Office of Human Resources - Benefits: Health

Benefits: Insurance: Medical Insurance

Changing Elections
Comparison of Plan Benefits
Electing or Declining Coverage
Filing Claims
How the Blue Cross PPO Plan Works
How the Blue Cross Traditional Plan Works
Medical Insurance

Medical Insurance

Eligible employees can enroll themselves and their eligible dependents for medical coverage, and have the choice of a Blue Cross of Idaho Traditional or PPO plan. Review the complete plan design online at:

State of Idaho Group Insurance Contracts

How the Blue Cross of Idaho Traditional Plan Works

After you pay an annual deductible, the plan generally pays 80% of most Allowable Charges. You can use any provider you want -- but you may save money when you use providers who belong to the Blue Cross of Idaho network of participating providers.

Participating Providers have negotiated with Blue Cross of Idaho to provide plan participants with services at the plan's Allowable Charges. That means they'll accept plan benefits plus your share of the costs (any deductible, coinsurance or co payments) as payment in full.
Non-Participating Providers may charge more than the plan's Allowable Charges, which means you're responsible for any amounts that exceed the Allowable Charges plus any deductible and coinsurance amounts.

To locate participating providers, refer to the Blue Cross of Idaho Online Provider Directory.

How the Blue Cross of Idaho PPO Plan Works

The PPO provides for In-Network and Out-of-Network benefits for most commonly provided services. After you pay an annual deductible, the plan generally pays 85% of most Allowable Charges provided by an In-Network provider. In-Network Physician Office Visits (office exam only) require a $20 co payment and are not subject to the annual deductible. Eligible Out-of-Network services are subject to a separate deductible, and are generally reimbursed at 70% of most Allowable Charges.

The PPO is not a managed care plan and you are not required to select a primary care physician. In addition, referrals are not required under the plan, you can use any provider you want. However, you save money when you use providers who belong to the Blue Cross of Idaho PPO network of participating providers.

Participating Providers have negotiated with Blue Cross of Idaho to provide plan participants with services at the plan's Allowable Charges. That means they'll accept plan benefits plus your share of the costs (any deductible, coinsurance or co payments) as payment in full.
Non-Participating Providers may charge more than the plan's Allowable Charges, which means you're responsible for any amounts that exceed the Allowable Charges plus any deductible and coinsurance amounts.

To locate participating providers, refer to the Blue Cross of Idaho Online Provider Directory.

