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2008

Medicare &
You

PUBLICATION
CONTENTS:

Introduction

What Is
Medicare?

Medicare's
Gaps

Medicare
Part A Gaps

Medicare
Part B Gaps

Who Pays
First

Making A
Wise Choice

Preferred
Providers

Submitting
Claims

Prescription
Drugs

Medicare
Advantage

Preventive
Care

FEP BlueVision

Discount Drug
Program

Vision Care
Affinity
Program

Blue Health
Connection

Fraud And
Abuse

Terms And
Definitions

If You Have
Questions

The Advantages Of Using Preferred Network Providers

Your Blue Cross and Blue Shield Service Benefit Plan coverage includes the advantage of access to Preferred network physicians, hospitals, pharmacies, and dentists all over the United States. Having access to Preferred network providers whether you're at home or away can make a big difference in your out-of-pocket costs, particularly if the Service Benefit Plan pays first.

Why Use Preferred Providers?

• Preferred network providers file your claims for you.

• You pay less for health care when you use Preferred network providers because we pay more of the total cost for covered services.

• Preferred providers accept our allowance as payment in full. You pay only your deductible, copayment and/or coinsurance amounts for covered services. If you have Medicare Part B as your primary coverage, these amounts are waived (except for prescription drugs).

• Your hospital copayment for covered inpatient care is less when you use a Preferred network hospital. And, the hospital copayment is waived when Medicare Part A is the patient's primary payer.

• Preferred network providers may help obtain precertification for you. Precertification must be obtained for all inpatient admissions. Benefits are reduced by $500 if it is not obtained before a planned admission or within two business days after an emergency or unscheduled admission. If you're not sure about the precertification procedures for your hospital admission, be sure to call your local Plan for instructions.

If Medicare is your primary insurer (your benefits are paid first by Medicare, and then by the Blue Cross and Blue Shield Service Benefit Plan), please remember:

• The precertification requirement for hospital stays does not apply to you if Medicare Part A is primary. Also, hospitals will file your Medicare claims for you.

• If Medicare Part B is primary, doctors and other covered providers will file your Medicare claims for professional care.

• Your claim will usually be automatically forwarded to the local Blue Cross and Blue Shield Plan for any balance due after Medicare's payment.

• If you have Basic Option coverage the provider must be in our Preferred network for the care to be eligible for benefits, even if Medicare is the primary payer.

For a directory of Preferred network providers, call your local Blue Cross and Blue Shield Plan or check the provider directory under the Provider Directory feature on this web site. And please remember that the Preferred network status of a provider can change during the year, so it's always a good idea to call the Plan to double check the provider's current status.

How Your Bills Are Paid

When you use Non-preferred providers and the Blue Cross and Blue Shield Service Benefit Plan is primary:

Basic Option:

Benefits are only available for care rendered by Preferred providers except in certain situations. Therefore, Basic Option benefits are not available when you use Non-preferred providers.

Standard Option:

Participating physicians have an agreement with us to accept a certain amount from us for your health care services. Benefits for covered services provided by Participating physicians are paid based on the Participating Provider Allowance (PAR), a negotiated allowance Participating professional providers agree to accept as payment in full.

Participating providers also agree to submit claims for your care directly to us, which saves you the trouble of filing claims.

Participating physicians should not bill you for any amount over the PAR. If you have Medicare Part B and you use services covered under the Blue Cross and Blue Shield Service Benefit Plan, your physician's bill usually will be paid in full (after Medicare pays its secondary benefits) when you use these physicians.

If you use a Non-participating physician, benefits will be paid based upon the Non-participating Provider Allowance (NPA). This is an allowance based on the greater of (1) the Medicare participating fee schedule payment for the service or supply or if there is no equivalent Medicare fee schedule amount, 60 percent of the Billed charge if there is no equivalent Medicare fee schedule amount, or (2) 100 percent of the 2008 Usual, Customary and Reasonable (UCR) amount. Non-participating providers are under no obligation to accept the NPA as payment in full. You are responsible for amounts above the Plan's payment up to the provider's total charge except in certain circumstances. In addition, you are responsible for any applicable deductible, coinsurance or copayment amounts.

Refer to the Plan Allowance definition in Section 10 of the 2008 Service Benefit Plan brochure (RI 71-005) for more information about how different types of providers are paid under your coverage and your payment responsibility. You can also refer to Section 4 in the brochure under Differences between our allowance and the bill.

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