Blue Cross/Blue Shield
Indemnity Plan Member Handbook

Section II — Hospital

Hospital Benefits

Covered Services

The following inpatient services will be covered for semi-private bed patients when consistent with the diagnosis and treatment and when administered by an employee of a facility. This coverage is provided for admissions occurring on or after your effective date:

1. Bed and board, including special diets and general nursing care;
2. Intensive Care Unit and Cardiac Unit;
3. Use of operating, delivery, recovery,cystoscopic, treatment and other specialty service rooms, plus equipment and supplies;
4. Casts;
5. Surgical dressings and supplies;
6. Physical Therapy;
7. Radiation Therapy;
8. Oxygen and Oxygen Therapy;
9. Chemotherapy;
10. Administration of blood and blood plasma, including the processing of blood from donors (but excluding the cost of blood and blood plasma);
11. Anesthetic supplies and the use of anesthetic equipment;
12. Anesthesia;
13. All drugs, medications and combinations thereof (including intravenous injections and solutions) for use while in the hospital, which are released for general use and are commercially available to hospitals;
14. Laboratory examinations;
15. X-ray examinations and radiation testing;
16. Cardiographic examinations and electroencephalograms.

Subscriber Co-Payment

The participant pays to the facility $5 per day for the first 15 days of each inpatient admission during any 12 month period up to a maximum payment of $75 for all participants under the Plan.

Duration of Benefits

Regular Admissions: You and each of your enrolled dependents will be entitled to 365 days per calendar year of hospital care.

Special Admissions

Mental and Nervous Disorders: Up to 30 of the participant’s eligible benefit days are available for this care during any consecutive 12 month period.

Psychiatric Care: Full coverage is provided for psychiatric care when received in an approved day or night care center, under a program approved by Blue Cross. Each visit will count as ½ day toward the 30 days provided for mental and nervous disorders.

Alcohol or Drug Abuse Treatment:

1. Inpatient detoxification when provided either in a participating Hospital or on an inpatient basis in a participating non-hospital facility which is licensed as an approved alcohol and/or drug addition treatment program and is approved by the Department of Health. The inpatient detoxification treatment is subject to a lifetime limit of 4 admissions and reimbursement per admission is limited to 7 days of treatment. The following services will be covered when administered by an employee of the facility;
   1. Lodging and dietary services.
   2. Physician, psychologist, nurse, certified addiction counselors and trained staff services.
   3. Diagnostic X-ray.
   4. Psychiatric, psychological and medical laboratory testing.
   5. Drugs, medicines, equipment use and supplies.
2. Non-hospital residential alcohol or other drug abuse services when provided in a participating non-hospital facility which is appropriately licensed by the Department of Health as an alcoholism or drug addiction treatment program. This treatment will be limited to 30 days per year subject to a lifetime maximum of 90 days. In those specialized cases where an approved facility has a contract with BCNEPA which provides for additional treatment, the benefits will not be limited to 30 days per year. The following services will be covered when administered by an employee of the facility:
   1. Lodging and dietary services.
   2. Physician, psychologist, nurse, certified addiction counselors and trained staff services.
   3. Rehabilitation Therapy and counseling.
   4. Family counseling and intervention.
   5. Psychiatric, psychological and medical laboratory testing.
   6. Drugs, medicines, equipment use and supplies.
3. Outpatient alcohol or other drug abuse services when provided in a participating facility appropriately licensed by the Department of Health as an alcoholism or drug addiction treatment program. Thirty outpatient, full session visits or equivalent partial visits are available per benefit year and are subject to a lifetime maximum of 120 outpatient, full session visits or equivalent partial visits. The following services will be covered when administered by an employee of the facility.
   1. Physician, psychologist, nurse, certified addiction counselors and trained staff services.
   2. Rehabilitation Therapy and counseling.
   3. Family counseling and intervention.
   4. Psychiatric, psychological and medical laboratory test.
   5. Drugs, medicines, equipment use and supplies.
4. An additional 30 outpatient, full session visits or equivalent partial visits, which may be exchanged on a two-for-one basis for up to 15 non-hospital, residential alcohol or drug treatment days, shall be available in addition to the benefits in 2. and 3. These additional benefits are subject to the lifetime maximums indicated.
5. If alcohol or other drug abuse services are provided in a non-hospital facility that is located outside of the Service Area and the facility does not have a contract with the Blue Cross Plan servicing the area in which it is located, BCNEPA will pay to the subscriber 70% of the eligible billed charges.
6. All inpatient and outpatient treatment must be pre-certified by BCNEPA. In order to obtain pre-certification, the attending physician must provide evidence prior to ordering such treatment, in a form satisfactory to BCNEPA, that alcohol or drug abuse treatment is medically necessary and appropriate. Prior to admission, the Alcohol or Drug Abuse Facility shall advise the Plan’s Medical Review Department by telephone with necessary information. Also, the same procedure is to be followed should the participant’s condition require an extension of inpatient or outpatient treatment beyond the approved period.

