Blue Cross of California Right Plan 40
Here at BenefitPackages.com, we’re believers in offering our prospective clients an assortment of Blue Cross Life and Health plans in addition to a modular brand of health coverage, thereby ensuring our clients’ medical indemnity needs. The Blue Cross Life and Health Company has well-deserved and unsurpassed reputation for offering its customers the kinds of innovative health plans they’re looking for. BC has earned the trust and approval of its customers and healthcare providers alike. They’re committed to offering consumers affordable, reliable medical coverage options to prudent buyers of health insurance and the Right Plan PPO not only has the right benefits and cost-effective pricing but the Blue Cross Right Plan 40 was also designed especially for the direct health care needs of an assortment of physically active life styles that includes:
- Healthy and active young adults
- Recent college grads about to fall off of their dependant coverage plan
- Empty Nesters
- Early Retirees
- Self-employed singles
When they enroll in Right Plan 40, consumers will directly benefit from:
- Pre-negotiated affordably priced health provider fees that dramatically reduce members’ out of pocket medical expenses.
- Full access to well over 42,000 PPO network providers.
- Full access to both out-of-country and out-of-state emergency health coverage.
- Member health and well-being enhancement services, including everything from substantial discounts on a variety of health related products, services and health improvement programs.
Blue Cross’ Right Plan PPO offers more than just health care coverage in the event of injury of illness. The PPO 40 Plan also provides for access to meaningful preventative medical care and a variety of health maintenance targeted programs. Even if you’re young and physically active, an unexpected injury or serious illness – and mounting medical bills can quickly begin to pose a substantial financial risk. The RightPlan PPO works hard to do everything from limiting its member’s out-of-pocket medical care costs, protecting their assets to safeguarding their future earnings.
Right Plan 40 members get a selectable slate of health care benefits, meaning that if a family thinks it may need maternity care, that care is available but, if they’ve decided that they won’t be needing maternity coverage anytime in the near future then they won’t have to pay for an add-on benefit they may never use. The PPO 40 provides health benefits specifically designed to the various aspects of your lifestyle, providing first-dollar healthcare coverage with no medical deductible, primary care office visits with a $40 co-payment, three separate levels prescription drug benefits and lower insurance premiums overall.
Furthermore, the RightPlan PPO has been priced and designed in order to make it a proper fit for single policyholders. Right Plan’s single policy holder price structure is based on the options each individual policy holder selects and results in a significant savings over other PPO plans. Members can also reduce their premiums by selecting either a no prescription drug or generic only medication option with their PPO 40 plan.
GENERAL PPO 40 PROVISIONS:
Blue Cross Life and Health’s PPO 40 offers the emergency services coverage needed to screen, stabilize sudden onset emergency medical conditions-including severe pain, chest pains, shortness of breath or difficulty breathing, heavy bleeding, sudden numbness of the arm, leg, face or side of the body and or weakness of one of the former-with neither pre-certification nor authorization required in order to qualify.
The Right Plan PPO40 additionally provides for medically required treatments for diagnoses of severe mental illnesses in members of any age. As defined by the Diagnostic and Statistical Manual of the America Psychiatric Association, the list of severe mental illnesses includes schizophrenia, schizoaffective disorders, manic-depressive illnesses (bipolar disorders), major depressive, panic disorders, obsessive-compulsive disorders, bulimia nervosa, anorexia nervosa and autism or pervasive developmental disorders.
Furthermore, PPO 40 provides for the treatment of substance abuse, non-severe nervous and mental disorders in the form of professional services (twenty visits per year maximum) with a $25 per visit co-payment and impatient hospital services (thirty days per year maximum) with a $175 per day co-payment. Right Plan also provides the same level of mental health coverage for diagnoses of behavior that contradicts expected developmental norms in children in addition to any of the disorders above.
PPO 40 BENEFITS:
- The PPO 40 has an annual deductible of $0
- A Lifetime compensation limit of $5,000,000
- An annual out-of-pocket maximum of $7,500 for both non-participating and participating providers combined.
