CareFirst State of Maryland 2015 Health Care Options

10455 Mill Run Circle
Owings Mills, Maryland 21117-5559
www.carefirst.com
January 1, 2015 – December 31, 2015
2015 Health Care Options
CareFirst BlueCross BlueShield
Your plan for healthy living
CareFirst is not only the largest health care insurer in the Mid-Atlantic, we are also
your neighbor. As fellow Marylanders, we value our relationship with State of Maryland
employees and retirees and look forward to continuing as your health insurance provider for
many years to come. This guide outlines the 2015 changes to your plan as well as the many
resources and tools available to help you continue on the path to good health.
Quality health plans, satisfied
members
We help you take charge of
your health
While it’s important for us to offer you high-quality
health plans, we also strive to keep you happy and
healthy. That’s the true measure of a health care plan’s
success. According to a 2013 regional independent study1,
CareFirst ranks first among other major carriers in the
region in all key categories including:
Whether you’re looking for health and wellness tips,
discounts on health-related services, or support to
manage a health condition, we have resources to help.
With our Health + Wellness Program, you can:
■■ Identify habits that could put your health at risk
with an online Health Risk Assessment.
■■ Overall satisfaction
■■ Manage a chronic condition such as diabetes,
■■ Number of doctors
or deal with unexpected health issues and
medical emergencies with the support of a
coordinated health care team.
■■ Likelihood to recommend
■■ Caring about its members
■■ Being there when you need it
■■ Improve your health with programs that target
your specific health or lifestyle issues.
We connect with you on
the move
With CareFirst mobile you can access all your plan
information from your smartphone.
■■ Find a provider
■■ Review claims
■■ Contact us
■■ View your ID card
■■ View benefit information
■■ Find a nearby urgent care center
Comprehensive Satisfaction Survey conducted by Mathew Greenwald & Associates, an independent marketing research firm. Results are among members of large
employers (200+) in the CareFirst service region for 2013. Survey included other carriers providing health care benefits in the CareFirst service region including Cigna,
United and Aetna.
1
New for January 1, 2015
■■ Wellness Program
■■ Mental health now administered by CareFirst
for all plans
EPO
(Offered to all active employees and retirees with or
without Medicare regardless of where they reside.)
■■ Office visit–$15 PCP copay / $30
■■ EPO copayment out-of-pocket changed to
$1,500 individual/$3,000 family
Specialist copay.
■■ Emergency room Copay–$75 facility copay plus
■■ Diagnostic and lab related to Diabetes,
Hypertension, Coronary Artery Disease, Asthma
and COPD including test strips in-network pays
at 100%
$75 physician copay; waived if admitted.
■■ Plan pays 100% of Allowed Benefit in-network
for services not associated with a copay; no
out-of-network benefits other than medical
emergency services.
■■ Acupuncture and Chiropractic copayments $30
for all products
■■ Copayment out-of-pocket–$1,500 individual/
$3,000 family; applies to all medical and
behavioral health services.
PPO
(Offered to all active employees and retirees with or
without Medicare regardless of where they reside.)
■■ Office Visit–$15 PCP copay / $30
Specialist copay.
■■ Emergency Room–$75 facility copay plus $75
physician copay, copays waived if admitted.
■■ Plan pays 90% of Allowed Benefit in-network
and 70% of Allowed Benefit out-of-network for
services not associated with a copay.
■■ Total Medical out of pocket limits­­–in-network
$2,000 individual/$4,000 family; out of network
$3,250 individual/$6,500 family
Coinsurance and Deductible out-of-pocket–
in-network $1,000 individual/$2,000
family; out-of-network $3,000
individual/$6,000 family.
Copayment out-of-pocket–$1,000
individual/$2,000 family; applies to all
medical and behavioral health services.
Out-of-network benefits subject to
deductibles–($250 individual/$500 family).
If you are a current Point of Service (POS)
member you must select a new plan for
1/1/15 or you won’t have coverage. The
CareFirst plan most similar to your current
coverage is our PPO plan offering out-ofnetwork benefits or consider our EPO with
in-network coverage only.
