUFFIX: 00 Global Core Service Center (the address is on the form). The claim Traditional/Indemnity Benefits form is available from Blue KC, the BCBS Global Core Service GROUP#: 30100000 EMERG ROOM URGENT CARE Center or online at bcbsglobalcore.com. PLAN: HMO OFFICE VISIT ® SMITH, JOHN SPECIALIST 816-000-0000 INPATIENT CUSTOMER SERVICE: OUTPATIENT IN AN EMERGENCY, GO TO THE NEAREST HOSPITAL. 816-000-0000 / 000-000-0000 RXBIN: 003858 PCN: A4 Group KCBA Blue KC HMO plan members can leverage the Away From Home program, which provides convenient healthcare coverage while you are away from your Home HMO. Contact your Blue KC Representative for more information. 11
MyBlueKC.com MOBILE TOOLS TO STAY CONNECTED Our mobile site is designed to give you access to our most frequently used tools. Whether you simply need to find a doctor quickly or have a moment to check on a claim, it’s all at your fingertips. Once logged in, take a look at how easy it is to access these tools and manage your healthcare even when you’re on the go. Go to MyBlueKC.com on your phone Find Care Search for providers and find the most up-to-date and accurate information about doctors and hospitals in your Blue KC network. Claims & Usage A quick way to take a look at past claims and check on the status of current ones. ID Cards Quickly view, print or email a copy of your member ID card. 12
Important Resources ROUTINE PREVENTIVE SERVICES Covered by Your Blue KC Health Plan Information about in-network routine preventive care and the related office visit. Routine preventive services In-network routine preventive care services and the related office visit for routine preventive care services is covered at 100%. Services must be billed with a primary diagnosis of preventive to be covered at 100%. Routine preventive care services are subject to the terms, conditions and limitations of your Contract/Certificate of Coverage. Not all plans will cover all preventive services at 100%, so be sure to consult your Certificate of Coverage for details. Your provider may order tests during your preventive care visit that are not preventive care. These tests may be subject to deductibles, copays and/or coinsurance. Your provider may also treat an existing condition (or you may have symptoms of an illness at the time of your visit). Treatment or tests for that existing condition are not preventive care and are subject to deductibles, copays and/or coinsurance. Prostate exams and prostate specific antigen (PSA) tests Additional examinations, testing and services: Pelvic exams and pap smears1, including those performed at the direction • Hemoglobin/Complete Blood Count (CBC) of a Physician in a mobile facility certified by Centers for Medicare and • Metabolic screening1 Medicaid Services (CMS) • Hearing exams Mammograms if ordered by a Physician, including those performed at the Immunizations: direction of a Physician in a mobile facility certified by CMS Covered Immunizations are limited to the parameters recommended Colorectal cancer exams1 and laboratory tests consisting of a digital rectal by the Advisory Committee on Immunization Practices and/or adopted exam and the following: Fecal occult blood test, Fecal DNA test, by the Center for Disease Control.1 Flexible sigmoidoscopy, Colonoscopy; Double contrast barium enema • Catch-up for Hepatitis B • Catch-up for varicella Newborn hearing screening, audiological assessment and follow-up, and • Catch-up for MMR initial amplifications • Tetanus boosters as necessary, including tetanus, diphtheria and Childhood Immunizations1 pertussis; diphtheria and tetanus; and tetanus only • Pneumococcal vaccine • At least 5 doses of vaccine against diphtheria, pertussis,tetanus; • Influenza virus vaccine • At least 4 doses of vaccine against polio, Haemophilus Influenza • Meningococcal vaccine Type b (Hib); • Catch-up for Hepatitis A • At least 3 doses of vaccine against Hepatitis B; • HPV vaccine • 2 doses of vaccine against measles, mumps, and rubella; • Zoster vaccine • 2 doses of vaccine against varicella; • Polio vaccine • At least 4 doses of vaccine against pediatric pneumococcal (PCV7); • Haemophilus Influenza Type b (Hib) vaccine • 1 dose of vaccine against influenza; • At least one dose of vaccine against Hepatitis A; Urinalysis • 3 doses of vaccine against Rotavirus; Glucose screening • Such other vaccines and dosages as may be prescribed by the State Department of Health Thyroid stimulating hormone screening Lipid cholesterol panel Lead testing HIV screening Outpatient physician examinations1 HPV testing2 Chest x-ray Chlamydia Trachomatis testing Electrocardiogram (EKG) Gonorrhea testing 13