- A $40 doctors’ office visit co-payment for participating providers and a fifty percent of the negotiated PPO fee plus one-hundred percent of the excess co-pay for non-participating providers.
- A 40% of the negotiated fee copay for professional medical care services (x-rays, lab services, anesthesia, surgery, etc.) for participating providers and a 50% of the PPO 40′s negotiated fee plus 100% of any excess amount co-payment for non-participating health providers.
- A hospital outpatient co-payment equal to 40 – percent of the negotiated fee (plus $400 per outpatient surgery admissions) in the case of PPO 40 participating providers. In the case of non-participating providers members will be responsible for all charges except $380 per day.
- An emergency services co-payment of 40% of the negotiated fee when using a PPO 40 participating provider. When using a non-participating provider the Right Plan member will be responsible for 40% of reasonable and customary for the first forty-eight hours plus 100% of any excess. After forty-eight hours, the member will be responsible all charges in excess of $650 per day.
- Preventative care services from participating providers carry a $40 per office visit plus 40% of the negotiated fee copay for routine mammograms, PAP and PSA tests as well as well baby and well child care (thru age 6) and a $25 and $75 co-payment for basic screenings at BC-L&H Healthy Check Centers. In the case of preventative care-services from non-participating providers the PPO 40 member will be responsible for charges equal to 50% of the negotiated fee plus any excess for all of the former.
- A co-pay of 40% of the PPO 40 negotiated fee for ambulance services, in the case of participating providers and a co-pay of 50% of the PPO negotiated fee plus 100-percent of excess for non-participating providers.
- In the case of physical therapy, occupational therapy or chiropractic services from participating providers PPO 40 members will be responsible for all charges except 40% of the plan’s negotiated fee (up to a limit of 12 visits per year). In the case of physical therapies, occupational therapies and or chiropractic services from non-participating providers RightPlan members will be responsible for all applicable charges except for $25 per visit (12 visit limit per year).
- In the case of acupressure or acupuncture alternative care services PPO 40 members will be responsible for all charges except for $25 per visit (for up to twenty-four visits each year).
PPO 40 EXCLUSIONS and LIMITATIONS:
Even though Blue Cross Life and Health specifically designed its PPO 40 plan to care for your health care needs, there are items that the BC-L&H medical plan does not offer coverage for. Therefore, Benefits Packages recommends that you take a moment or two and review the PPO-40 exclusions and limitations listed below. We’re here to help you to understand what the Right Plan coverage does and does not include before you decide to enroll. The listings below are intended for overview only and The Right Plan PPO 40 Policy’s plan booklet should be consulted for a comprehensive list of the PPO 40 exclusions and limitations. If you’d like to get a sample copy, feel free to contact us.
The PP0 40 can not offer coverage for services in the event that a member is entitled to Medicare benefit reimbursement for the services in question without payment of an additional premium for Medicare coverage. For the portions of the Medicare program requiring additional premium payments, PPO-40 services are excluded for the portions of Medicare in which the member has enrolled.
Dental care and treatment or treatment on or to the teeth and gums, unless covered under accidental injury. Outpatient Drugs and Medications – Coverage for medications, drugs and or other substances administered or dispensed in any outpatient setting unless the specific policy states otherwise.
Durable Medical Equipment – The PPO 40 plan assists plan members with medical equipment including but not limited to shoe inserts or orthopedic shoes, air conditioners, humidifiers and or air purifiers, exercise equipment, spas, treadmills, elevators, supplies for comfort support and or hygiene or correction appliances.
Hospice Services – Blue Cross provides benefits for hospice services up to a lifetime limit of $10,000 per PPO 40 member for non-participating and participating plan providers combined.
Outpatient Speech Therapy – RightPlan does not provide coverage for members with outpatient speech therapy needs except following injury, surgery or non-congenital organic disease.
Domiciliary, or rest related cures for which facilities and or the services of a general acute care hospital that are not medically required-including resident treatment centers, are excluded from Right Plan PPO 40.
Custodial Care – For the purposes of BC’s PPO 40, “custodial care needs” shall be defined as care that does not necessitate the services of trained health or medical personnel, including, but not limited to, help walking, bathing, preparation and feeding or special diet maintenance, dressing, or supervision of ordinarily self-administered medications.