As the largest health care insurer in the
Mid-Atlantic region, CareFirst BlueCross
BlueShield has a lot to offer through our
EPO and PPO plans:
■■
■■
■■
■■
One of the most widely recognized and accepted
health care identification cards.
Access to our network of more than 40,000 doctors
and specialists and 76 hospitals in Maryland,
Washington DC and Northern Virginia.
You can take your health care benefits with you across
the country and around the world.
While EPO members have access to in-network
providers, the PPO plan offers the additional freedom
for members to visit providers outside of the network
so they can receive care from the provider of
their choice.
■■
No referrals to see a specialist.
■■
FirstHelp™ 24-hour nurse line.
■■
Blue 365 delivers great discounts from top national
and local retailers on fitness gear, gym memberships,
family activities, healthy eating options and more.
How to locate a provider
www.carefirst.com/statemd
1. Go to www.carefirst.com/statemd.
2. Click the Find a Doctor link at the top of the
Home page.
3. Click the Find a Doctor button on the
landing page.
4. Choose your health plan and click Continue.
If you need assistance finding a provider, call Customer
Service at 410-581-3601/1-800-225-0131.
My Account
Online access to your claims
Signing up is easy
Visit www.carefirst.com/statemd, My Account and set up
your User ID and Password. You’ll just need information
from your member ID card.
Features of My Account
■■ Request replacement ID card.
Secure
■■ Find out who’s covered on your policy and the
Your log-in information is completely secure. Select your
own User ID and Password, which you can change at any
time. Our staff will never ask you for your password and
to protect your security you’ll be logged out automatically
after 15 minutes of inactivity.
effective date of your coverage.
■■ Check your deductible and out-of-pocket costs
for your current and previous plan year.
■■ Review up to one year of medical claims – total
charges, benefits paid, and costs for a specific
date range.
■■ Email a nurse and receive a secure, online
response within 24 hours.
■■ Plan for surgeries and other procedures
Paperless
You can help control rising health care costs, while
protecting the environment, by switching to paperless
communications through My Account.
by comparing outcomes and other quality
measures for nearby hospitals.
CON N E CT W ITH US :
Customer Service: 410-581-3601/1-800-225-0131
www.carefirst.com/statemd
CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
BOK5314-1S (9/14)
Benefits
PPO – Preferred Provider Option (using the PPO national network)
In-Network
Benefit Period 1/1/2015 – 12/31/2015
TOTAL MEDICAL OUT-OF-POCKET
COINSURANCE/DEDUCTIBLE OUT-OF-POCKET
Out-of-Network
$2,000 individual/$4,000 family
COPAY OUT-OF-POCKET
CareFirst EPO
$3,250 individual/$6,500 family
$1,000 individual/$2,000 family
In-Network (using the PPO national network)
$1,500 individual/$3,000 family
$1,500 individual/$3,000 family
$1,000 individual/$2,000 family
$3,000 individual/$6,000 family
None
DEDUCTIBLE
None
$250 individual/$500 family
None
LIFETIME MAXIMUM
None
None
None
Well Baby/Child Visits and associated lab
(0–36 months, up to 13 visits; 3 years–21 years, 1 visit per plan year)
100% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Immunizations for adults and children as recommended by the Centers for Disease
Control, U.S. Task Force of Preventive Care, and American Academy of Pediatrics
including Lyme Disease, but excluding recommendations for travelers.
100% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Annual Adult Physicals and associated lab
(22+ years) 1 per plan year
100% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Flu Shots
100% of Allowed Benefit
Not covered
100% of Allowed Benefit
Routine GYN Services (includes pap)
100% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Nutritional Counseling and Health Education for Chronic Disease
(contact CareFirst for more information)
100% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Screening Mammography
(One screening every year 35+)
100% of Allowed Benefit
70% of Allowed Benefit
100% of Allowed Benefit
Room & Board (includes maternity) and Ancillary Services
(includes nursery charges)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Organ Transplants
(preauthorization required)
90% of Allowed Benefit for cornea, kidney, bone marrow, heart, heart-lung, single
or double lung, liver and pancreas
70% of Allowed Benefit after deductible for cornea, kidney, bone marrow,
heart, heart-lung, single or double lung, liver and pancreas
100% of Allowed Benefit for cornea, kidney, bone marrow, heart, heart-lung,
single or double lung, liver and pancreas
Acute Inpatient Rehab for Stroke and Traumatic Brain Injury
(when medically necessary)
90% of Allowed Benefit
Not covered
100% of Allowed Benefit
Extended Care Facility (ECF) – 180 days per plan year (preauthorization required)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Hospice Care
(inpatient or at home; preauthorization required)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Physician Surgical Services
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Anesthesia
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Consultations (including follow-visits) & Physician Visits (includes ECF)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Radiation Therapy, Chemotherapy, and Renal Dialysis
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
PREVENTIVE/WELL CARE (ROUTINE)
INPATIENT HOSPITAL/FACILITY SERVICES
(Preauthorization required)
INPATIENT PROFESSIONAL/PRACTITIONER SERVICES
OUTPATIENT HOSPITAL/FACILITY SERVICES
Emergency Room Services – In-network and out-of-network
100% of Allowed Benefit after $75 facility copay and $75 physician copay.
100% of Allowed Benefit after $75 facility copay and $75 physician copay.
OUTPATIENT HOSPITAL/FACILITY SERVICES
Cardiac Rehabilitation (Outpatient Freestanding Clinic or Outpatient Hospital only,
36 sessions in 12-week period with physician supervision and in medical facility;
medical necessity with physician authorization and history of heart attack in
past 12 months, CABG surgery, angioplasty, heart valve surgery, heart transplant,
stable angina pectoris, compensated heart failure.)
90% of Allowed Benefit
70% of Allowed Benefit; after deductible
100% of Allowed Benefit
Home Health Care (120 days per plan year)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Minor/All Surgery (includes hospital based and freestanding surgical centers)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Preadmission Testing
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Diagnostic Tests (includes X-rays, machine tests, pathology,
CAT scans, MRIs, and Holter Monitors)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Laboratory Testing related to Diabetes, Hypertension, Coronary Artery Disease,
Asthma, COPD (including test strips for Diabetes)
100% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Diagnostic Mammogram (no age limit)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Physician Office Visit – Primary Care
$15 copay
70% of Allowed Benefit after deductible
$15 copay
Physician Office Visit – Specialist
$30 copay
70% of Allowed Benefit after deductible
$30 copay
Urgent Care Centers
$30 copay
70% of Allowed Benefit after deductible
$30 copay
Minor/All Surgery
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Anesthesia
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Allergy testing, injection and serum (copay applies to testing and serum)
$15 copay (PCP); $30 copay (Specialist)
70% of Allowed Benefit after deductible
$15 copay (PCP); $30 copay (Specialist)
X-rays, machine tests and pathology, CAT SCANS, MRIs, and Holter Monitors
(physician interpretation of results)
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Physical Therapy, Occupational Therapy and Speech Therapy
Note: Contact health plan if Speech Therapy provided due to catastrophic illness
for consideration of additional visits.
$30 copay; up to 50 days per plan year combined for Occupational, Physical and
Speech Therapy. Based on medical necessity. Occupational and Physical Therapy
requires precertification after 6th visit. Speech precertification after 1st visit.
70% of Allowed Benefit after deductible; up to 50 days per plan year combined
for Occupational, Physical and Speech Therapy. Based on medical necessity.
Occupational and Physical Therapy requires precertification after 6th visit.
Speech precertification after 1st visit.
$30 copay; up to 50 days per plan year combined for Occupational, Physical and
Speech Therapy. Based on medical necessity. Occupational and Physical Therapy
requires precertification after 6th visit. Speech precertification after 1st visit.
Hearing Exams and Hearing Aids
(Includes Hearing Aid Mandate for minor children)
Exam: $15 copay (PCP), $30 (Specialist); 100% of the plan allowance for the basic
standard device, per ear, every 36 months.