MyBlueKC.com One-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have Abdominal aortic aneurysm screening: men ever smoked. Clinicians screen adults age 18 years or older for alcohol misuse and provide persons engaged in risky or Alcohol misuse: screening and counseling hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in Aspirin to prevent cardiovascular adults aged 50 to 59 years who have a 10% or greater 10-year cardiovascular risk, are not at increased risk disease: adults for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. Screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks’ gestation or Bacteriuria screening: pregnant women at the first prenatal visit, if later. Screening for high blood pressure in adults age 18 years and older obtaining measurements outside of the Blood pressure screening: adults clinical setting for diagnostic confirmation before starting treatment. Primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with BRCA risk assessment and an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). genetic counseling/testing Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk Breast cancer preventive medication for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. Screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women Breast cancer screening age 40 years and older. Breastfeeding interventions2 Provide interventions during pregnancy and after birth to promote and support breastfeeding. Screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for Cervical cancer screening women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. Screening for chlamydia in sexually active women age 24 years or younger and in older women who are at Chlamydia screening: women1 increased risk for infection. Colorectal cancer screening Screening for colorectal cancer starting at age 45 years and continuing until age 75 years. All FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for Contraceptive methods and counseling2 women with reproductive capacity. Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth Dental caries prevention: infants and eruption in primary care practices. Primary care clinicians prescribe oral fluoride supplementation starting at children up to age 5 years age 6 months for children whose water supply is fluoride deficient. Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be Depression screening: adolescents implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. Screening for depression in the general adult population, including pregnant and postpartum women. Screening Depression screening: aduts should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 14
Important Resources Screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 Diabetes screening years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Falls prevention in older adults: exercise or Exercise or physical therapy to prevent falls in community-dwelling adults age 65 years and older who are at physical therapy increased risk for falls. Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at Falls prevention in older adults: vitamin D increased risk for falls. All women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 Folic acid supplementation to 800 µg) of folic acid. Gestational diabetes mellitus screening2 Screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. Prophylactic ocular topical medication for all newborns for the prevention of gonococcal Gonorrhea prophylactic medication: newborns ophthalmia neonatorum. Screening for gonorrhea in sexually active women age 24 years or younger and in older women who are at Gonorrhea screening: women increased risk for infection. Healthy diet and physical activity counseling Offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) to prevent cardiovascular disease: adults with risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity cardiovascular risk factors for CVD prevention. Hemoglobinopathies screening: newborns Screening for sickle cell disease in newborns. Hepatitis B screening: nonpregnant adolescents Screening for hepatitis B virus infection in persons at high risk for infection. and adults Hepatitis B screening: pregnant women Screening for hepatitis B virus infection in pregnant women at their first prenatal visit. Screening for HCV infection in persons at high risk for infection. Also recommends offering a 1-time Hepatitis C virus infection screening: adults screening for HCV infection to adults born between 1945 and 1965. HIV screening: nonpregnant adolescents Clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and and adults1 older adults who are at increased risk should also be screened. Clinicians screen all pregnant women for HIV, including those who present in labor who are untested and HIV screening: pregnant women1 whose HIV status is unknown. Hypothyrodism screening: newborns Screening for congenital hypothyroidism in newborns. Clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and Intimate partner violence screening: women of provide or refer women who screen positive to intervention services. This recommendation applies to women childbearing age2 who do not have signs or symptoms of abuse. Annual screening for lung cancer with low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening Lung cancer screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. Screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 Obesity screening and counseling: adults or higher to intensive, multicomponent behavioral interventions. Obesity screening and counseling: children Clinicians screen for obesity in children and adolescents age 6 years and older and offer them or refer them and adolescents to comprehensive, intensive behavioral interventions to promote improvement in weight status. Screening for osteoporosis in women age 65 years and older and in younger women whose fracture risk is Osteoporosis screening: women equal to or greater than that of a 65-year-old white woman who has no additional risk factors. 15
