January 3, 2007

BC-07-03
HP-07-03
SA-07-03

HHA-07-03
DC-07-03

Essential Blue is a new Blue Choice product that Blue Cross and Blue Shield of Kansas has began offering qualifying Kansans and is designed to provide members with the essential health care coverage at affordable premiums.

The program is ideal for basic routine preventive care coverage such as doctor check-ups, generic prescription drugs and hospital stays while still offering coverage for many other services.  Essential Blue pays a maximum of $30,000 in benefits for all covered health services (subject to deductibles and coinsurance) per covered person, each benefit period.

COVERED SERVICES:

The following services are covered up to their benefit maximums.  Then services are covered under the “other services” benefits portion of the program, subject to separate deductible and coinsurance amounts.

Office Visit Services* - $25 copay per visit (except for an accidental injury) up to a maximum of five visits for each covered person (15 visits for three-or-more persons) each benefit period. 

Initial Outpatient Coverage for Accidental Injuries* - $50 copay for the initial outpatient visit if provided within 60 days of the date of injury. 

Outpatient Radiology & Lab Services (including accidental injury services)* - pays a maximum of $300 of combined services for each covered person ($900 for three-or-more persons) each benefit period.
Hospice Rider – pays 100% of home health care up to $2,500 per person each benefit period.  Pays Hospice 100% with a $5,000 lifetime maximum.

BlueRx Direct Outpatient Prescription Drugs (generic drugs only) - $100 deductible for each covered person ($300 maximum for three-or-more persons).  Then benefits are paid at 50% of allowable charges for the remainder of the benefit period.  Drug costs do not count toward the benefit period maximum.

*Other Services – deductible is $1,000 for each covered person ($3,000 maximum for three-or-more persons).  After the deductible, the member pays 20% of the allowable charges to a maximum out-of-pocket expense of $1,000 for each covered person ($3,000 for three-or-more persons).

Covered services include in-hospital care, ambulance services, surgery and anesthesia, outpatient surgery, nervous and mental services (limited), maternity and newborn service and amounts in excess of the maximums for office visit and outpatient medical services as shown above.

Benefit Period Maximum - $30,000 in benefits for all covered health services (subject to deductibles and coinsurance) per covered person, each benefit period.

Blue Choice Provider Network – to get the most from their Essential Blue coverage, members should receive services from providers who participate in the Blue Choice provider network. 

The Blue Choice provider network includes:

• All professional providers who participate with BCBSKS as a CAP (Competitive Allowance Program) provider,
• All non-hospital institutional providers (home health, hospice, end stage renal disease facilities, substance abuse facilities, birthing centers, etc.) who participate with BCBSKS as a CAP (Competitive Allowance Program) provider,
• All hospitals that have agreed to participate in the Blue Choice network by signing the Blue Choice hospital provider contract.

An additional 20% coinsurance will apply when a Blue Choice member (including members enrolled in Essential Blue) receives services from a non-Blue Choice provider.  This coinsurance is limited to a combined maximum of $2,000 per person, $4,000 family each benefit period.  This coinsurance is in additional to other Blue Choice deductible and coinsurance amounts.

Eligibility and claim status information is available at the BCBSKS Web site www.bcbsks.com or by calling the BCBSKS customer service center 1-800-432-3990.  Provider telephone calls will be authenticated and handled by our interactive voice response system.

drb