HomePower Bluecross

Choose the Right Plan for You

What the Plans Do Not Cover

Mental Health Coverage

Emergency Care

Utilization & Pre service Review Procedures

Member and Anthem blue cross Rights & Obligations
Anthem blue cross of California has been providing health coverage to Californians for 65 years. We are committed to keeping you connected to quality health care services by offering affordable coverage you can rely on.

Your Key to Quality Health Care Services
The Anthem blue cross provider network is among the largest in the state, consisting of more than 42,000 Preferred Provider (PPO) physicians, 27,000 Health Maintenance (HMO) physicians and 440 hospitals.

Cost Savings
We've negotiated discounts for you when you use a doctor or facility from our vast network. By using a participating Anthem blue cross doctor, your costs will be substantially lower and you will save money. You can also save money when you use a non-participating doctor or facility, but not as much.

Your Choice from a Wide Selection of Health Plans
We offer a broad range of health plans that vary in price and health care coverage levels so that you can choose the medical plan that's right for you.

Your Access to Health Care
Preferred Provider Organizations (PPO) Plans offer you the freedom to choose any doctor or facility within the Anthem blue cross PPO Network for covered medical services. If you choose from the more than 42,000 participating doctors or 440 participating hospitals that belong to the Anthem blue cross of California PPO Network, your costs will be based on negotiated fees, (the fees we agreed upon when the doctor or hospital joined our network) and you will save substantially.

The Good News About PlanScape®

You choose the doctors you want to use - all but one of the plans are PPO's.

Your health care is up to you and your doctor. You don't need pre service authorization for most covered treatment. (If you're not sure whether a service is covered, you can avoid unplanned expenses by asking your doctor to contact Anthem blue cross in advance. When a claim is submitted, services are reviewed to determine coverage amounts.)

You can choose different plans for different family members through our Family Elect program.

You get The Power of Blue:

- the best negotiated prices for services by the largest network of doctors and hospitals in the state

- access to HealthyCheckSM Centers and additional value through Healthy Extensions

- our Blue Card® program that provides access to network doctors and hospitals whenever you travel throughout the U.S.







What You Pay For Professional Services



Assumptions:
Billed charges: $1,000
Anthem blue cross negotiated fee: $600
In-Network Out-of-Network
Billed charges $1,000 $1,000
Anthem blue cross
discount - $400 N/A
Anthem blue cross
negotiated
fee $600 N/A
Anthem blue cross Payment* - $420
(70% of negotiated fee)
$300
(50% of negotiated fee)
You pay* $180(30% coinsurance) $700
*Assuming any deductible has been met and you have not yet reached your out-of-pocket maximum.




Choosing the Right Plan For You



Anthem blue cross of California offer a broad range of health plans, varying costs, levels of health coverage, and accessibility to health care. These are important considerations for helping you identify which plan is right for you.

Your Plan Type and Access to Health Care
The plan type you choose will determine how you select and access health care services. In general, the wider your choice of doctors and hospitals, the higher your costs will be in terms of premiums and/or levels of health care coverage.

Preferred Provider Organization (PPO) Plans featuring PlanScape®
The PPO Plans offer you the most flexibility in your choice of doctors and hospitals (providers). PPO Plans provide coverage (at different levels) for services from both Participating and Non-Participating Providers. Please see he PPO Plan section of this brochure for definitions of these and other terms related to PPO Plan Coverage.

Health Maintenance Organization (HMO) Plans
The Anthem blue cross of California HMO Plans cover more of the costs of your health care than any other plan type. HMO Plans provide coverage only for services received from doctors and hospitals within the HMO Network. You choose a specific health care group and physician within the network to coordinate all of your health care needs.

Anthem blue cross of California Plan Selections

PPO PLAN SELECTIONS
PlanScape® PPO Share Plans
The Anthem blue cross PPO Share Plans all cover the same comprehensive package of health care services. The difference is in the deductibles, coinsurance amounts and annual out-of-pocket maximums. Anthem blue cross offers a variety of PPO Share Plans so that you can more precisely choose the best pricing options for you.

Basic PPO and PPO Saver Plans
The Basic PPO and PPO Saver Plans offer in-hospital and surgical coverage with low affordable monthly premiums. These plans are designed to protect against great financial losses due to unexpected illness or injury. Both plans offer limited coverage for professional services; however, for a slightly higher premium, the PPO Saver Plan provides more covered professional services.