MyBlueKC.com Phenylketonuria screening: newborns Screening for phenylketonuria in newborns. Use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are Preeclampsia prevention: aspirin at high risk for preeclampsia. Rh incompatibility screening: Rh (D) blood typing and antibody testing for all pregnant women during their first visit for first pregnancy visit pregnancy-related care. Rh incompatibility screening: Repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks’ gestation, 24–28 weeks’ gestation unless the biological father is known to be Rh (D)-negative. Intensive behavioral counseling for all sexually active adolescents and for adults at increased risk for sexually Sexually transmitted infections counseling2 transmitted infections. Adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or Statin preventive medication: adults ages 40–75 ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when years with no history of CVD, 1 or more CVD risk all of the following criteria are met: 1) they are ages 40 to 75 years; 2) they have 1 or more CVD risk factors factors, and a calculated 10-year CVD event risk (i.e., dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a of 10% or greater cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults ages 40 to 75 years. Counseling children, adolescents, and young adults ages 10 to 24 years who have fair skin about minimizing Skin cancer behavioral counseling their exposure to ultraviolet radiation to reduce risk for skin cancer. Syphilis screening: nonpregnant persons Clinicians screen persons at increased risk for syphilis infection. Syphilis screening: pregnant women Clinicians screen all pregnant women for syphilis infection. Clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to Tobacco use counseling and interventions: adults who use tobacco. This includes two tobacco cessation attempts per year (both prescription and nonpregnant adults over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization. Clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. This includes two tobacco Tobacco use counseling: pregnant women cessation attempts per year (both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization. Clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco Tobacco use interventions: use in school-aged children and adolescents. This includes two tobacco cessation attempts per year (both children and adolescents prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in- network health care provider without prior authorization. Tuberculosis screening: adults Screening for latent tuberculosis infection in populations at increased risk. Vision screening at least once in all children ages 3 to 5 years to detect amblyopia Visual screening: children or its risk factors. Out-of-network services All services received from an out-of-network provider are subject to the out-of-network deductible and coinsurance, except for childhood immunizations, which are paid at 100%. This summary is being provided for informational purposes only, and is subject to change. 1 Indicates services that are required by the Affordable Care Act (ACA), but are already covered by Blue KC. 2 Indicates services that are required by the ACA as part of the Preventive Services for Women. This information is intended as a reference tool for your convenience and is not a guarantee of payment. Your provider has access to current diagnosis and procedure codes associated with these services for correct claims submission. 16
FINDING A PROVIDER 17
MyBlueKC.com FIND THE BEST CARE OPTION Where to Go for Medical Care Know your care options so you can make the best decision for you and your family. Your health and wellness are important to us. We want to help you make the best decision about where to go for medical care. The following guidelines and chart can help you determine when and where you should go to seek medical care. First Option: Primary Care Physician If you need medical care, but it is not an emergency, you should always call your Primary Care Physician (PCP) for an appointment. If you are not sure if your symptoms require emergency care, contact your PCP to help you evaluate your symptoms and determine where you need to go. Whether you receive care in an emergency room or at an urgent care center, you should notify your PCP of your visit when you can. Keeping your PCP informed is the best way to ensure he or she is aware of your medical history. Alternative Options: Urgent Care Center, Walk-In Clinic or Telehealth (Amwell) If you need to take care of a problem right away because you feel sick or uncomfortable, and you do not have a PCP or your PCP is not available, an urgent care center, walk-in clinic or telehealth visit Emergency Option: Emergency Room may be the next best option. Emergency rooms are set up to focus on medical emergencies, and not routine healthcare. When you go to the emergency room, Generally, urgent care centers offer walk-in service and are often a healthcare provider, who may not be familiar with your medical open before and after regular business hours and weekends. In history, will determine whether you need emergency care. We also most cases, an appointment is not necessary. want you to be aware that if you go to the emergency room for a problem that is not an emergency, it may cost you more. Additionally, Blue Cross and Blue Shield of Kansas City (Blue KC) expanded our network to include American Well (Amwell*), bringing you care wherever you are 24/7 – right in the palm of your hand. IMPORTANT – Members with serious or life-threatening injuries The Amwell mobile app can be downloaded directly to your phone or illnesses should be taken directly to an emergency room, or or tablet. Or, if you prefer the Web, visit Amwell.com. After creating call 911. You must notify Blue KC of any emergency hospital an account, you can view a list of available doctors and select one to admission within 48 hours of the admission time, or as soon engage in a secure live video visit. Tip: Be sure to select Blue KC as reasonably possible. from the plan drop-down list. *American Well’s online Care Group is an independent provider contracted to participate in Blue KC’s commercial provider networks. 18