Determination by BCNEPA as to eligibility for benefits shall be conclusive.

Skilled Nursing Care Facility: Following at least 3 days in the hospital, benefits will be provided in a Skilled Nursing Facility if admitted within 14 days following discharge, for continued treatment of the same or related condition which required hospitalization, when certified as medically necessary by a doctor. Three days in a Skilled Nursing Facility will count as 1 day in a hospital against the subscriber’s eligible benefit days.

Pre-Admission Certification (PAC)

When any participant requires treatment on an inpatient basis, benefits for covered services as described in this Section II will be provided only if a licensed physician provides evidence prior to such admission, in a form satisfactory to BCNEPA that the following hospitalization is medically necessary and appropriate:

1. All out-of-area inpatient medical/surgical admissions.
2. All psychiatric and substance abuse inpatient admissions.
3. Skilled Nursing Facility admissions.
4. Home Health services.
5. Private Duty Nursing cases.
6. Complications of same day surgeries requiring inpatient admission.
7. Partial psychiatric hospitalizations.
8. Physical rehabilitation hospitalization.
9. Dental extraction of impacted wisdom teeth as inpatient or same day surgery (not physician office).

Determination by BCNEPA as to eligibility for benefits under 1 through 9 above shall be conclusive;

When a proposed inpatient stay is determined not to be eligible for benefits under this provision, if otherwise medically necessary and appropriate, benefits will be provided for outpatient services as set forth in Section II of this booklet.

Pre-Admission Certification for emergency inpatient admissions is waived. However, the physician must submit an admission notification to Blue Cross within 48 hours or the first regular business day of the emergency admission so that a specific number of inpatient days can be assigned.

Maternity Admissions

Normal deliveries as opposed to a surgical delivery (Caesarean Section) do not need pre-certification (PAC).

Any Caesarean Section or complications of pregnancy which require greater than three (3) days inpatient hospitalization requires PAC in out-of-area hospitals only.

Appeal Procedure: In the event BCNEPA has determined that the participant is not eligible for benefits, the participant may submit an appeal by telephone within 24 hours or in writing to Blue Cross. Such appeal must be submitted not later than 60 days from the date Blue Cross notified the subscriber of its determination and should include specific information in support of the subscriber’s eligibility for benefits. Blue Cross will then notify the subscriber of its final decision in writing, not later than 60 days following receipt of the subscriber’s appeal.

Note: Certification of your admission refers only to the medical necessity of the admission. Once the certified admission takes place, payment of benefits is subject to the patient’s eligibility on the admission date.

Oral Surgery

Full coverage is provided for oral surgery if the participant’s doctor certifies that hospitalization is necessary and only if such surgery consists of cutting procedures for the treatment of fractures and dislocations of the jaw, for removal of bone- impacted teeth and for surgery for injuries to the jaw or any structure contiguous to the jaw or dislocation of any facial bone.

Transplant Services

Full coverage is provided for eligible human transplant services, including services performed for the removal of an organ from a donor when the donor is not a participant and not covered under another health care Plan. The services must be directly and specifically related to the transplantation to be eligible.

If an organ or tissue is sold rather than donated to the participant, no benefits will be payable for the purchase price of such organ or tissue.

