For 2011, Federal Employee Program (FEP) insureds who choose health care coverage through Blue Cross and Blue Shield of Kansas (BCBSKS) can select either the Basic or Standard Option benefit programs. These same options were available to them last year.
The Patient Protection and Affordable Care Act (PPACA) was signed on March 23, 2010. There are several provisions within the PPACA that affect eligibility and benefits under the Federal Employee Health Benefits (FEHB) Program effective January 1, 2011.
- Preventive Services: Coverage for preventive care, including annual physicals, immunization, and cancer screening will be provided with no cost-sharing for members when performed by a Preferred Provider.
- Coverage for Children Up to Age 26: The PPACA requires the extension of coverage for adult children up to age 26 under the parent's health insurance enrollment. For FEHB, this enhanced coverage includes natural, step and foster children as well as extension of coverage for children incapable of self-support.
- Grandfather Health Plan Status Under the PPACA: The PPACA requires that all health plans included consumer protections and benefit coverage that affect FEHB plans beginning in 2011. A Grandfathered health plan can preserve the basic health insurance coverage that was in effect when the PPACA was enacted. Grandfathered health plans have to comply with some but not all of the requirements under the PPACA. The BCBSKS Benefit Plan will not be a Grandfathered health plan as of January 1, 2011, and as such, will comply as provisions are implemented, with all of the benefit coverage requirements as consumer protections of the PPACA.
As a reminder,
Standard Option
- Uses the basic CAP Blue Cross contracting provider contract as their preferred provider network.
- Standard Option identification cards will reflect an enrollment code of:
- 104 = Standard Option/Single
- 105 = Standard Option/Family
Basic Option
- Utilizes the Blue Choice provider network. Except for emergency care,
- NO BENEFITS are available for services provided by institutional providers who are not part of the Blue Choice provider network.
- Non-hospital institutional providers (home health agencies, hospice agencies, end stage renal disease facilities, birthing centers, and freestanding substance abuse facilities) who are in the CAP* provider network are considered to be Blue Choice providers.
- Basic Option identification cards will reflect the word BASIC within an outline of the United States and an enrollment code of:
- 111 = Basic Option/Single
- 112 = Basic Option/Family
The following is a sampling of the 2011 benefits for institutional providers:
| Benefit |
Standard Option |
Basic Option |
| Deductible |
$350 individual/$700 family |
None |
Hospital Inpatient: Medical/Behavioral Health
Precertification Required |
$250 per admission copayment for unlimited days |
$150 per day up to $750 for unlimited days |
| Outpatient Surgery |
Subject to deductible,
15% coinsurance |
$75 per day facility copayment |
| Outpatient Laboratory, Pathology services, and EKG |
Subject to deductible,
15% coinsurance |
None |
Outpatient
- EEG
- Ultrasounds
- X-rays (including set for portable X-ray equipment
|
Subject to deductible,
15% coinsurance |
$25 copayment per day, per facility |
Outpatient
- Bone density tests – diagnostic
- CT/MRI/PET scans
- Diagnostic angiography
- Genetic testing – diagnostic (note: genetic screening is not covered)
- Nuclear medicine
|
Subject to deductible,
15% coinsurance |
$75 copayment per day, per facility |
| Outpatient Behavioral Health |
15% coinsurance |
$25 copayment per day, per facility |
| Outpatient Physical, Occupational, and Speech Therapy |
Subject to deductible, 15% coinsurance
Benefits are limited to 75 visits per person, per calendar year for physical, occupational, and speech therapy, or a combination of all three. |
$75 per day facility copayment
Benefits are limited to 50 visits per person, per calendar year for physical, occupational, and speech therapy, or a combination of all three. |
| Accidental Injury |
Nothing for covered charges for services within 72 hours of accident. 72 hours regular medical and outpatient hospital benefits apply. |
$125 ER copayment per visit |
| Medical Emergency Care |
Subject deductible, 15% coinsurance |
$125 copayment |
Home Health
Precertification Required |
15% coinsurance
Up to 2 hours per day, up to 25 visits per calendar year |
$25 copayment per visit
Up to 2 hours per day, up to 25 visits per calendar year |
Hospice
Precertification Required |
Call BCBSKS at
800-782-4437 |
Call BCBSKS at
800-782-4437 |
|
NOTE: For 2011, benefits are provided for up to 7 consecutive days in a facility licensed as an inpatient hospice facility. Each inpatient stay must be separated by at least 21 days of traditional home hospice care. The member does not have to be enrolled in a home hospice care program to be eligible for the first inpatient stay. However, the member must be enrolled in a home hospice care program in order to receive benefits for subsequent inpatient stays. |
- Prior approval is required for outpatient surgery for morbid obesity.
- Prior approval is required for all outpatient IMRT services except IMRT related to the treatment of head, neck, breast, or prostate cancer. Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT of brain cancer. Medical evidence is required to make a coverage determination.
Complete FEP benefit information is available at
http://www.bcbsks.com/CustomerService/Providers/index.htm
FEP eligibility and claim status information is available by calling the BCBSKS customer service center at 785-291-4181 or 1-800-432-0379. Provider telephone calls will be authenticated and handled by our interactive voice response system.
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