Comparison of Plan Benefits

Blue Cross of Idaho For a network of providers see www.bcidaho.com 1-866-804-2253
BENEFIT PROVISION For Active Employees	Blue Cross of Idaho TRADITIONAL			Blue Cross of Idaho PPO
Annual Deductible	$350 Individual $1,050 Family			In-Network			Out-of-Network
				$250 Individual $750 Family			$500 Individual $1,500 Family
Comprehensive Lifetime Benefit Limit	$1,000,000 combined
Out of Pocket Maximum	$4,300 / Individual $8,600 / Family			$3,250 Individual $6,750 Family			$6,500 Individual $13,500 Family
Ambulance Transportation Dental Services Related to Injury or Injury to Sound Natural Teeth Diagnostic Services DME, Prosthetics, Orthotics Emergency Services Hospital Services Medical Professional Services Surgical Services Therapy Services (chemo, radiation, etc.)	80% of allowable charges after deductible			85% of allowable charges after deductible			70% of allowable charges after deductible
Chiropractic Care	80% of allowable charges after deductible for contracting providers 50% of allowable charges after deductible for non-contracting providers Limited to $500 per insured per benefit period			85% of allowable charges after deductible			50% of allowable charges after deductible
				Limited to $500 per benefit period, in-network and out-of-network combined
Mammography (Preventive Screening Mammogram)	Covered under wellness benefits			$20 co-payment			70% of allowable charges after deductible
Mammography (All other diagnostic mammograms)	80% of allowable charges after deductible			85% of allowable charges after deductible			70% of allowable charges after deductible
Maternity Services	80% of allowable charges after deductible No benefits for elective abortion			85% of allowable charges after deductible No benefits for elective abortion			70% of allowable charges after deductible No benefits for elective abortion
Routine Newborn Nursery Services	Allow benefits for newborn nursery services, subject to deductible and coinsurance			Allow benefits for newborn nursery services, subject to deductible and coinsurance
Physician Office Visits	80% of allowable charges after deductible			$20 Co-payment (office exam only, services subject to deductible and coinsurance)			70% of allowable charges after deductible
Outpatient Physical Therapy	80% of allowable charges after deductible; limited to $800 per insured per benefit period			See Outpatient Therapy Services			No benefits
PRESCRIPTION DRUG BENEFITS (TRADITIONAL AND PPO)
Network and Non-network Dispensing		Network Pharmacy Co-payments				Non-network Pharmacy Co-payments
34—day supply per co-payment Maintenance drugs—2 co-payments per 90-day supply (1-34 day supply—one co-payment; 35-90 day supply—2 co-payments)		Generic-$12 Brand-No generic equivalent-$18 Brand with generic equivalent-$40 plus difference between brand and generic				$25 co-payment plus 20% of balance.
DIABETIC SUPPIES (TRADITIONAL AND PPO)
Insulin syringes and needles covered within 30 days of insulin purchase, subject to one prescription drug co-payment; after 30 days, insured pays 100% $10 co-payment per item; blood sugar diagnostics, lancets, swabs and test strips.
CONTRACEPTIVES
Oral contraceptives only are covered for the enrolled employee or employee’s enrolled spouse. Birth control prescription drugs are not covered for dependent children.
WELLNESS/PREVENTATIVE SERVICES
Traditional			PPO
			In-Network		Out-of-Network
Specifically listed preventative care covered services are covered at 100%, up to a $250 maximum benefit per insured. When maximum has been met, specifically listed preventative care covered services are subject to deductible and coinsurance. Preventative care services not specifically listed are subject to deductible and coinsurance.			$20 co-payment, then 100% for specifically listed benefits. Preventative care services not specifically listed are subject to deductible and coinsurance.		No wellness benefits except for screening mammography services at 70% of allowable charges after deductible.
Specific Services: Well baby and well child care; routine or scheduled examinations, including Rubella and PKU tests; adult annual exams, including pap tests, fecal occult blood test, PSA tests and cholesterol panel, Complete Blood Count, (CBC) and Blood Chemistry Panel, (SMAC) tests. Immunizations. No travel vaccines. For preventative screening mammograms, see mammograms on prior pages. Disease Management Program: Focuses on two chronic ailments, Congestive Heart Failure and Diabetes. Programs serve to coordinate medical resources and information for both the plan member and the provider. This coordination can shift the care of chronic conditions from one of treatment, to that of prevention and early detection.

Electing or Declining Coverage

To enroll yourself and eligible dependents, you must complete an enrollment form and return it to Human Resources. To decline coverage, complete the declination of coverage section of the medical enrollment form and return it to Human Resources.

Once you have enrolled in a medical plan, (PPO or Traditional), you may not change to the other plan type until the next Open Enrollment period.

Changing Elections

After your initial enrollment period, you may:

Add family members at any time. You have 60 days to enroll new family members acquired through marriage, birth or adoption, in which case their coverage will begin the first of the month after they became part of your family (or, in the case of newborns and newborn adoptive children, on the date of birth). If you wait longer than 60 days to enroll them, coverage will be effective the first day of the month following the date you complete the enrollment form.
Drop coverage for yourself or dependents at any time, (effective date being the first of the month after an election form is completed).

Filing Medical Claims

After you enroll, you will receive an identification card from Blue Cross of Idaho. Whenever you receive services from a participating or In-Network provider, just show your ID card - the provider will bill the plan on your behalf.

When you use a Non-Participating or Out-of-Network provider, you may have to make a claim for reimbursement.

Submit a detailed invoice from your provider. Be sure to include your name, Blue Cross of Idaho subscriber identification number, and the name of your employer. The address is:

Blue Cross of Idaho
PO Box 7408
Boise, ID 83707

Idaho State University