Maternity Care

Maternity benefits for all female participants who are enrolled under the Plan will be provided in the same manner as for any other medical condition. This coverage includes medically necessary diagnostic services in connection with pregnancy as well as the services of a State approved Birthing Center.

Newborn Care

Nursery care of the newborn child also will be covered for this same period while the mother is hospitalized.

Private Room

If you use a private room, you will be expected to pay the difference between the private room charge and the average charge made by the hospital for its regular semi-private accommodations. You will receive full allowance for all other services previously described.

If, due to overcrowded conditions, semi-private accommodations are not available and you or your covered dependent must use a private room or other accommodations, BCNEPA will arrange with the hospital that during the time the semi-private accommodations are not available, such other accommodations be provided on a basis which will involve no charge therefore to you. However, if you are hospitalized in an institution where only private room accommodations are available, BCNEPA ill pay to the hospital an amount equal to the average semi-private charges being made in that general are. You will be expected to pay the difference between the private room charges and this amount.

Outpatient Care

Accidental Injury: Full service benefits will be provided for hospital treatment rendered within 72 hours of an accident.

Emergency Medical Care: Full service benefits will be provided for emergency medical care (initial visit only, not follow-up care) rendered within 72 hours of the onset of the medical emergency. This includes heart attacks, strokes, convulsions, diabetic coma, etc.

Note: If you should require outpatient services

Outside Northeastern Pennsylvania, pay the bill and submit your itemized receipt to Blue Cross of Northeastern Pennsylvania. Write your Agreement number and Plan number on the receipt. If the reason for which treatment was given is not indicate, attach a brief note explaining the circumstances.

Diagnostic Services

All accepted, medically necessary diagnostic testing is covered when ordered by a doctor.

Outpatient diagnostic services are not provided for care of teeth, research studies, screening, routine physical examinations or checkups, premarital examinations and audiometric testing or eye refraction examinations.

Routine Gynecological Examination And Routine Papanicolaou Smear

Benefits are provided for one (1) routine Gynecological Examination, including a pelvic examination and clinical breast examination and one (1) routine Papanicolaou Smear per calendar year for all female participants. Benefits are exempt from all deductibles and maximums.

Mammography Screening

One mammography screening per calendar year is covered for all participants age 40 and over whether or not directed toward a definite condition of disease or injury. Mammographs which are recommended by a physician are covered for all subscribers.

Benefits for mammography screening are payable only if performed by a mammography service provider who is properly certified by the Department of Health in accordance with the Mammography Quality Assurance Act of 1992.

Diabetes Education Services

Covered services include participation in one diabetes self-management education program per member per lifetime and one consultation in each year following participation in and completion of the diabetes education program.

Limitation: Benefits will only be provided if the member completes the diabetes education program. Services must be provided by a Participating Hospital. Services must be

performed in conjunction with a program certified by the Pennsylvania Department of Health or the American Diabetes Association and recognized by Blue Cross of Northeastern Pennsylvania.

Pediatric Immunizations

Benefits are provided for those pediatric immunizations, including the immunizing agents, which as determined by the Department of Health, conform with the standards of the Advisory Committee on Immunization Practices of the Center for Disease Control of the U.S. Department of Health and Human Services. Benefits are limited to dependent children and are exempt from deductibles or maximums.

Outpatient Surgery

Full service benefits will be provided for outpatient surgery. This includes necessary follow-up care received within 72 hours of the initial surgery, except for application or reapplication of casts, in which case there is no time limit.

Radiation Therapy

Outpatient Radiation Therapy is covered when received in the outpatient department of a hospital and billed for by the hospital.

Chemotherapy

Outpatient Chemotherapy is covered when received in the outpatient department of a hospital and billed for by the hospital. This includes related hospital charges incurred the same day that treatment is given.

Respiratory and Physical Therapy

Outpatient Respiratory and Physical Therapy are covered, following an illness or injury for which the participant was hospitalized, during the 90 day period following discharge. Speech and Occupational Therapy are not covered.

Home Health Care

Following an inpatient admission or where medically feasible in place of hospitalization, the participant will be eligible for up to 100 Skilled Home Care visits in a period of 12 consecutive months following the date of the first visit.

