Description
Kayla is a 30-year-old African American accounts receivable manager at Augusta University. She is married to Justin, a 31-year-old, African American, self-employed computer programmer. They have recently bought a 3- bedroom house. They have a 2- year-old daughter, Ashleigh who is healthy and attends day care. Kayla makes $44,000 and Justin makes $80,000 but does not have benefits.Kayla has a history of mild pre-eclampsia with her pregnancy with Ashleigh but is otherwise healthy with no known medical conditions. Justin has no known medical conditions. Neither takes any prescription medications. Kayla’s family medical history includes hypertension on her mother’s side of the family and her paternal grandfather died of colon cancer. Justin’s family medical history includes hypertension on both sides of his family, and both maternal grandparents died in a car accident four years ago. Kayla and Justin drink once or twice a week, usually on the weekends when they like to prepare gourmet meals for family and friends. They both enjoy spending time with Ashleigh. Justin also enjoys remodeling their house.Part One: Review the insurance plans offered to Kayla through her employer and choose the best plan for her and her family. Choose one of the three plans USG- Blue Choice, USG Consumer Choice or USG Comprehensive Care. The cost of the premiums for each plan can be found in the Insurance Premium Plan Cost Sheet in D2L. The Insurance Premium Plan Sheet shows what the employee pays and what the employer pays and the total cost of the plan. Be sure to use the employee payment only in deciding on your choice of plans.Kayla and Ashleigh only had their routine wellness visits this year. A beam fell across Justin while he was remodeling their house causing severe injuries to his legs. He was rushed to the ER by ambulance. He needed orthopedic surgery on his legs to repair the damage. The surgery was successful, but Justin needed physical therapy twice a week for 2 months. Justin made a full recovery and vowed to be more careful when remodeling the house.Part Two: Download and complete the Case Study Work Sheet. The information you will need to complete the assigment will be found in whichever plan you chose. The documents are long, but most of the information should be within the plan overview. Look for key words such as deductible, preventive care or wellness care, co-pay and co-insurance. It is not always easy to find some of the costs!
Unformatted Attachment Preview
Kayla and Ashleigh only had their routine wellness visits this year. A beam fell across Justin
while he was remodeling their house causing severe injuries to his legs. He was rushed to the ER
by ambulance. He needed orthopedic surgery on his legs to repair the damage. The surgery was
successful, but Justin needed physical therapy twice a week for 2 months. Justin made a full
recovery and vowed to be more careful when remodeling the house.
Your choice of insurance plan: ____________________________________________________
1.
What factors lead to your decision to choose this plan?
The insurance claims for Kayla and her family are listed below. Along with the cost before the
insurance company paid its portion of the bill. You will need to determine how much Kayla (and
her family) will pay for each claim based on the information provided in the insurance policy.
Kayla’s Primary Care visit
Wellness/Preventive care with family medicine- Pre-insurance cost $150.00.
2.
How much will Kayla pay for this claim based on the plan you selected for her
family?
Ashleigh’s Pediatric visit
Wellness/Preventive care- Pre-insurance cost $150.00.
3.
How much will Kayla pay for this claim based on the plan you selected for her
family?
Justin’s ambulance to the ER
Ambulance fee- Pre-insurance cost $800.00
4.
How much will Kayla pay for this claim based on the plan you selected for her
family?
ER charges- (Justin was admitted to the hospital from the ER)
ER Trauma Charge- Pre-insurance cost $7,500.00
5.
How much will Kayla pay for this claim based on the plan you selected for her
family?
Hospital In-patient charges for Justin
Pre-insurance cost 20,000.00
6.
How much will Kayla pay for this claim based on the plan you selected for her
family?
Justin’s Outpatient Physical Therapy
Outpatient PT fee $120 * 2/week for 8 weeks- Pre-insurance cost $1920.00
7.
How much will Kayla pay for this claim based on the plan you selected for her
family?
Add the family’s payments together for a grand total for the year.
8.
How much did Kayla pay in insurance claims this year?
Review the options for insurance that you did and did not choose for Kayla’s family.
9.