Finding A Provider Guide to Finding the Best Care Option Primary Care Retail Walk-in Telehealth/ Urgent Care Emergency Physician Clinic Amwell Center Room Mild Asthma Minor Headaches Sprains, Strains Nausea, Vomiting, Diarrhea Bumps, Cuts, Scrapes Burning with Urination Coughs, Sore Throat Ear and Sinus Pain Eye Swelling, Irritation, Redness or Pain Minor Allergic Reactions Minor Fevers, Colds Rashes, Minor Burns Vaccinations Animal bites Stitches X-rays Back Pain Any life-threatening or disabling condition including difficulty breathing Sudden or unexplained loss of consciousness Chest pain, numbness in face, arm or leg; difficulty speaking Severe shortness of breath High fever with stiff neck, mental confusion or difficulty breathing Coughing up or vomiting blood Cut or wound that won’t stop bleeding Major injuries Possible broken bones * For many members, deductibles and coinsurance may also apply, which can make an even greater difference in the cost between an emergency room and other care options. 19
MyBlueKC.com DOCTOR AND HOSPITAL FINDER Access to High-Quality Healthcare Providers After logging in – Click Find Care on the left and then click Find a Doctor to access the Blue KC Doctor and Hospital Finder. Complete the following search fields: A B C A. Your Location – Select your search location (city, ZIP, etc.). B. Your Plan – Your plan’s network should display, but if it does not, you can find your network name at the top of your Blue KC member ID card. C. Select a Category – Search using many The Blue KC Doctor and Hospital Finder helps you make more categories, such as: informed decisions using many features like search filters, cost estimates, comparison options, provider reviews and • Doctors by name or specialty - Search by first quality information. or last name, or a specialty, such as “primary care physician” or “OB/GYN” Start your search • Places by name or specialty - Enter the name of Log into the Blue KC Doctor and Hospital Finder on MyBlueKC.com a hospital or clinic, or types of facilities near you to find the most up-to-date search results for doctors, hospitals or • Costs for procedures - Get cost estimates for other healthcare providers in your network. If this is your first time medical procedures, such as “MRI,” “flu shot” or logging in, you will need your Blue KC member ID card to reference. “eye exam” • Treatment timelines - Search treatment information for long-term medical conditions that include stages of healing, such as “total knee replacement” or “coronary bypass surgery” • Condition information - Search conditions such as “deviated septum” or "lumbar (low back pain)" and read medical information to find treatment options and doctors, which can provide insights into how you can lower your total costs and the support you might need 20
Finding A Provider Narrow your search results Compare providers Use filters to narrow your search results, such as by provider gender, distance, specialty and/or languages spoken. With your search results, you can select various providers or facilities to compare. • From your search results, select providers to compare. Use the “BDTC” filter to search for a • After selecting providers, view a side-by-side comparison of Blue Distinction Total Care doctor. each profile so you can see how they rank. Provider reviews Easily read and write provider reviews and rate your care on a scale Use the BDTC filter to find a Blue Distinction Total Care provider. of one to five stars. Your feedback helps doctors and staff make Use the Blue Distinction Specialties filter to find a healthcare improvements, plus, by rating your doctor, you will help others facility recognized for specialty care, such as cardiac care, knee/hip locate physicians with high patient satisfaction scores. Surveys are replacement, etc. NOTE: you must use the search term “hospital” confidential – doctors will not know you rated them. on the previous page in order to display these results. Blue Distinction Total Care (BDTC) doctors go above and beyond to enhance the overall health of their patients, providing preventive services Having Trouble? and health coaching, and supporting patients with Please call the Customer Service number found on your chronic conditions to better manage their care. Blue KC member ID card. 1 Designation as a Blue Distinction Total Care Provider means the Provider or Facility has met the established national criteria. To find out which services are covered under your policy, please log into your MyBlueKC.com member portal to access your member certificate. To Blue Distinction Centers (BDC) are facilities find out which providers are in your network, please use the Doctor and Hospital Finder on MyBlueKC.com. Blue KC is not responsible for any damages, losses, or non-covered charges awarded the Blue Distinction Centers and Blue that may result from using Blue Distinction or receiving care from a Blue Distinction or other provider. Distinction Centers+ designations for their proven 2 Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, history of delivering better quality and results for developed with input from the medical community. Blue Distinction Centers+ (BDC+) also the following areas of specialty care: met cost measures that address consumers’ need for affordable healthcare. Each provider’s cost of care is evaluated using data from its Local Blue Plan. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a • Bariatric Surgery, Cardiac Care, Complex provider’s in-network status, log into your MyBlueKC.com member portal and use the Doctor and Hospital Finder. To find out which services are covered under your policy, please log into and Rare Cancers, Knee/Hip Replacement, your MyBlueKC.com member portal to access your member certificate. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or Maternity Care, Spine Surgery and Transplants other losses or damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers. 21
BRINGING HOME GREAT CARE 23
MyBlueKC.com IMMEDIATE ACCESS TO CARE Telehealth Online Doctor Visits Live and immediate 24/7 access to care for common medical issues. SAVE TIME WITH AMWELL TELEHEALTH VISITS Blue Cross and Blue Shield of Kansas City (Blue KC) wants to improve your access to care. That’s why we’ve expanded our networks to include American Well (Amwell)1, a service that can bring you care from the comfort and convenience of your home or wherever you are. Amwell is available to most Blue KC members (Medicare Advantage members do not have access). Use this service for easy access to care for common medical issues like cold, flu, fever, abdominal pain, migraines, possible ear infection, rash and sinusitis. Amwell visits are considered “urgent care” and will process according to your urgent care benefits, cost sharing or copay unless otherwise noted in your member certificate.2 Get started today 1. Download the Amwell Mobile App or visit Amwell.com. 2. Create an account in a few simple steps. Be sure to use your Blue KC member ID card in order to input your insurance information. Also be sure to choose Blue KC from the plan drop-down list. 3. View a list of available doctors, their experience and ratings, and then select one that works for you. 4. Stream a live visit directly from the Web or your mobile device. TELEHEALTH BENEFITS Open 24 Hours Safe & Secure Doctors are available 24 Your information is kept hours a day, 365 days a year. private throughout the visit. Care that Goes Anywhere Install the Amwell mobile app and No Appointments access healthcare from anywhere, Just sign in – no more anytime. waiting rooms. To learn more about Amwell, visit Amwell.com. 1 American Well's Online Care Group is an independent provider contracted to participate in Blue KC's commercial provider networks. 2 If special Amwell benefits apply, this will be noted as a “Designated Telehealth” benefit on your certificate. You can access your certificate on MyBlueKC.com. 24
Bringing Home Great Care HEALTHY COMPANION™ PROGRAM Support for Chronic Health Conditions Education and support Healthy Companion helps you understand your condition and HEALTHY COMPANION TOOLS treatment options with access to nurses, tools, resources and AND RESOURCES one-on-one support. Condition management The level of support you receive from the program will be based ONLINE TIPS on your needs and preferences. Our nurses may contact you occasionally to assist with your care plan, answer your questions, EDUCATIONAL CLINICAL and provide support and encouragement. Updates are provided to REMINDERS SUPPORT your doctor so they stay informed of your health status. Eligibility Members who have been identified with any of the conditions If you have recently been diagnosed, and would like to sign up listed below are automatically enrolled. for immediate support, contact Healthy Companion. • Asthma • Chronic Obstructive Pulmonary Disease (COPD) CALL: 816-395-2076 | Toll Free 1-866-859-3813 • Depression • Diabetes EMAIL: HealthyCompanion@BlueKC.com • Heart Disease • Heart Failure • High Blood Pressure • Metabolic Syndrome • Stress and Anxiety 25
YOUR PRESCRIPTIONS 27
MyBlueKC.com CLOSE-UP ON GENERIC DRUGS A Quality, Cost-Efficient Alternative Using a generic instead of a brand name drug can help save you money. Understanding generics WHAT IS THE DIFFERENCE BETWEEN A GENERIC AND BRAND NAME DRUG? WHAT ARE GENERIC DRUGS? Just the name and the price. The generic drug has the same active A generic drug is a less expensive version of its brand name ingredients and same medical effect. Generic drugs just have a counterpart. Generic drugs are made with the same active name based on the chemical compound that makes up the drug ingredients and are available in the same strength and dosage as and cost you less. the brand name version. WHAT PROCESS DO GENERIC DRUGS GO THROUGH FOR APPROVAL? Availability A generic drug has to meet the same strict standards the U.S. HOW CAN I GET GENERIC DRUGS? government sets for a brand name drug. The U.S. government Call your doctor and ask if any prescriptions you are currently taking strictly regulates the manufacturing process of all drugs, and all can be filled with a generic version. manufacturers have to meet the same standards. GENERIC DRUG PRESCRIPTION? DO ALL DRUGS HAVE GENERIC EQUIVALENTS? You can receive the highest level of coverage on prescription drugs No. A generic version does not exist for every brand name drug. through your Blue Cross and Blue Shield of Kansas City (Blue KC) Some brand name drugs are protected by patents for up to 20 health plan by remembering to ask your doctor for a generic version years, so a generic cannot be produced immediately. However, of the prescription. Double check with your pharmacist that you’re about half of all prescription drugs currently on the market do have a receiving the most cost-effective prescription medication. generic version available. 28