PPO Plan Highlights

Direct access to the doctors, hospitals and specialists of your choice
Immediate (deductible-free) benefits for office visits and generic drugs (except for the Basic PPO 1000 plan)
Payment at 100% for most covered services once you've met your out-of-pocket maximum
Coverage up to $5 million in benefits over your lifetime
Annual wellness screenings through HealthyCheck centers
MedCall 24-hour nurse access
Access to participating doctors and facilities nationwide through the BlueCard program when you travel
HMO PLAN SELECTIONS

The Anthem blue cross Individual HMO Plan provides extensive coverage with low out-of-pocket costs for covered health care services you received only from HMO Network doctors and hospitals.

The Anthem blue cross HMO Saver Plan provides the same coverage as the Individual HMO Plan, but has a deductible amount for services you receive from hospitals and other health facilities to keep the premiums lower.

For more information on what each plan covers, see Medical Plans At A Glance

The average office visit costs less with PlanScape®

When you visit a Anthem blue cross participating doctor, most of our PlanScape® plans require you to pay 20% or 30% of the negotiated cost of the visit. For a typical office visit, that 20% or 30% is less than the fixed copayments required by our competitors.

For example, the average negotiated cost of office visits to Anthem blue cross doctors is $60.

With PlanScape® you pay:

20% of $60 = $12
or
30% of $60 = $18

That's less than our competitors' copayment plans that require you to pay copayments of $20,$25,$30,$35 or $40!

Staying Healthy With HealthyCheckSM

Preventive Care Screenings

Take Control
Your health is your most important asset. Anthem blue cross helps put you in control of your health through affordable preventive care screenings that promote your physical well being. Staying healthy supports an active and fulfilling lifestyle.

Know Your Health
The HealthyCheck program offers members an annual preventive care screening that evaluates a variety of health risks. Screening results may confirm good health, identify where health may be improved, and may also reveal conditions that need further evaluation by your doctor.

Each HealthyCheck Screening includes:

Your choice of two levels of screenings for adults
A detailed, personalized health status report with recommendations for developing a healthier lifestyle,
A variety of educational materials to help you achieve and maintain optimum health, and
A summary of your results sent to your personal physician and available for you to take home immediately.
Keep a Record
You may elect to receive your detailed health status report by mail, or register your screening results on your designated web site for an instant report. Access and update your personal health information on our web site at any time and as often as you wish. Interactive features can help you keep track of your health status on a monthly, weekly, or even a daily basis.

It's Fast, Easy and Affordable

Screenings take just 30-45 minutes
You'll receive immediate results
Appointments are scheduled within 60 days and 30 miles of your home or place of employment
Screenings are available for just $25 or $75, depending on your choice of service options.
You'll Learn More About

Exercise and stress management
Nutrition
Men's and women's health issues
Back care and injury prevention
Tobacco, alcohol and drug abus
AIDS and STD's
Home Safety
$25 Screening includes

Blood pressure, body mass index, pulse and resting heart rate, skin cancer education and assessment of the heart lungs and abdomen;
Tetanus-diptheria booster and flu shots in season;
For adults, a total cholesterol, HDL ("good" cholesterol), and glucose fingerstick screening, monthly self-exam instruction and an individualized health status report;
For children, a hemoglobin fingerstick screening, urinalysis, vision and hearing screenings and may also include measles-mumps-rubella, polio and tetanus-diptheria boosters.
$75 Screening
includes services listed above, plus
(Available for adults 19 and over)

LDL ("bad' cholesterol)
Triglycerides
Colorectal cancer screening
Urinalysis
Flexibility testing
Body composition
Vision screening
Posture analysis
Self-care textbook (over 300 pages)
Additional HealthyCheck Services
(Available for both adult screening options)

Discounted blood pressure home test kit (for participants with borderline results)
Other Things You Should Know

Trained, licensed health care professionals administer all screenings. They will review screening results and lifestyle recommendations with you at your HealthyCheck screening appointment.
If you do not receive a flu shot during your screening because it is not flu season, you will be eligible for a future flu shot during flu season at no charge through a HealthyCheck provider.
About 10 days before your appointment, you'll receive a confirmation packet with instructions on how to complete your health status questionnaire (either paper or Internet version)
For adults, HealthyCheck also offers an online method for accessing and monitoring your health. Visit the HealthyCheck Web site (www.blucrossca.com/healthcheck), and choose the Health Status Report link to access the Health Quotient (HQ) Questionnaire. Once you complete it, you will have a personal web page that includes your health profile. You will also receive a Health Quotient score with personalized messages highlighting health concerns, potential risks and steps you can take to improve your overall health.
When Traveling - BlueCard®Extend the Power of Blue

At no additional cost, the BlueCard program provides coverage for PPO plan members who suddenly become sick or have a medical emergency outside California. The BlueCard gives you access to doctors and hospitals in participating local Blue plan networks throughout the nation as negotiated rates.