Did you choose the best plan for the family considering their medical needs this
year? Why or why not?
THE BLUECHOICE
HMO HEALTHCARE
PLAN
“Creating A More Educated Georgia”
THE
UNIVERSITY
SYSTEM OF
GEORGIA
BlueChoice HMO Healthcare Plan Design – Effective January 1, 2021
Booklet Revised – December 2020
RESOURCE CONTACTS
Should you have questions regarding your BlueChoice HMO healthcare plan benefits, please contact
the appropriate resource(s) identified below:
For Questions About:
Please Contact
Location
Claims/Coverage Provided
1-866-204-9818
Accolade
by the Plan
TDD 711
For information regarding the
participating providers.
Online Tools and Online Provider
Directory
Accolade
member.accolade.com
Pre-certification for Specific
Outpatient/All Inpatient Hospital
Services
Anthem Blue Cross Blue
Shield
1-800-233-5765
TDD/1-800-368-4424
Accolade
1-866-204-9818
TDD 711
Centers of Excellence Transplant
Program
Anthem Blue Cross Blue
Shield
1-866-694-0724
TDD/1-800-368-4424.
Behavioral Health & Substance
Abuse Providers/Facilities
Anthem Blue Cross Blue
Shield
Call the number located on your
identification card.
1-800-292-2879
CVS/Caremark
1-877-362-3922
Secretary
U.S. Dept. of Health and Human
Services
Office of Civil Rights, Region IV
61 Forsyth St. SW, Suite 3B70
Atlanta, GA 30303-8909
404-562-7886 (metro Atlanta)
1-866-627-7748 (outside of metro
Atlanta)
Accolade NurseLine
After hours assistance only
Pharmacy Benefits
HIPAA
University System of Georgia benefits website: https://benefits.usg.edu/
Table of Contents
INTRODUCTION ………………………………………………………………………………………………………………………… 6
How to Get Language Assistance …………………………………………………………………………………………….. 6
BENEFITS AT A GLANCE …………………………………………………………………………………………………………… 7
BENEFITS AT A GLANCE …………………………………………………………………………………………………………… 8
WHO CAN ENROLL ………………………………………………………………………………………………………………….. 14
HOW TO ENROLL ……………………………………………………………………………………………………………………. 14
DEPENDENT COVERAGE ………………………………………………………………………………………………………… 15
WHEN EMPLOYEE COVERAGE BEGINS ………………………………………………………………………………….. 15
WHEN DEPENDENT COVERAGE BEGINS ………………………………………………………………………………… 15
ADDING OR DELETING DEPENDENTS……………………………………………………………………………………… 16
USG OPEN ENROLLMENT PERIOD ………………………………………………………………………………………….. 17
THE COST OF YOUR HEALTHCARE COVERAGE ……………………………………………………………………… 17
QUALIFYING EVENTS FOR CHANGES IN HEALTHCARE PLAN COVERAGE……………………………… 17
CONTINUATION OF HEALTHCARE COVERAGE INTO RETIREMENT…………………………………………. 20
USG RETIREE OPEN ENROLLMENT PERIOD …………………………………………………………………………… 20
for Pre-65 retirees and dependents …………………………………………………………………………………………… 20
QUALIFYING EVENTS FOR CHANGES IN RETIREE HEALTHCARE PLAN COVERAGE ………………. 20
PERMISSIBLE USG RETIREE HEALTHCARE PLAN CHANGES …………………………………………………. 22
HOW YOUR BENEFITS WORK FOR YOU ………………………………………………………………………………….. 22
Introduction …………………………………………………………………………………………………………………………… 22
Out-of-Network Services ………………………………………………………………………………………………………… 23
How to Find a Provider in the Network ……………………………………………………………………………………. 23
What’s Covered ……………………………………………………………………………………………………………………….. 24
Allergy Services …………………………………………………………………………………………………………………….. 24
Ambulance Services ………………………………………………………………………………………………………………. 24
Autism Services / Applied Behavior Analysis (ABA) ……………………………………………………………….. 24
Autism Services …………………………………………………………………………………………………………………….. 24
Behavioral Health Services …………………………………………………………………………………………………….. 25
Cardiac Rehabilitation ……………………………………………………………………………………………………………. 26
Chemotherapy ……………………………………………………………………………………………………………………….. 26
Chiropractic Services …………………………………………………………………………………………………………….. 26
Cochlear Implants ………………………………………………………………………………………………………………….. 26
Dental Services (All Members / All Ages) ………………………………………………………………………………… 26
Preparing the Mouth for Medical Treatments ……………………………………………………………………………… 26