Your Prescriptions Rx SAVINGS SOLUTIONS HELPS YOU SAVE ON PRESCRIPTIONS There are new ways to save on prescription medications. Blue Some of the ways you might save include: KC has partnered with Rx Savings Solutions to bring cutting-edge • Switching pharmacies technology that will notify you via text message and/or email when you and your family can save at the pharmacy. • Trying a generic or a different generic medication • Trying therapeutic alternatives DID YOU KNOW? STEP 1 Rx Savings Solutions was created by a pharmacist who found ways to help consumers save money. GET TEXT AND EMAIL ALERTS Prescription prices can vary widely, even within the same ZIP code. HOW TO SET UP ALERTS A Visit MyBlueKC.com. Once logged in, click on Once on the Rx Savings page, B C If you are a first-time visitor, Plan Benefits on the fill in your email address and click REGISTER NOW. Please left. Then click mobile phone number. have your member ID card Pharmacy Plan Info Start receiving email and/or text alerts available to reference. and then Spend Less from Rx Savings Solutions! at the Pharmacy. STEP 2 REVIEW YOUR SAVINGS OPTIONS AND SHARE WITH YOUR DOCTOR STEP 3 START SAVING ON PHARMACY A PRESCRIPTIONS PHARMACY B Example: Switch from Pharmacy A to Pharmacy B. Example: Switch to a different, equally effective medication. DON’T WANT TO WAIT? For more You don’t have to wait for a savings notification. information, call Take a look for yourself and start saving today. the Customer • Log in to MyBlueKC.com. Service number listed on your • Click on Plan Benefits on the left, then click the member ID card. Pharmacy Plan Info and Spend Less at the Pharmacy. • Check your Rx Savings Solutions home page for savings opportunities or use the search feature to view different medications. 29
MyBlueKC.com PRESCRIPTION HOME DELIVERY Save on Prescription Costs Express Scripts pharmacy handles millions of prescriptions each year through home delivery. Express Scripts, the company that manages your prescription plan for Blue KC, wants to ensure you are doing all you can to save on your maintenance prescription costs. Maintenance prescription drugs are HOME DELIVERY HELPS! considered those taken on a regular basis and are appropriate for up to a 102-day supply. TAKE YOUR Transfer your maintenance medications MEDICATIONS to home delivery AS PRESCRIBED • Log into MyBlueKC.com. Click Plan Benefits on the left. SAVE ON SAVE TIME WITH PRESCRIPTION NO TRIPS TO • Then select the Pharmacy Plan Info. From that screen click COSTS THE PHARMACY the Visit Express Scripts button to be redirected to the Express Scripts website. • Once redirected, the screen will display a message that says “We’ll do the work for you.” Click on the link in the message to CONTACT EXPRESS SCRIPTS view your prescriptions that are eligible for home delivery. If you do not have internet access, or if you would like Express Scripts to assist you in transferring your • Complete the steps and submit your form. Once received, routine medications to home delivery, or if you have any Express Scripts will reach out to your doctor to obtain an questions, please call: (toll free) 855-812-7198 updated prescription to initiate home delivery. Express Scripts is an independent company which serves as the Pharmacy Benefits Manager (PBM) on behalf of Blue KC. 30
LIVING HEALTHY 31
MyBlueKC.com A HEALTHIER YOU™ Personalized Online and Mobile Wellness Take Control of Your Health. Get Healthy and Earn Chances to Win Great Prizes The Blue Cross and Blue Shield of Kansas City (Blue KC) A Healthier You program gives you convenient online and mobile access to several wellness tools that allow you to get healthy and earn chances to win great prizes. LOG ON TO MYBLUEKC.COM FROM YOUR COMPUTER AND CLICK ON HEALTH & WELLNESS (USE GOOGLE CHROME) OR DOWNLOAD THE BLUE KC A HEALTHIER YOU MOBILE APP FROM YOUR APP STORE. First-time users will be prompted to complete registration personalization questions. Please have your member ID card available to reference. TRACK YOUR HEALTH, EARN POINTS AND GET SUPPORT Take the Health Risk Assessment and receive your personal health summary. WHEREVER YOU ARE. Get answers or search symptoms within Configure your Personalized Care plan and your Personalized Care plans. view your screening results (if available). Complete health actions and earn points to Connect and manage your devices and enter monthly sweepstakes drawings. apps for more points. 32
