The State of Kansas (SOK) employee group renewed for 2011. Options available through BCBSKS continue to include:
- For active employees
- For retirees (Medicare eligible)
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 |
|