Dental Treatment of Accidental Injury ……………………………………………………………………………………….. 27
Other Dental Services …………………………………………………………………………………………………………….. 27
Diabetes Equipment, Education, and Supplies ………………………………………………………………………… 27
Diagnostic Services ……………………………………………………………………………………………………………….. 27
Diagnostic Laboratory and Pathology Services ………………………………………………………………………. 27
Diagnostic Imaging Services and Electronic Diagnostic Tests ……………………………………………………… 28
Advanced Imaging Services …………………………………………………………………………………………………….. 28
Dialysis …………………………………………………………………………………………………………………………………. 28
Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and
Surgical Supplies …………………………………………………………………………………………………………………… 28
Durable Medical Equipment and Medical Devices ………………………………………………………………………. 28
Orthotics ……………………………………………………………………………………………………………………………….. 29
Prosthetics …………………………………………………………………………………………………………………………….. 29
Medical and Surgical Supplies …………………………………………………………………………………………………. 29
Emergency Care Services ………………………………………………………………………………………………………. 29
i
Emergency Services ……………………………………………………………………………………………………………….. 29
Emergency Care …………………………………………………………………………………………………………………….. 30
Home Health Care Services…………………………………………………………………………………………………….. 30
Infusion Therapy ……………………………………………………………………………………………………………………. 31
Hospice Care …………………………………………………………………………………………………………………………. 31
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services ………………………………. 31
Covered Transplant Procedure ………………………………………………………………………………………………… 31
Prior Approval and Precertification ……………………………………………………………………………………………. 32
Donor Benefits ……………………………………………………………………………………………………………………….. 32
Transportation and Lodging ……………………………………………………………………………………………………… 32
Infertility Services ………………………………………………………………………………………………………………….. 33
Inpatient Services …………………………………………………………………………………………………………………… 33
Inpatient Hospital Care ……………………………………………………………………………………………………………. 33
Inpatient Professional Services ………………………………………………………………………………………………… 34
Maternity and Reproductive Health Services …………………………………………………………………………… 34
Maternity ……………………………………………………………………………………………………………………………….. 34
Contraceptive Benefits …………………………………………………………………………………………………………… 35
Sterilization Services ……………………………………………………………………………………………………………… 35
Abortion Services …………………………………………………………………………………………………………………… 35
Infertility Services ………………………………………………………………………………………………………………….. 35
Nutritional Counseling ……………………………………………………………………………………………………………. 35
Occupational Therapy …………………………………………………………………………………………………………….. 35
Office Visits and Doctor Services ……………………………………………………………………………………………. 35
Orthotics………………………………………………………………………………………………………………………………… 36
Outpatient Facility Services ……………………………………………………………………………………………………. 36
Physical Therapy ……………………………………………………………………………………………………………………. 37
Preventive Care ……………………………………………………………………………………………………………………… 37
Prosthetics …………………………………………………………………………………………………………………………….. 38
Pulmonary Therapy ………………………………………………………………………………………………………………… 39
Radiation Therapy ………………………………………………………………………………………………………………….. 39
Rehabilitation Services …………………………………………………………………………………………………………… 39
Habilitative Services ………………………………………………………………………………………………………………. 39
Respiratory Therapy ………………………………………………………………………………………………………………. 39
Skilled Nursing Facility …………………………………………………………………………………………………………… 39
Speech Therapy ……………………………………………………………………………………………………………………… 39
Surgery ………………………………………………………………………………………………………………………………….. 39
Oral Surgery ………………………………………………………………………………………………………………………….. 40
Reconstructive Surgery …………………………………………………………………………………………………………… 40
Mastectomy Notice …………………………………………………………………………………………………………………. 40
Telemedicine ………………………………………………………………………………………………………………………….. 40
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services …………………………………… 41
Therapy Services ……………………………………………………………………………………………………………………. 41