BREAST PUMP COVERAGE Information and In-Network Providers If you have a breast pump benefit on your plan, Blue KC will cover the allowable charge. Breastfeeding is one of the best ways you can protect your baby’s 3.) ORDER health. And if you’ve decided to do so, your Blue KC health plan may At about 30 weeks, order your breast pump by contacting one of have coverage for a breast pump. the in-network local or mail-order breast pump providers listed on the following page. Learn More Please allow roughly four weeks to receive your breast pump in the Find out if you have a breast pump benefit and how to order mail. Contact your breast pump provider with ordering questions as by taking these steps: they can best assist you. 1.) INQUIRE If you have a breast pump benefit on your plan, Blue KC will cover Call Blue KC Customer Service at the number on your member the allowable charge for a manual or electric breast pump, either ID card. double or single to meet the needs of you and your baby. The allowable benefit coverage may vary if you live outside the Blue KC 2.) GET A PRESCRIPTION service area. If your plan includes a breast pump benefit, ask your doctor for a prescription for a breast pump once you reach 26-28 weeks. In-network breast pump providers will have certain types of brands on hand. You are limited to one breast pump per pregnancy. If you have benefit-related questions, contact Blue KC Customer Service by calling the phone number on your member ID card. 33
MyBlueKC.com Living Healthy In-Network Breast Pump Providers Helpful Tips: • If you have not obtained a prescription from your doctor for a • There are walk-in locations within the Blue KC service area, or breast pump, you can ask the breast pump provider to request you may contact an in-network mail-order provider. the prescription for you. • You will need your Blue KC member ID card on hand when you place your order. WALK-IN LOCATIONS*: KANSAS CITY IN-NETWORK PROVIDERS *For a complete listing of local walk-in locations, call Blue KC Customer Service at the number listed on your member ID card. Freedom Preferred-Care Phone Network and BlueSelect and Covered Network Location Blue and Blue-Care Number Freedom BlueSelect Plus Preferred-Care Network Select Advanced Medical Lenexa, KS (913) 745-4468 X X X Solutions American Care Overland Park, KS (913) 383-3456 X X X X Equipment Elite Medical Lenexa, KS (913) 940-0491 X X X X Innovations Expresscare Kansas City, KS (913) 789-9573 X X X Medical Services Mobility First Independence, MO (816) 350-7600 X X X X Nevada, MO (800) 562-8876 X X X Rich Hill, MO (800) 410-9184 X X X Wilkinson Lebanon, MO (888) 383-4431 X X X Homecare Lamar, MO (888) 986-3784 X X X Equipment (7 locations in Missouri) Holden, MO (888) 660-6103 X X X El Dorado Springs, MO (800) 824-6098 X X X Camdenton, MO (888) 573-0014 X X X In-Network Mail Order Providers* *State access varies; please call the listed provider to ensure breast pumps are available for your location. Edgepark Better Living Now Web: edgepark.com / Phone: (800) 321-0591 Web: betterlivingnow.com / Phone: (800) 854-5729 When prompted for “breast pump,” press 1. Better Living Now is not a contracted provider in our BlueSelect network. Progressive Medical Yummy Mummy Web: pmikc.com / Phone: (913) 685-5861 Web: yummymummystore.com / Phone: (855) 879-8669 Email: service@progressivemedicalinc.com Yummy Mummy is not a contracted provider in our BlueSelect network. Progressive Medical is not a contracted provider in our BlueSelect network. Byram Healthcare Centers, Inc. Medline Industries, Inc. Web: byramhealthcare.com / Phone: (877) 773-1972 Web: medline.com / Phone: (877) 436-8522 Email: breast-pumps@byramhealthcare.com Medline Industries is not a contracted provider in our BlueSelect network. Byram Healthcare Centers, Inc. is not a contracted provider in our BlueSelect network. Mobility First Aeroflow Web: mobilityfirst.com / Phone: (816) 350-7600 Web: aeroflowinc.com / Phone: (888) 973-0279 Aeroflow is not a contracted provider in our BlueSelect network. 34
SAVE MONEY. LIVE HEALTHY. Join Blue365® and start saving today! With Blue365, great deals are yours for every aspect of your life – like 20% off at Reebok.com, discounted CHECK OUT THESE TOP BRANDS products through Jenny Craig, or a gym membership WITH DISCOUNTS JUST FOR YOU for only $25 a month. Register now at Blue365deals.com/BlueKC to take advantage of Blue365. It’s an online destination featuring healthy deals and discounts exclusively for our members. Just have your Blue KC member ID card handy. In a couple of minutes, you will be registered and ready to shop. Every week we will send a special deal straight to your email inbox. © 2000-2018 Blue Cross Blue Shield Association – All Rights Reserved. The Blue365 program is brought to you by the Blue Cross Blue Shield Association. The Blue Cross Blue Shield Association is an association of independent, locally operated Blue Cross and/or Blue Shield Companies. Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross Blue Shield Association. Blue365 offers access to savings on health and wellness products and services and other interesting items that Members may purchase from independent vendors, which are different from covered benefits under your policies with your local Blue Company, its contracts with Medicare, or any other applicable federal healthcare program. To find out what is covered under your policies, contact Blue KC. The products and services described on the Site are neither offered nor guaranteed under your Blue Company’s contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding your health insurance products and services may be subject to your Blue Company’s grievance process. BCBSA may receive payments from vendors providing products and services on or accessible through the Site. Neither BCBSA nor any Blue Company recommends, endorses, warrants, or guarantees any specific vendor, product or service available under or through the Blue365 Program or Site. 35