Benefits will be available if the participant is essentially homebound and the attending physician has: (1) ordered Home Health Care, (2) received Pre-Certification approval from BCNEPA, and (3) furnished, in consultation with the Member Home Health Agency’s professional personnel prior to the first visit, a written plan of treatment stating that the services ordered are medically necessary. Continuing eligibility requires that the attending physician provide such a plan of treatment at intervals of no less than every 30 days.

Covered services include drugs that under Federal law may be dispensed only by written prescription and are approved for general use by the Food and Drug Administration.

BCNEPA will issue a Prescription Drug identification card for the participant to the Participating Home Health Agency. The Agency will distribute the card to the participant and obtain it at the time of a discharge, or when benefits are exhausted or terminated by Blue Cross. The Prescription Drug identification card is only eligible for the covered Benefit Period as determined by the Blue Cross Pre-Certification process. Each prescription is limited to a 15 day supply.

In addition, the following Home Health Care services are covered when provided by qualified health care professionals: Registered or Licensed Practical Nurse Services, but not including special duty nurses; home health aide services as assigned and supervised by a registered nurse; physical therapy treatments; speech pathology services; occupational

Therapy treatments; a medial social service consultation; nutritional guidance counseling; diagnostic and therapeutic radiology services; laboratory services; machine diagnostic testing; oxygen and inhalation therapy; medical-surgical supplies, including bandages, dressings and casts; the rental of durable medical equipment on a short term basis only (if not Agency owned); and other services necessary for intermittent skilled services which are approved by the Plan.

Only benefits provided by a Participating Home Health Agency of a Blue Cross Plan will be eligible. Home care does not cover the following: meals; professional medical services of housekeepers; private duty nursing; ambulance service; drugs other than prescription drugs and such other non-legend drugs not specifically designated by Blue Cross; or services of immediate relatives or members of the participant’s household.

Pre-Certification of Home Health Care:

When any participant requires Home Health Care, benefits for covered services will be provided as follows:

1. The attending physician must provide evidence prior to ordering such treatment, in a form satisfactory to BCNEPA, that Home Health Care is medically necessary and appropriate;
2. For each admission the Participating Home Health Agency shall advise the Plan’s Medical Review Department by telephone with necessary information. Also, the same process is required should the participant’s condition require an extension of skilled home health care visits beyond the approved period.
3. Determination by BCNEPA as to eligibility for benefits under 1 and 2 above shall be conclusive.

Hospice Care

Hospice care benefits are available if the attending physician has certified that the patient is terminally ill with a prognosis of 6 months or less to live and has received approval by Blue Cross prior to referring the patient to a Blue Cross Participating Hospice Organization. In addition, the participant must reside within a reasonable distance of a Participating Hospice Organization.

Eligible Hospice Care Services include the following:

1. Professional nursing services;
2. Home health aid services;
3. Laboratory services;
4. Therapy services (except for dialysis treatments);
5. Medical-Surgical supplies and durable medical equipment;
6. Prescribed drugs;
7. Oxygen and its administration;
8. Medical social services;
9. Palliation for pain control and symptom management;
10. Respite care in a member Blue Cross Skilled Nursing Facility (limited to 5 days in a 3 month period);
11. Family counseling related to the patient’s terminal condition;
12. Dietitian services;
13. Hospice inpatient room, board and general nursing services for acute pain management (payable under the basic hospital benefit); and
14. Bereavement counseling (limited to 2 visits).

The maximum hospice benefit payment by Blue Cross will be $8,000. No benefits will be provided for services provided by a Non-Participating Hospice Organization.

Pre-Admission Testing (PAT)

Outpatient benefits will be provided for services ordinarily received on an inpatient basis for the participant who, when scheduled for admission to a Participating Hospital, receives, prior to actual admission as an in patient, the usual and specific diagnostic services ordinarily associated with the condition requiring hospitalization.

If the condition to which PAT is related would not be covered under this program if the participant were admitted as an inpatient, PAT benefits will not be available.

