Blue Cross Newsletter
 

December 21, 2010

BC-10-21
HP-10-16
SA-10-16
MS-10-17

HHA-10-16
DC-10-15
ASC-10-14

To: All Blue Cross Contracting Providers
From: Cindy Garrison, CPC – Education/Communication Coordinator
Institutional Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association
Subject: 2011 Special Group Update - State of Kansas Employee Group

The State of Kansas (SOK) employee group renewed for 2011.  Options available through BCBSKS continue to include:

  • For active employees
    • Plan A and B
  • For retirees (Medicare eligible)
    • Kansas Senior Plan C

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 State of Kansas Health Benefits (SOK) Program effective January 1, 2011.

  • Non-Grandfather Health Plan Status Under the PPACA:  The SOK has choose not to be a "grandfathered" plan.  As such, the SOK program will not be exempt from the PPACA's provisions.
  • Preventive Care:  Coverage for preventive care, including well woman and well man exams, annual physicals, and immunization will be provided with no cost-sharing for members when performed by a Network 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. 

The following is a sampling of the 2011 benefits for institutional providers:

  Cost to member when receiving services from network providers Cost to member when receiving services from non-network providers
  Plan A Plan B Plan A and B
Annual Plan Deductible $300 individual/
$600 family
$150 individual/ $300 family $500 individual/$1,500 family
Coinsurance For All Eligible Expenses (unless otherwise noted) 20% coinsurance 35% coinsurance 50% coinsurance
Annual Coinsurance Maximum (does not include copay) $1,400 individual/
$2,800 family
$3,000 individual/
$6,000 family
$3,650 individual/
$7,300 family
Lifetime Benefit Maximum none none none
 
Inpatient
(Precertification is required)
Deductible plus 20% coinsurance Deductible plus 35% coinsurance $600 copay per admission plus deductible and 50% coinsurance
Out-Patient Surgery Deductible plus 20% Coinsurance   Deductible plus 35% coinsurance Deductible Plus 50% Coinsurance
Out-patient Laboratory Services
  • Quest Diagnostics – Lab Card
  • Other participating/ contracting labs
  Covered in full   Deductible plus 20% Coinsurance   Covered in full   Deductible plus 35% coinsurance   Not available   Deductible plus 50% Coinsurance
Major Diagnostic Testing
Includes but not limited to PET scans, CT scans, nuclear cardiology studies, MRI, computerized topography/
angiography  
  Deductible plus
20% coinsurance
  Deductible plus 35% coinsurance   Deductible plus
50% coinsurance
Emergency Room $100 copay, deductible plus 20% coinsurance $100 copay, deductible plus 35% coinsurance $100 copay ,    deductible plus
35% coinsurance
Copay does not apply toward annual coinsurance maximum
Home Health
(services must be prior authorized)
Deductible plus
20% coinsurance
Deductible plus 35% coinsurance Deductible plus
50% coinsurance

Hospice
(services must be prior authorized)
Deductible plus
20% coinsurance
Deductible plus 35% coinsurance Deductible plus
50% coinsurance
Inpatient is limited to 6 months
Rehabilitation – Inpatient and Outpatient Facility Deductible plus
20% coinsurance
Deductible plus 35% coinsurance $600 copayment per admission plus deductible and 50% coinsurance (copayment does not apply towards annual coinsurance maximum)
Manipulations limited to 30 visits per calendar year benefit maximum
Behavioral Health Inpatient Same as medical Same as medical
Behavioral Health Outpatient Same as medical Same as medical
Autism Services
(services must be prior approved)
Deductible plus
20% coinsurance
Deductible plus 35% coinsurance Deductible plus
50% coinsurance

Autism Services:
Coverage is available for the diagnosis and treatment of Autism Spectrum Disorder (ASD).  Benefits must be pre-approved by BCBSKS and may include Applied Behavioral Therapy, developmental Speech Therapy, developmental Occupational Therapy, or developmental Physical Therapy as appropriate.  Periodic re-evaluations and assessments are required and continuous improvement must be shown in order to qualify for continued treatment.  Call New Directions at 1-800-952-5906 for prior approval.

