HMO
General Information
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Your
Access to Health Care |
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Anthem Blue
Cross Health Maintenance Organization
(HMO) Plans cover more of the costs
of your health care than any other
plan type. With HMO plans, you choose
a Participating Medical Group (PMG)
or Independent Practice Association
(IPA) from the Blue Cross HMO Network
listed in your directory. You also
choose a doctor within the group to
serve as your Primary Care Physician
(PCP), and you can select a different
Primary Care Physician for each family
member enrolled in your HMO Plan.
Your HMO plan coverage applies only
when you receive health care services
through your Primary Care Physician.
He or she will coordinate all of your
health care, either by treating you
directly, or by referring you to a
specialist.
For more information on accessing
doctors and the referral process,
be sure to read about the DirectAccessSM and SpeedyReferralSM programs.
Anthem Blue Cross
NCQA is an independent,
not-for-profit organization that evaluates
managed care organizations. Its mission
is to provide information that enables
purchasers and consumers of managed
health care to distinguish among plans
based on quality, so they can make
more informed decisions. |
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In an Anthem
Blue Cross HMO, you get:
- Low out-of-pocket costs
- Comprehensive health care coverage
- Unlimited lifetime benefits for
covered services
- Mimial copays for office visits
- Self-referral for OB/GYN (women's
health specialists)
- Blue Cross DirectAccess
- Blue Cross SpeedyReferral
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Taking
Care of Your Health with Blue
Cross HMO Plans |
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Staying
Healthy – Preventive Care
Your Blue Cross HMO plan gives
you comprehensive health care
coverage that includes physical
exams by your Primary Care
Physician, and routine cancer
screenings, such as mammograms,
Pap smears and testing for
prostate cancer.
Well Woman Preventive
Care
Self Referral for OB/GYN
Care
For well woman exams, including
mammography and Pap testing,
all women enrolled in a Blue
Cross HMO plan have the option
to use their Primary Care
Physicians or select an obstetrician
and/or gynecologist (OB/GYN)
directly from a participating
specialist, without referral
from their Primary Care Physicians.
Your medical group can provide
you with a list of participating
OB/GYN referral physicians
Self Referral for OB/GYN
is not only for well woman
exams. It extends to other
health care services offered
by obstetricians and gynecologists
including pregnancy, birth
control, and other women’s
health concerns, such as menopause.
HealthyExtensions
HMO Plan members can also
take advantage of discounts
for healthy lifestyles resources.
HealthyExtensions* lets members
know about independent vendors
and professional who offer
10%-50% discounts on a variety
of alternative health care
and wellness products and
services, including programs
to lose weight and quit smoking,
eyecare, hearing impairment,
nutritional supplements, fitness
and sports equipment and more.
Additionally, HealthyExtensions
informs members about health
and wellness practitioners
who offer 10%-25% discounts
on massage therapy, hypnotherapy,
yoga and nutrition.
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When
you need care, simply call your Primary
Care Physician for an appointment.
He or she can help you when you are
ill, either by treating you directly,
or referring you to a specialist.
Programs for Quick Access to Specialists
Blue Cross provides you with additional
options for accessing health care
through the following special programs
for our HMO members:
Blue Cross DirectAccessSM
Blue Cross DirectAccess allows HMO
plan members to select specialists
for some services without authorization
from their Primary Care Physicians.
The speciality services include allergy,
dermatology, and ear, nose and throat.
The program is available to HMO members
who choose a medical group or IPA
that participates in DirectAccess.
Participation of a medical group or
IPA is indicated in the provider directory.
It is important that you check participation
before utilizing DirectAccess.
Blue
Cross SpeedyReferralSM
With SpeedyReferral, HMO members
can be referred by their Primary Care
Physicians for specialist visits without
prior authorization from the medical
group or IPA. Specialty services include,
cardiology, dermatology, ear, nose,
and throat, endocrinology, gastroenterology,
general surgery, hematology, neurology,
oncology, ophthalmology, orthopedic
surgery, podiatry, routine laboratory,
routine x-ray and urology.
This program is available to HMO
members who choose a medical group
or IPA that participates in SpeedyReferral.
Participation of a medical group or
IPA is indicated in the provider directory.
It is important that you check participation
before utilizing SpeedyReferral.