BC’s PPO 40 does not offer reimbursement coverage for contraceptive drugs or certain contraceptive devices, including Norplant’s and Norplant kits, with the exception of injection delivered contraceptives administered by physicians. (please note: certain oral contraceptive devices/methods are covered under a plan’s prescription benefits schedule).
Any and all medical services that are related to the evaluation and or treatment of issues related to infertility, including any and all tests, medications, consultations, surgical procedures, lab work and reversal of a sterilization procedure.
Private duty nursing care, including both outpatient and inpatient services delivered by a private duty nurse. Contact lenses or eyeglasses unless otherwise specified the member’s plan policy.
The PPO 40 plan from Blue Cross Life & Health does not offer coverage reimbursements for certain eye care surgeries, including those exclusively for the purpose of correcting a refractive defect of the eye including as myopia (nearsightedness), presbyopia (farsightedness) and astigmatism.
The Right Plan from BC-L&H does not cover for mental or nervous disorders, substance abuse related issues, and or learning disabilities, except as specifically stated under the benefits sections of the plan policy.
Orthopedic shoes (except when joined to braces) or shoe inserts, except for limited benefits as stated in the Policy.
Orthodontic services related to braces applications, and or 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. 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.
Health care services that were furnished thru an outdoor treatment program.
Medical consultations that were provided either by telephone or fax.
Educational services except as specifically provided or arranged by BC Life & Health.
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 the policy.
The PPO 40 does not offer coverage for conditions covered by workers’ compensation legislation or similar laws.
Right Plan does not cover experimental and or investigative health care or therapy.
The PPO 40 does not cover supplies or services not specifically listed as covered under the Right Plan PPO agreement.
BC-L&H’s RightPlan does not offer coverage for services received before members’ “Effective Date” (the date their coverage began) or during an inpatient hospital or alternative care facility stay that began before their “Effective Date,” or after coverage plan ends.
Supplies or services that are not deemed medically necessary, as determined by BC Life & Health.
Sex change/gender change operations or related treatments and studies.
Services and supplies primarily intended for purposes of weight reduction or treatment of obesity, or other care that involves a weight reduction procedure as its primary method of treatment, except in the event of a medically necessary treatment for a member’s morbid obesity.
The BC Right Plan does not reimburse monetary amounts in excess of PPO 40′s maximum coverage amounts as laid out within the Maximum Comprehensive and Co-payment/Coinsurance Lists sections of the policy.
Routine physical examinations, with the exception of preventive health care services (e.g., physical exams for the purposes of either insurance, licenses, employment, or school are not covered).
The Right Plan will not cover health services provided either by relatives or professional services received from an individual who resides within a member’s home or who is related to them by blood, marriage or adoption.
The PPO-40 does not provide re-imbursement for either services or supplies for which no monetary charge has been made, or for which no charge will be made if the member had no health care insurance coverage, or services for which they are not legally obliged to pay.
The PPO 40 plan does not cover the costs of cosmetic surgery or other surgical services related to beautification-including medical complications that arise from, or are the result of cosmetic surgical procedures, except for procedures related to reconstructive surgery to restore a deformity or correct a bodily function caused by injury, or a medically necessary reconstructive surgical procedure performed in order to restore symmetry following a mastectomy.
Blue Cross L & H’s Right-Plan PPO 40 was both priced and designed to suit the healthcare needs of Individual policy holders. Only the policyholder named can be eligible for Right Plan benefits under the PPO 40 policy. Other individuals, including, but of course not limited to, the policy-holder’s dependents, (e.g. spouse, newborn, legal ward, natural and or adopted children) are not eligible for PPO 40 plan coverage under the same policy as the policy holder. Said dependants may, however, make a separate application for coverage of their own by completing an Enrollment Application of their own. They are also free to make use of the Family Elect option on said Enrollment Application.
Here at Benefits Packages, we believe in offering various levels of Blue Cross health coverage as well as a modular brand of health care coverage, thereby ensuring our clients’ health care needs.
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