Services are limited as follows:
Coverage limits for Network and Non Network services combined:

  • Children under age 7 limited to $36,000/year
  • Children age 7-19 limited to $27,000/year
  • Children age 19 or over, not covered

Intravenous and Injectable Anti-Cancer Drug Rider:
The SOK has developed an Intravenous and Injectable Anti-Cancer Drug Rider.  This rider has a separate coinsurance and coinsurance maximum for anti-cancer medication.  The medical deductible and coinsurance do not apply to this rider.  A list of the applicable anti-cancer drugs is attached to this newsletter.  The list of covered IV and Injectable medications is subject to periodic review and modification.

  Plan A & B –
Services from a network provider
Plan A & B –
Services from a non- network provider
Intravenous and Injectable Anti-Cancer Drugs 25% coinsurance to a maximum of $75 per date of service.

Coinsurance maximum of $750 per member per year.

Once the coinsurance maximum has been met, coverage is 100% of the MAP for the remainder of the calendar year.
The benefits are the same as a network provider except any amount above MAP is the member's responsibility.
Exclusions
  • Charges to administer or inject any drug. (This is covered under medical benefits and is subject to deductible plus coinsurance).
  • Compound drugs not containing at least one (1) ingredient with a valid National Drug Code (NDC) number and requiring a physician's order to dispense.
  • Benefits are not available to the extent an anti-cancer medication has been covered under another SOK health plan.

 

General Information:

  • Request for Additional Information:  There may be occasions when additional information is needed in order to process a claim.  The requested information must be received within 1 year and 90 days from the date of service.  However, if the request is close to the end of the 1 year and 90 days from the date of service, then the provider has 90 days from the date this information is requested to furnish this additional information.  If the additional information is not received by BCBSKS within 90 days, the claim will be denied.
  • Adjustment of Claim:  Requests to adjust a claim must be received within 1 year and 90 days from the date of service.  After one 1 year and 90 days from the date of service, only claims that require adjustments due to legal finding or audits will be adjusted if the request is received within 180 days of the completion of the legal finds or audit.  There will be no limit on claims that have involved fraudulent billing.

Exclusion (not a complete list) :

    • Blood, Blood Products, Blood Storage
    • Surgical treatment or other related services for surgical treatment of obesity
    • Sleep studies provided within the home
    • Supplies and prescription products for tobacco cessation programs and treatment of nicotine addiction.

Kansas Senior Choice Plan C Summary

  • Covers the Medicare Part A & B deductible and coinsurance
  • The 1st three pints of blood are covered
  • Hospice care is available effective January 1, 2011.
  • There is no coverage for charges in excess of Medicare's approved amounts
  • Skilled nursing – The Member must meet Medicare's requirements including having been in the hospital for at least 3 days and entered a Medicare-approved facility within 30 days of leaving the hospital.   Medicare provides benefits for all approved amounts for the first 20 days; subsequently no coverage is needed under Plan C.  For the 21st through 100th day Medicare pays all but the amounts in the Chart; therefore, Plan C will pay those amounts.  For the 101st day or after Medicare provides no coverage, subsequently Plan C provides no coverage.

For complete information about the SOK benefit package, visit our Web site at http://www.bcbsks.com/CustomerService/Members/State/index.htm 

 

State of Kansas eligibility and claim status information is available at the BCBSKS Web site www.bcbsks.com or by calling the BCBSKS customer service center at 785-291-4185 or
1-800-332-0307.  Telephone calls will be authenticated and handled by our interactive voice response system.