MORE INFORMATION 37
IMPORTANT INFORMATION ABOUT YOUR PLAN __________________________________________________________________ As a current or prospective member of Blue Cross and Blue Shield of Kansas City (Blue KC), we believe it is important for you to fully understand all aspects of your health plan. This information is provided to help you understand your rights and your coverage. Please read the following information carefully. __________________________________________________________________ About your Benefit Summary Your benefit summary is for informational purposes only and contains only a partial, general description of plan benefits. This summary is provided to give you a brief outline of your benefits. It does not constitute a contract. Consult your plan documents (Schedule of Benefits and Certificate of Coverage) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan. As with all healthcare plans, there are certain services that are not covered. Some services are subject to limitations. All the terms and conditions of your plan are subject to the terms of the contract and to applicable law and regulations. The availability of a plan or program may vary by geographic service area. Member Rights and Responsibilities As a member of Blue KC you have certain rights and responsibilities. For your benefit we have outlined the rights and responsibilities of our members for the various plans we offer. You have the right to: • Receive considerate and courteous care with respect and recognition of personal privacy, dignity and confidentiality. • Have a candid discussion of medically necessary and appropriate treatment options or services for your condition from any participating physician, regardless of cost or benefit. • Receive medically necessary and appropriate care or services from any participating physician or other participating healthcare provider from those available as listed in your managed care plan directory or from any nonparticipating physician or other healthcare provider. • Receive information and diagnosis in clear and understandable terms, and ask questions to ensure you understand what you are told by your physician and other medical personnel. • Participate with Providers and practitioners in making decisions about your healthcare, including accepting and refusing medical or surgical treatments. • Give informed consent to treatment and make advance treatment directives, including the right to name a surrogate decision maker in the event you cannot participate in decision making. 38 MCM_ Important Info – Insured 03/16 03/16
• Discuss your medical records with your physician and have health records kept confidential, except when disclosure is required by law or to further your treatment. • Be provided with information about your managed healthcare plan, its services and the practitioners and providers providing care, as well as have the opportunity to make recommendations about your rights and responsibilities. • Communicate any concerns with your managed healthcare plan regarding care or services you received, receive an answer to those concerns within a reasonable time, and initiate the complaint and grievance procedure if you are not satisfied. You have the responsibility to: • Respect the dignity of other members and those who provide care and services through your managed healthcare plan. • Ask questions of your treatment physician or treatment provider until you fully understand the care you are receiving and participate in developing mutually agreed upon treatment goals to the degree possible. • Follow the mutually agreed upon plans and instructions for care that you have discussed with your healthcare practitioner, including those regarding medications. Comply with all treatment follow-up plans, and be aware of the medical consequences of not following instructions. • Communicate openly and honestly with your treatment provider regarding your medical history, health conditions, and the care you receive. • Keep all scheduled healthcare appointments and provide advance notification to the appropriate provider if it is necessary to cancel an appointment. • Know how to use the services of your managed healthcare properly. • Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care. How to Obtain Care After Hours If you need to obtain care after normal business hours, on the weekend or on a holiday, use the following options: 1) Emergency care – If you are in need of emergency care, seek services at the nearest network emergency department, if possible. If the situation is critical, visit the nearest non-network emergency department. 2) Urgent care – If you are in need of urgent care, call the physician office to speak to an on- call doctor after regular hours. 3) Non-urgent care – If the need for care is not urgent or an emergency, we encourage you to wait and call during normal business hours. Online (Website) Security Policy Blue KC has implemented numerous security features to prevent the unauthorized release of or access to personal information. Please see BlueKC.com for further information about online security. 39 MCM_ Important Info – Insured 03/16 03/16
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