Benefits In Non-Participating Hospitals

1. Inside United States:
   1. Outpatient treatment for accidental injury within 72 hours and for outpatient surgery, the program will pay up to $50 or 70% of billed charges, whichever is greater. Payment to school infirmaries will be up to $12 per day.
   2. For outpatient x-ray and laboratory tests, up to $100 or 70% of billed charges, whichever is greater.
   3. For all other medically necessary eligible services as set forth herein, the program will pay 70% of billed charges.
2. Outside United States:
   1. Outpatient treatment for accidental injury within 72 hours and for outpatient surgery, the program will pay up to $50 or 80% of billed charges, whichever is greater.
   2. For outpatient x-ray and laboratory tests, up to $100 or 80% of billed charges, whichever is greater.
   3. For all other medically necessary eligible services as set forth herein, the program will pay 80% of billed charges.
3. Admissions for Mental or Nervous Disorders:
   1. Blue Cross will pay the billed amount for hospital services provided for mental and nervous disorders up to $10 per day for a maximum period of 30 days in any consecutive 12 month period.

Benefits in Non-Participating Skilled Nursing Facilities

In a Non-Participating Skilled Nursing Facility, Blue Cross will pay to the participant 70% of billed charges made by the Skilled Nursing Facility for the services described in this section.

Exclusions

Unnecessary inpatient admission for treatment, diagnosis, diagnostic study or medical observation when care could be provided on an outpatient basis and the condition of the participant or the nature of the procedure does not medically necessitate the participant’s being hospitalized as an inpatient. However, benefits will be provided for diagnostic procedures which would have been eligible for coverage if received on an outpatient basis.

Inpatient or Outpatient Hospital Care for:

1. Dental Care, even if medically necessary, except when provided under Oral Surgery in the Plan.
2. Custodial care; research studies; screening examinations; checkups; rest cures; convalescent care; weight reduction; routine physical or pre-marital examinations; hearing test; and eye refraction examinations.
3. Cosmetic surgery or treatment, unless required for correction of damage caused by accidental injury sustained while the participant is covered under the Plan.

Services, Facilities and Supplies when:

1. The expenses are paid or which the participant is entitled to have paid or obtain without cost in accordance with law or the regulations of Medicare, CHAMPUS-CHAMPVA, the Department of Defense for Active Personnel, the Veterans’ Administration, the National Health Service of the Bureau of Vocational Rehabilitation;
2. Furnished in federal Institution;
3. Furnished in connection with a disease contracted or injury sustained during military service or war;
4. Furnished for an occupational condition, ailment or injury arising out of and in the course of employment, for which hospitalization coverage is or was available in full or in part under Worker’s Compensation laws or similar state or federal legislation, even though the participant’s rights have been waived or expired;
5. Charges for them are recoverable by or on behalf of the participant in any action at law or in compromise or settlement of a claim against a party other than an insurer of the subscriber;
6. Furnished without charge to the participant;
7. Treatment for alcohol or drug abuse is rendered in a facility located within the Plan’s Service Area which does not have a contract with Blue Cross of Northeastern Pennsylvania.

Services covered under the other subscriber Agreements issued by any Blue Cross Plan, provided, however, that this provision will not operate to deny such coverage by both/all Plans.

Charges for blood donor; cost of blood, blood plasma or derivative.

Services of attending or emergency room doctors, surgeons, other specialists; charges for services or board of private duty nurses.

Home Care Services for: meals; professional medical services billed for by a doctor; custodial care; services of housekeepers; prescription and non-prescription drugs and biologicals; Occupational Therapy; services of immediate relatives or members of the participant’s household.

Services, supplies, or charges which are Experimental/Investigative in nature.

Inpatient admissions not certified as eligible under the Pre-Admission Certification provision.

Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid under a Plan or policy of motor vehicle insurance, including a certified self-insured Plan, or payable under the Catastrophic Loss Trust Fund established under the Pennsylvania Motor Vehicle Financial Responsibility law.

Sexual dysfunction not related to organic disease.

Treatment in connection with transsexual surgery, artificial insemination, in-vitro fertilization.

For elective abortions, except however, services rendered to treat illness or injury resulting from an elective abortion, services which are necessary to avert the death of the woman and services to terminate pregnancies caused by rape or incest will be covered.

Services other than described herein.

Member Hospitals in Northeastern Pennsylvania

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