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STATE OF KANSAS INTRAVENOUS AND INJECTABLE ANTI-CANCER DRUG LIST

CPT Code Description
J0594 Injection, busulfan, 1 mg
J9001 Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg
J9010 Injection, alemtuzumab, 10 mg
J9015 Injection, aldesleukin, per single use vial
J9017 Injection, arsenic trioxide, 1 mg
J9020 Injection, asparaginase, 10,000 units
J9025 Injection, azacitidine, 1 mg
J9027 Injection, clofarabine, 1 mg
J9031 Bcg (intravesical) per instillation
J9033 Injection, bendamustine hcl, 1 mg
J9035 Injection, bevacizumab, 10 mg
J9040 Injection, bleomycin sulfate, 15 units
J9041 Injection, bortezomib, 0.1 mg
J9045 Injection, carboplatin, 50 mg
J9050 Injection, carmustine, 100 mg
J9055 Injection, cetuximab, 10 mg
J9060 Cisplatin, powder or s0lution, per 10 mg
J9062 Cisplatin, 50 mg
J9065 Injection, cladribine, per 1 mg
J9070 Cyclophosphamide, 100 mg
J9080 Cyclophosphamide, 200 mg
J9090 Cyclophosphamide, 500 mg
J9091 Cyclophosphamide, 1.0 gram
J9092 Cyclophosphamide, 2.0 gram
J9093 Cyclophosphamide, lyophilized, 100 mg
J9094 Cyclophosphamide, lyophilized, 200 mg
J9095 Cyclophosphamide, lyophilized, 500 mg
J9096 Cyclophosphamide, lyophilized, 1.0 gram
J9097 Cyclophosphamide, lyophilized, 2.0 gram
J9098 Injection, cytarabine liposome, 10 mg
J9100 Injection, cytarabine, 100 mg
J9110 Injection, cytarabine, 500 mg
J9120 Injection, dactinomycin, 0.5 mg
J9130 Dacarbazine, 100 mg
J9140 Dacarbazine, 200 mg
J9150 Injection, daunorubicin, 10 mg
J9151 Injection, daunorubicin citrate, liposomal formulation, 10 mg
J9155 Injection, degarelix, 1 mg
J9160 Injection, denileukin diftitox, 300 micrograms
J9165 Injection, diethylstilbestrol diphosphate, 250 mg
J9171 Injection, docetaxel, 1 mg
J9175 Injection, elliotts' b solution, 1 ml
J9178 Injection, epirubicin hcl, 2 mg
J9181 Injection, etoposide, 10 mg
J9185 Injection, fludarabine phosphate, 50 mg
J9190 Injection, fluorouracil, 500 mg
J9200 Injection, floxuridine, 500 mg
J9201 Injection, gemcitabine hydrochloride, 200 mg
J9202 Goserelin acetate implant, per 3.6 mg
J9206 Injection, irinotecan, 20 mg
J9207 Injection, ixabepilone, 1 mg
J9208 Injection, ifosfamide, 1 gram
J9211 Injection, idarubicin hydrochloride, 5 mg
J9214 Injection, interferon, alfa-2b, recombinant, 1 million units
J9215 Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu
J9216 Injection, interferon, gamma 1-b, 3 million units
J9217 Leuprolide acetate (for depot suspension), 7.5 mg
J9218 Leuprolide acetate, per 1 mg
J9219 Leuprolide acetate implant, 65 mg
J9225 Histrelin implant (vantas), 50 mg
J9226 Histrelin implant (supprelin la), 50 mg
J9230 Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg
J9245 Injection, melphalan hydrochloride, 50 mg
J9250 Methotrexate sodium, 5 mg
J9260 Methotrexate sodium, 50 mg
J9261 Injection, nelarabine, 50 mg
J9263 Injection, oxaliplatin, 0.5 mg
J9264 Injection, paclitaxel protein-bound particles, 1 mg
J9265 Injection, paclitaxel, 30 mg
J9266 Injection, pegaspargase, per single dose vial
J9268 Injection, pentostatin, 10 mg
J9270 Injection, plicamycin, 2.5 mg
J9280 Mitomycin, 5 mg
J9290 Mitomycin, 20 mg
J9291 Mitomycin, 40 mg
J9293 Injection, mitoxantrone hydrochloride, per 5 mg
J9300 Injection, gemtuzumab ozogamicin, 5 mg
J9302 Injection, ofatumumab 10 mg
J9303 Injection, panitumumab, 10 mg
J9305 Injection, pemetrexed, 10 mg
J9307 Injection, pralatrexate , 1mg
J9310 Injection, rituximab, 100 m
J9315 Injection, romisdepsin, 1 mg
J9320 Injection, streptozocin, 1 gram
J9328 Injection, temozolomide, 1 mg
J9330 Injection, temsirolimus, 1 mg
J9340 Injection, thiotepa, 15 mg
J9350 Injection, topotecan, 4 mg
J9351 Injection, topotecan, 0.1mg
J9355 Injection, trastuzumab, 10 mg
J9357 Injection, valrubicin, intravesical, 200 mg
J9360 Injection, vinblastine sulfate, 1 mg
J9370 Vincristine sulfate, 1 mg
J9375 Vincristine sulfate, 2 mg
J9380 Vincristine sulfate, 5 mg
J9390 Injection, vinorelbine tartrate, 10 mg
J9395 Injection, fulvestrant, 25 mg
J9600 Injection, porfimer sodium, 75 mg
J9999 Not otherwise classified, antineoplastic drugs
Q2017 Injection, teniposide, 50 mg