Your PPO plan member ID card will have the toll-free BlueCrad number printed on the back so that you always have the number with you when you travel. You can save money and have the security of knowing you have access to quality health care wherever you travel in the U.S.

George and Lisa are recently married and have started their own Internet company. With all the business startup costs, they need the most affordable health insurance they can get. They choose the PPO Share 2500, because they also hope to start a family in the next couple of years and that plan includes maternity coverage





What the Plans Do Not Cover



Every health plan has exclusions and limitations - what the plans do not cover. The primary exclusions and limitations for each of the plans described in this brochure are listed on the following pages.

Please take a few moments to review these listings. We want you to understand what your coverage does not include before you enroll.

These listings are an overview only. A comprehensive list of each plan's exclusions and limitations can be found in the plan-specific Evidence of Coverage booklet.

Exclusions and Limitations Common to All Individual Medical Plans

Conditions covered by workers' compensation or 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, services are excluded for those parts of Medicare the member has enrolled in.

Services or supplies that are not medically necessary, as determined by Anthem 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.

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 and for farsightedness (presbyopia)

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 Anthem 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.

Services furnished through outdoor treatment programs.

Outpatient speech therapy

Benefits for Hospice services are limited to a lifetime maximum of $10,000 per member for participating an non-participating providers combined (BC Life PPO Share 5000, BC Life PPO Share 1000, BC Life PPO Share 5000, PPO Saver, PPO Basic only).
Additional Exclusions and Limitations for Basic PPO Only

Maternity care.

Preventive benefits, except for Pap and PSA tests, and mammograms, not specifically listed in the plan policy.

Outpatient prescription drugs

Acupuncture/Acupressure

Physician office visits and associated costs, except as specifically described in the Certificate.

Physical or occupational medicine or chiropractic services, except provided during an inpatient hospital confinement.

Eye glasses and eye examinations.

Additional Exclusions and Limitations for PPO Saver Only
Maternity Care




Mental Health Coverage



Anthem 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 developmental norms.

For all PPO plans, coverage is provided for non-severe mental and nervous disorders and substance abuse as follows:

Inpatient Hospital (30 days/year maximum) -You pay all charges except $175/day.
Professional Services (1 visit/day; 20 visits/year maximum) - You pay all charges except $25/visit.
For more details regarding these benefits, refer to the Evidence of Coverage (EOC).




Emergency Care



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
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. Once your condition is stabilized, it is important for the hospital, you or a family member to contact your physician or Anthem blue cross about authorization of additional services.




Utilization and Preservice Review Procedures



Benefits are provided for services covered by the contracted Anthem blue cross plan. For your convenience, Anthem blue cross will review any inpatient hospital stay, skilled nursing facility stay, and other services and procedures to determine coverage. Your provider coordinates all preservice reviews. Preservice review is provided as a courtesy to help members avoid costs for any ineligible services. If you have any doubt about the coverage for any service, procedure or length of stay, please have your provider contact Anthem blue cross for preservice review.




Member and Anthem blue cross Rights and Obligations



No-Obligation Review Period

After you enroll in a Anthem 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 Anthem blue cross.

Your Right to Privacy

We do no 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 Anthem 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 Anthem 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 cal basis any claim or controversy against the other.

Grievances

All complaints and disputes relating to your coverage must be resolved in accordance with Anthem blue cross' grievance procedure. Grievances may be made by telephone or in writing; the phone number and address are located on your Anthem blue cross ID card. All grievances received by Anthem blue cross will be answered in writing, together with a description of how Anthem 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 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

Anthem 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 Anthem blue cross of California's incurred loss ratio for 2001 was 80.28 percent. This loss ratio was calculated after provider discounts were applied.
Anthem blue cross of California and BC Life & Health Insurance Company are independent licensees of the Anthem blue cross Association and are licensed to conduct business in the State of California