The University of Scranton — Access Care II Member Handbook

INTRODUCTION

Welcome To The Access Care II Program

Access Care II is a comprehensive health care coverage program which is tailored to meet the needs of a changing environment. Under Access Care II, you will continue to enjoy the freedom of selecting any network provider, while benefiting from managed care elements included in the product structure.

Access Care II provides members with comprehensive coverage through an extensive national network of facilities and physicians. This network structure, called a Preferred Provider Organization (PPO), allows Blue Cross of Northeastern Pennsylvania and Pennsylvania Blue Shield to contract with specific providers and keep quality of care high while holding costs down. This PPO structure extends outside of the Blue Cross of Northeastern Pennsylvania 13-county service area, to all areas of the country. As a result, you can take advantage of PPO discounted rates no matter where you live or travel. Members are welcome to seek care outside the Access Care II network of preferred providers although your out-of-pocket costs will generally be higher. However, in instances where covered services are unavailable from within the preferred provider network, members may be treated outside the network (with proper approval), and coverage will increase to the in-network payment level.

In order to ensure that you are receiving the proper services to which you are entitled, and are not being subjected to additional, unnecessary charges, Access Care II requires that certain diagnoses and procedures be precertified. This means that either you or the provider calls the Plan toll free at 1-888-338-2211 prior to the procedure, in order to receive authorization.

In emergencies, you should seek care from the nearest available provider. You will be covered at in-network levels, regardless of where you seek care. If the service requires precertification, you are responsible for contacting the Plan within forty-eight hours after the emergency, or as soon as reasonably possible.

This handbook will serve as a summarization of the benefits and main features of Access Care II. However, the complete terms and conditions are set forth in the contract between your employer, University of Scranton and Blue Cross of Northeastern Pennsylvania and Pennsylvania Blue Shield. Final interpretation of any specific provision is governed by reference to those documents.

Access Care II Benefits

Access Care II coverage includes benefits for facility, physician, and other professional provider services for you and your eligible dependents. Some benefits and services are subject to precertification before qualifying for coverage, and some services require copayment, coinsurance, or satisfaction of a deductible. A brief description of each of these terms is below, followed by an overview of your Access Care II benefits. If you have any questions, you should contact either your group, or call customer service, toll free 1-888-338-2211.

Copayments

A copayment is a specified amount of the Provider’s reasonable charge for specific benefits for which you are responsible. You are responsible for a copayment of $10 for physician office visits, a $35 copayment for visits to the emergency room and a $10 copayment for prescription drugs.

Coinsurance

Coinsurance is a specified percentage of the provider’s usual, customary and reasonable charge for covered services of which you are responsible. The coinsurance selected by your group is 0% for preferred providers and 20% coinsurance for non-preferred providers based on applicable usual, customary and reasonable fee schedule. Coinsurance applies to all covered services except emergencies and those services that are subject to a copayment or where specifically prohibited by law.

Payment for covered services performed by Non-Participating Professional Providers will be made to you on the basis of 80% of the applicable UCR fee schedule allowance or the amount charged, whichever is less. Such payment will constitute full discharge of Blue Shield’s liability under the program. Non-Participating Professional Providers are not obligated to accept the UCR fee schedule allowance as payment-in-full. You shall be responsible for payment of the remaining charges.

Out-of-Pocket Maximum

The out-of-pocket maximum is the highest amount of coinsurance for which you are responsible each calendar year. This feature is for your protection, to limit the amount of coinsurance expenses for which you are responsible. Your out-of-pocket annual maximum is $2,000 per individual; $4,000 per family for non-preferred providers.

Lifetime Maximum

When you use preferred providers you are not subject to a lifetime maximum. There is a $1,000,000 lifetime benefit maximum applied to all services performed by non-preferred providers. The lifetime benefit maximum is non-renewable.

Deductible

A deductible is a specified amount of covered services that must be incurred by you before the Plan will assume any liability for all or part of the remaining covered services. The deductible applies to all covered services, except for emergency care and services specifically prohibited by law.

While there is no annual deductible for preferred providers, your group specific annual deductible for non-preferred providers is $200 per individual; $400 per family.