Blue Cross MedCall – 24
Hour Medical Advice
Not sure how serious it is? HMO plan
members can get professional, reliable
health care information instantly
by phone, toll-free, any time of the
day or night, from the registered
nurse at MedCall. They can answer
questions from how to gauge your current
symptoms to medication side effects,
and more. MedCall also provides over
200 educational audiotapes on health
related topics. |
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Anthem Blue Cross covers emergency services necessary
to screen and stabilize your condition.
No authorization or precertification
is required if you reasonably believe
an emergency medical condition exists.
A medical emergency is an unexpected
acute illness, injury or condition
that could endanger your health if
not treated immediately. Examples
of medical emergencies include:
- Severe Pain
- Chest Pains
- Heavy Bleeding
- Difficulty breathing or shortness
of breath
- Sudden loss of consciousness
- Active natal labor (childbirth)
- Sudden weakness or numbness of
the face, arm or leg on one side
of the body
When you consider a medical condition
to be an emergency, immediately call
911 or go to the nearest hospital
emergency room. If as a result of
the medical emergency you are admitted
into the hospital through the emergency
room, you or a member of your family
must notify your Primary Care Physician
or medical group as soon as possible,
but not later than 48 hours after
the initial care has been provided.
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Blue Cross
provides the same level of coverage
as other medical diagnoses for the
medically necessary treatment of severe
mental illnesses in persons of any
age. Severe mental illness, as defined
by the American Psychiatric Association
in the Diagnostic and Statistical
Manual (DSM), includes the following
diagnoses:
- Schizophrenia
- Schizoaffective disorder
- Bipolar disorder (manic-depressive
illness)
- Major depressive disorders
- Panic disorder
- Obsessive-compulsive disorder
- Pervasive developmental disorder
or autism
- Anorexia nervosa
- Bulimia nervosa
Anthem Blue Cross also provides the
same level of coverage as other medical
diagnoses for serious emotional disturbances
in children that result in behavior
inappropriate to the child’s age,
according to expected development
norms. More limited benefits are provided
for other mental disorders such as
primary substance use disorder and
developmental disorder. For more details
regarding these benefits, refer to
the Evidence of Coverage (EOC). |
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Member
and Blue Cross Rights and Obligations |
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No-Obligation
Review Period
After you enroll in a Blue Cross
health plan, you will receive an Evidence
of Coverage policy booklet that explains
the exact terms and conditions of
coverage, including the plan’s exclusions
and limitations. You have 10 full
days to examine your plan’s features.
During that time, if you are not fully
satisfied, you may decline by returning
your Evidence of Coverage booklet
along with a letter notifying us that
you wish to discontinue coverage.
Evidence of Coverage booklets are
available for you to examine prior
to enrolling. Ask your agent or Blue
Cross.
Your
Right to Privacy
We do not release information that
identifies your diagnosis or medical
condition without your consent, except
as permitted by law. Your treating
physician also has rules about your
medical information. Physicians customarily
ask their patients to sign a release
form before they give their patients
medical information to anyone, even
Blue Cross. You may request to see
a copy of your physicians confidentiality
policy, and you should talk to your
physician about how your privacy is
protected.
Requirement for Binding Arbitration
If you are applying for coverage,
please note that Blue Cross requires
binding arbitration to settle all
disputes, including claims of medical
malpractice. California Health and
Safety Code Section 1363.1 and Insurance
Code Section 10123.19 require specified
disclosures in this regard, including
the following notice: “It is understood
that any dispute as to medical malpractice,
that is as to whether any medical
services rendered under this contract
were unnecessary or unauthorized or
were improperly, negligently or incompetently
rendered, will by California law,
and not by lawsuit or resort to court
process except as California law provides
for judicial review of arbitration
proceedings. Both parties to this
contract, by entering into it, are
giving up their constitutional right
to have any such dispute decided in
a court of law before a jury, and
instead are accepting the use of arbitration.
Both parties also agree to give up
any right to pursue on a class basis
any claim or controversy against the
other.
Grievances
All complaints and disputes relating
to your coverage must be resolved
in accordance with Blue Cross’ grievance
procedure. Grievances may be made
by telephone or in writing; the phone
number and address are located on
your Blue Cross ID card. All grievances
received by Blue Cross will be answered
in writing, together with a description
of how Blue Cross proposes to resolve
the grievance.
Department
of Managed Health Care
The California Department of Managed
Care is responsible for regulating
health care service plans. If you
have a grievance against your health
plan, you should first telephone your
health plan at (800) 333-0912 and
use your health plan’s grievance process
before contacting the department.