Physical Medicine Therapy Services …………………………………………………………………………………………. 41
Early Intervention Services …………………………………………………………………………………………………….. 41
Physical, Occupational and Speech Therapy ……………………………………………………………………………… 41
Other Therapy Services …………………………………………………………………………………………………………… 42
Transplant Services ……………………………………………………………………………………………………………….. 42
Urgent Care Services ……………………………………………………………………………………………………………… 42
Vision Services (All Members / All Ages) ………………………………………………………………………………… 43
Prescription Drugs Administered by a Medical Provider …………………………………………………………… 44
Important Details about Prescription Drug Coverage ………………………………………………………………. 44
Prior Authorization …………………………………………………………………………………………………………………. 44
Step Therapy ………………………………………………………………………………………………………………………….. 44
Therapeutic Substitution ………………………………………………………………………………………………………… 44
What’s Not Covered …………………………………………………………………………………………………………………. 45
ii
Claims Payment ………………………………………………………………………………………………………………………. 50
Maximum Allowed Amount …………………………………………………………………………………………………….. 50
Claims Review ……………………………………………………………………………………………………………………….. 50
Notice of Claim & Proof of Loss ……………………………………………………………………………………………….. 51
Claim Forms ………………………………………………………………………………………………………………………….. 51
Member’s Cooperation ……………………………………………………………………………………………………………. 51
Payment of Benefits ……………………………………………………………………………………………………………….. 51
Inter-Plan Programs ……………………………………………………………………………………………………………….. 52
Out of Area services ……………………………………………………………………………………………………………….. 52
BlueCard® Program ……………………………………………………………………………………………………………….. 52
Non-Participating Healthcare Providers Outside the Claims Administrator’s Service Area ……….. 53
Member Liability Calculation …………………………………………………………………………………………………….. 53
Exceptions …………………………………………………………………………………………………………………………….. 53
Getting Approval for Benefits …………………………………………………………………………………………………… 53
Types of Requests …………………………………………………………………………………………………………………. 54
Request Categories ………………………………………………………………………………………………………………… 54
Individual Case Management ………………………………………………………………………………………………….. 55
Eligibility………………………………………………………………………………………………………………………………… 55
Benefits …………………………………………………………………………………………………………………………………. 55
Covered Services …………………………………………………………………………………………………………………… 56
Utilization ………………………………………………………………………………………………………………………………. 56
Exclusions …………………………………………………………………………………………………………………………….. 57
Individual Case Management Definitions ………………………………………………………………………………… 57
Case Manager ……………………………………………………………………………………………………………………….. 57
Provider ………………………………………………………………………………………………………………………………… 57
Termination of Individual Case Management ……………………………………………………………………………… 57
Coordination of Benefits When Members Are Insured Under More Than One Plan …………………….. 58
Order of Benefit Determination Rules ……………………………………………………………………………………… 58
Facility of Payment …………………………………………………………………………………………………………………. 59
Right of Reimbursement…………………………………………………………………………………………………………. 60
Right of Reimbursement ………………………………………………………………………………………………………….. 61
Voluntary Incentive Program(s)………………………………………………………………………………………………… 62
How to Participate ………………………………………………………………………………………………………………….. 62
Programs Available ………………………………………………………………………………………………………………… 62
24/7 NurseLine ………………………………………………………………………………………………………………………. 62
Behavioral Health: ………………………………………………………………………………………………………………….. 62
Chronic Care: ………………………………………………………………………………………………………………………… 62
Case Management: ………………………………………………………………………………………………………………… 62
End-stage renal disease (ESRD) ……………………………………………………………………………………………… 62
Centers of Medical Excellence for Transplant Program …………………………………………………………… 63
Our Centers of Medical Excellence for Transplant (CME-T) program includes both our CMEs and Blue
Distinction Centers for transplant ……………………………………………………………………………………………… 63
Future Moms ………………………………………………………………………………………………………………………….. 63