70% of Allowed Benefit after deductible
Exam: $15 copay (PCP), $30 (Specialist); 100% of the plan allowance for the basic
standard device, per ear, every 36 months. ‘
Chiropractic and Acupuncture Pain Management
$30 copay
70% of Allowed Benefit after deductible
$30 copay
In Vitro Fertilization (IVF) and Artificial Insemination (AI) (preauthorization required)
90% of Allowed Benefit
70% of Allowed Benefit
100% of Allowed Benefit
Inpatient Hospital Care
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Partial Hospitalization Services
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
Outpatient Services (Includes Intensive outpatient services)
$15 copay
70% of Allowed Benefit after deductible
$15 copay
Residential Crisis
90% of Allowed Benefit
70% of Allowed Benefit after deductible
100% of Allowed Benefit
OUTPATIENT/OFFICE PROFESSIONAL SERVICES
IVF and AI benefits are available for a legally married couple if:
There is a history of infertility throughout the most recent two years
of marriage; or
■■ Female infertility is due to endometriosis exposure in womb to
diethylstilbestrol (DES) or blockage of or surgical removal of one
of more fallopian tubes; or
■■ Male infertility is the documented diagnosis.
■■
The patient’s oocytes must be fertilized with her spouse’s sperm.
Up to 3 attempts of AI and 3 attempts of IVF per live birth per lifetime.
The AI attempts must be taken before IVF attempts will be covered.
BEHAVIORAL HEALTH
PRESCRIPTION DRUGS
Not covered under Medical Plan. Refer to your 2015 Guide to Your Health Benefits booklet provided by
Employee Benefits Division which can be found at www.dbm.maryland.gov/benefits.
ROUTINE DENTAL
Not covered under Medical Plan. Refer to your 2015 Guide to Your Health
Benefits booklet provided by Employee Benefits Division which can
be found at www.dbm.maryland.gov/benefits.
ROUTINE ADULT VISION
Vision Exam
Prescription Lenses
$45 Allowed Benefit
70% of Allowed Benefit after deductible
$45 Allowed Benefit
Single Vision Lenses: $52 Allowed Benefit; Bifocal Lenses: $82 Allowed Benefit; Trifocal Lenses: $101 Allowed Benefit; Lenticular Lenses: $181 Allowed Benefit
Single Vision Lenses: $52 Allowed Benefit; Bifocal Lenses: $82 Allowed Benefit;
Trifocal Lenses: $101 Allowed Benefit; Lenticular Lenses: $181 Allowed Benefit
Frames (in lieu of contact lenses)
$45 Allowed Benefit
$45 Allowed Benefit
Contact Lenses (in lieu of frames & lenses)
Contact Lenses: $97 Allowed Benefit; Medically Necessary Contact Lenses: $285 Allowed Benefit
Contact Lenses: $97 Allowed Benefit; Medically Necessary Contact Lenses:
$285 Allowed Benefit
Vision Exam
100% of Allowed Benefit
100% of Allowed Benefit
Prescription Lenses (basic lenses which means spectacle lenses with no “addons” such as glare resistant treatment, ultraviolet coating, progressive lenses,
transitional lenses, etc.)
Single Vision Lenses: $40 Allowed Benefit; Bifocal Lenses: $60 Allowed Benefit; Trifocal Lenses: $80 Allowed Benefit; Lenticular Lenses $100 Allowed Benefit
Single Vision Lenses: $40 Allowed Benefit; Bifocal Lenses: $60 Allowed Benefit;
Trifocal Lenses: $80 Allowed Benefit; Lenticular Lenses $100 Allowed Benefit
Frames (in lieu of contact lenses)
$70 Allowed Benefit
$70 Allowed Benefit
Contact Lenses: $105 Allowed Benefit; Medically Necessary Contact Lenses: $225 Allowed Benefit
Contact Lenses: $105 Allowed Benefit; Medically Necessary Contact Lenses:
$225 Allowed Benefit
ROUTINE PEDIATRIC VISION
(for members through age 18)
Contact Lenses (in lieu of frames & lenses)
AB (Allowed Benefit): The maximum dollar amount allowed for services covered, regardless of the provider’s actual charge.
70 % of Allowed Benefit after deductible
This chart is a general summary of benefits and does not guarantee coverage. Please contact Customer Service or refer to www.carefirst.com/statemd
after the Open Enrollment for on-line PPO and EPO group benefit booklets or Evidence of Coverage with plan details.