Utilizing this grievance procedure
does not prohibit any potential legal
rights or remedies that may be available
to you. If you need help with a grievance
that has not been satisfactorily resolved
by your health plan, or a grievance
that has remained unresolved for more
than 30 days, you may call the department
for assistance. You may also be eligible
for an Independent Medical Review
(IMR). If you are eligible for an
IMR, the IMR process will provide
an impartial review of medical decisions
made by a health plan related to the
medical necessity of a proposed service
or treatment, coverage decisions for
treatments that are experimental or
investigational in nature and payment
disputes for emergency or urgent medical
services. The department also has
a toll-free telephone number (1-888-HMO-2219)
and a TDD line (1-877-688-9891) for
the hearing and speech impaired. The
department’s Internet Web site (http://www.hmohelp.ca.gov)
has complaint forms, IMR application
forms and instructions on-line.
Third-Party
Liability
Blue Cross of California is entitled
to reimbursement of benefits paid
if you recover damages from a legally
liable third party. Examples of third-party
liability include car accidents and
work-related injuries. For complete
information about third-party liability,
refer to the plan Evidence of Coverage
booklet.
Loss
Ratio
As required by law, we are advising
you that Blue Cross of California’s
incurred loss ratio for 2001 was 80.28
percent. This loss ratio was calculated
after provider discounts were applied.
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Exclusions and Limitations |
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Exclusions
and Limitations Common to All Individual
Medical Plans
- Conditions covered by workers’
compensationor similar laws.
- Experimental or investigative
care or therapy.
- Any services provided by a local,
state, county or federal government
agency, including any foreign government.
- Services or supplies not specifically
listed as covered under the plan
agreement.
- Services received before your
Effective Date or during an inpatient
stay that began before your Effective
Date.
- Services rendered before coverage
begins or after coverage ends.
- Services or supplies for which
no charge is made, or for which
no charge would be made if you
had no insurance coverage or services
for which you are not legally obligated
to pay.
- Services provided by relatives,
and professional services received
from a person who lives in your
home or who is related to you by
blood, marriage or adoption.
- Any services to the extent you
are entitled to receive Medicare
benefits for those services without
payment of additional premium for
Medicare coverage. For parts of
Medicare requiring additional premium
payment, service are excluded for
those parts of Medicare the member
enrolled in.
- Services or supplies that are
not medically necessary, as determined
by Blue Cross of California or BC
Life & Health.
- Routine physical exams, except
for preventive care services (e.g.,
physical exams for insurance, employment,
licenses or school are not covered)
except as specifically stated for
PPO Share 500/1000 plans.
- Services furnished through outdoor
treatment programs.
- Outpatient speech therapy, except
following surgery, injury or otherwise
as medically necessary
- Benefits for Hospice services
are limited to a lifetime maximum
of $10,000 per member for participating
and non-participating providers
combined (BC Life PPO Share 500,
BC Life PPO Share 100, BC Life PPO
Share 5000, PPO Saver, PPO Basic
only).
- Any amounts in excess of the maximum
amounts stated in the Maximum Comprehensive
and Copayment/Coinsurance Lists
sections of your agreement.
- Sex change operations or related
treatment and study.
- Cosmetic surgery or other services
for beautification, including any
complications arising from or the
result of cosmetic surgery, except
for reconstructive surgery.*
- Services primarily for weight
reduction or treatment of obesity,
or any care which involves weight
reduction as the main method of
treatment, except medically necessary
treatment of morbid obesity with
our prior authorization.
- Dental care and treatment or treatment
on or to the teeth and gums — unless
covered under accidental injury.
- Dental implants.
- Hearing aids.
- Contraceptive drugs or devices
including Norplant and Norplant
kits, except injectable contraceptives
when administered by a physician.
(Contraceptives are covered under
all plans’ prescription benefits
except the Basic Plan.)
- All services related to the evaluation
or treatment of infertility, including
all tests, consultations, medications,
surgical, medical or lab procedures,
and reversal of sterilization.
- Private duty nursing, including
inpatient or outpatient services
of a private duty nurse.
- Eyeglasses or contact lenses,
unless specified in your plan agreement.
- Certain eye surgeries, including
those solely for the purpose of
correcting refractive defects of
the eye such as nearsightedness
(myopia) and astigmatism.