Through the Future Moms prenatal care program, you’ll get: ……………………………………………………….. 63
Neonatal Intensive Care Unit (NICU) ……………………………………………………………………………………….. 63
Our case management program for high-risk births begins by first working with members in our Future
Moms maternity program …………………………………………………………………………………………………………. 63
MyHealth Note ……………………………………………………………………………………………………………………….. 63
MyHealth Note is an educational report card on your well-being that helps you save money and stay
healthy. You’ll get: …………………………………………………………………………………………………………………. 63
Member Rights and Responsibilities ………………………………………………………………………………………… 65
Your Rights to Appeal ……………………………………………………………………………………………………………… 67
Appeals (Grievances)……………………………………………………………………………………………………………… 67
How Your Appeal will be Decided …………………………………………………………………………………………… 69
iii
Notification of the Outcome of the Appeal ………………………………………………………………………………. 69
Appeal Denial …………………………………………………………………………………………………………………………. 69
Voluntary Second Level Appeals (Grievances)………………………………………………………………………… 69
Requirement to file an Appeal before filing a lawsuit ………………………………………………………………. 69
Continuation of Coverage under Federal Law (COBRA) ……………………………………………………………. 71
Qualifying events for Continuation Coverage under Federal Law (COBRA) ……………………………… 71
Second qualifying event …………………………………………………………………………………………………………. 72
Notification Requirements………………………………………………………………………………………………………. 72
Electing COBRA Continuation Coverage ………………………………………………………………………………… 72
Disability extension of 18-month period of continuation coverage …………………………………………… 72
When COBRA Coverage Ends ………………………………………………………………………………………………… 73
Other Coverage Options besides COBRA Continuation Coverage ……………………………………………….. 73
Continuation of Coverage Due to Military Service …………………………………………………………………… 73
Family and Medical Leave Act of 1993 …………………………………………………………………………………….. 73
For More Information ……………………………………………………………………………………………………………… 74
General Provisions ………………………………………………………………………………………………………………….. 75
Clerical Error …………………………………………………………………………………………………………………………… 75
When Your BlueChoice HMO Healthcare Plan Coverage Ends ……………………………………………………. 75
Medicare ………………………………………………………………………………………………………………………………… 75
Modifications …………………………………………………………………………………………………………………………. 75
Not Liable for Provider Acts or Omissions………………………………………………………………………………. 75
Policies and Procedures…………………………………………………………………………………………………………. 76
Relationship of Parties (Employer-Member Claims Administrator) …………………………………………… 76
Employer’s Sole Discretion …………………………………………………………………………………………………….. 76
Right of Recovery …………………………………………………………………………………………………………………… 76
Workers’ Compensation …………………………………………………………………………………………………………. 76
Definitions……………………………………………………………………………………………………………………………….. 78
Accidental Injury …………………………………………………………………………………………………………………….. 78
Administrative Services Agreement ………………………………………………………………………………………….. 78
Ambulatory Surgical Facility …………………………………………………………………………………………………….. 78
Appeals (Grievance) ……………………………………………………………………………………………………………….. 78
Applied Behavior Analysis (ABA) ……………………………………………………………………………………………… 78
Authorized Service(s) ……………………………………………………………………………………………………………… 78
Balance Billing ……………………………………………………………………………………………………………………….. 78
Benefit Booklet ………………………………………………………………………………………………………………………. 78
Benefit Period ………………………………………………………………………………………………………………………… 79
Benefit Period Maximum …………………………………………………………………………………………………………. 79
Centers of Excellence (COE) Network ………………………………………………………………………………………. 79
Claims Administrator ………………………………………………………………………………………………………………. 79
Copayment ……………………………………………………………………………………………………………………………. 79
Covered Services …………………………………………………………………………………………………………………… 79
Covered Transplant Procedure ………………………………………………………………………………………………… 80
Custodial Care …………………………………………………………………………………………………………..