- Diagnostic admissions, including
inpatient room and board charges
in connection with a hospital stay
primarily for diagnostic tests that
could have been safely performed
on an outpatient basis, and inpatient
admissions primarily for diagnostic
studies when inpatient bed care
is not medically necessary.
- Mental and nervous disorders,
substance abuse, and learning disabilities,
except as specifically stated under
the benefits sections of the plan
agreement.
- Orthopedic shoes (except when
joined to braces) or shoe inserts,
except for limited benefits as
stated in the Evidence of Coverage.
- Orthodontic services, braces,
and other orthodontic appliances.
- No payment will be made for services
or supplies for the treatment of
a preexisting condition during a
period of six months following your
effective date. This limitation
does not apply to a child born
or newly adopted by an enrolled
subscriber or spouse. Also, if you
were covered under qualifying prior
coverage within 63 days of becoming
covered under this Agreement, the
time spent under the qualifying
prior coverage will be used to satisfy,
or partially satisfy, the six-month
period.
- Consultations provided by telephone
or facsimile machines.
- Educational services except as
specifically provided or arranged
by Blue Cross.
- Nutritional counseling and food
supplements except as stated in
your plan agreement.
- No benefits are provided for care
and treatment furnished in a non-contracting
hospital, except for medical emergencies
as specified in your agreement.
- Items which are furnished primarily
for your personal comfort or convenience:
air purifiers, air conditioners,
humidifiers, exercise equipment,
treadmills, spas, elevators and
supplies for comfort, hygiene or
beautification.
- Custodial care. Custodial care
is care that does not require the
services of trained medical or
health professionals, such as, but
not limited to, help in walking,
getting in and out of bed, bathing,
dressing, preparation and feeding
of special diets, and supervision
of medications that are ordinarily
self-administered. Domiciliary,
or rest cures for which facilities
and/or services of a general acute
hospital are not medically required,
including resident treatment centers
are also excluded.
* Does not apply
to reconstructive surgery to restore
a bodily function or to correct a
deformity caused by injury or medically
necessary reconstructive surgery performed
to restore symmetry incident to mastectomy.
Exclusions
and Limitations Common to All Individual
Medical Plans
- Care not authorized by your Primary
Care Physician at your participating
medical group (PMG) or IPA.
- Growth hormone treatment.
- Amounts in excess of customary
and reasonable charges for out-of-area
emergency services.
- Eyeglasses or contact lenses unless
specified in your plan agreement.
- Acupuncture/Acupressure
- Chiropractic Services
- Immunizations for foreign travel
not specifically listed as covered.
- Treatment for chronic alcoholism
or other substance abuse unless
specified in the plan agreement.
- Inpatient mental care, including
acute alcoholism and drug addiction
benefits except detoxification.
- Treatment of mental and nervous
disorders except as stated in the
plan agreement.
- Rehabilitative care except as
stated in the plan agreement.
- Private room, unless specified
in the plan agreement.
- Reconstructive surgery, purchase
or replacement of artificial limbs
or prosthesis unless the medical
condition creating the need for
the limb or prosthesis occurred
while you were covered under the
plan.
- Medical, surgical and/or psychological
treatment of a sexual dysfunction
except when a sexual dysfunction
is a result of a physical abnormality,
defect or disease.
- Medical, surgical services, supplies
or treatment to the joint of the
jaw (temporomandibular joint), upper
jaw (maxilla) or lower jaw (mandible),
unless related to a tumor or accident
occurring while covered.
- Routine physical examinations
or tests that do not directly treat
an acute illness, injury or condition
unless authorized by your Primary
Care Physician, except in no event
will any physical examination or
test required by employment or government
authority, or at the request of
a third party, such as a school,
camp or sports-affiliated organization,
be covered unless medically necessary.
- Care or treatment of a pregnancy,
or any condition related to pregnancy
(except treatment of complications
of pregnancy or Cesarean section
deliveries) when conception has
occurred before the effective date
of the plan agreement. However,
if you were covered under Creditable
Coverage within 62 days of becoming
covered, the time spent under Creditable
Coverage will be used to satisfy,
or partially satisfy, the six (6)
month period.
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® Anthem is a registered trademark. ® The
Blue Cross name and symbol are registered
marks of the Blue Cross Association
© 2007 Anthem Blue Cross.
Serving California. Anthem Blue Cross
is the trade name of Blue Cross of California.
Anthem Blue Cross and Anthem Blue Cross
Life and Health Insurance Company are
independent licensees of the Blue Cross
Association. |
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