Summary of Benefits - Blue Cross and Blue Shield of Illinois

Blue Cross Community
Integrated Care Plan (ICP) SM
Summary of Benefits
January 1, 2015 - December 31, 2015
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an
Independent Licensee of the Blue Cross and Blue Shield Association.
ILICPSB15 Approved 02202015
227603.0115
Summary of Benefits
Thank you for your interest in Blue Cross Community ICP. Our
plans are offered by Blue Cross and Blue Shield of Illinois. This
Summary of Benefits tells you some features of our plan. It
doesn’t list every service that we cover or list every limitation
or exclusion; and all services must be medically necessary.
We are open between 8 a.m. to 8 p.m. local time, seven days
a week from October 1 to February 14. From February 15 to
September 30 we are open 8 a.m. to 8 p.m. Central time,
Monday through Friday. Alternate technologies (for example,
voicemail) will be used on the weekends and Federal holidays.
The call is free.
Where is Blue Cross
Community ICP Available?
Llame al 1-888-657-1211 TTY/TDD 711. Estamos abiertos
de 8 a.m. a 8 p.m., hora central, los siete días de la semana
del 1 de octubre al 14 de febrero. Durante el 15 de febrero
al 30 de septiembre, estamos abiertos 8 a.m. a 8 p.m.,
hora central, lunes a viernes. Se usará tecnologías alternas
(por ejemplo, correo de voz) durante los fines de semana y
feriados. La llamada es gratuita.
The service area for Blue Cross Community ICP includes
Cook, DuPage, Kane, Kankakee, Lake, and Will counties.
Who is Eligible to Join Blue
Cross Community ICP?
You can join Blue Cross Community ICP if you are:
• Age 65 or older, or have a disability and over age 19
• Receiving Medicaid but not eligible for Medicare
• Living in Cook, DuPage, Kane, Kankakee, Lake, Will
counties.
Do You Have Questions?
Here are some numbers to call for more information:
Blue Cross Community ICP
Member Services
If you have any questions about the plan, or if you need an
interpreter or translation help with this document, please
contact Member Services.
Call toll-free 1-888-657-1211 • TTY/TDD 711
Illinois Client Enrollment Services
For questions about enrolling call:
1-877-912-8880 (TTY: 1-866-565-8576)
Website: www.enrollhfs.illinois.gov
Other Languages:
You can get this document in Spanish, or speak with
someone about this information in other languages for free.
Call 1-888-657-1211 TTY/TDD 711. The call is free. You
can also call Member Services, toll free, to request this
information in other alternative formats such as Braille,
Large Print and other forms.
Usted puede obtener este documento en español o hablar
con alguien, de forma gratuita, acerca de esta información
en otros idiomas. Llame al 1-888-657-1211 TTY/TDD
711. La llamada es gratuita. Usted también puede llamar
al Servicio para Miembros, de forma gratuita, para solicitar
esta información en otros formatos alternos tales como en
Braille, en letra grande y de otras maneras.
1
Blue Cross Community Integrated Care Plan (ICP)
Benefit Category
Copay ICP Benefit Limit/Exclusions
Abortion
$0
Advanced Practice Nurse Services
Ambulatory Surgical Treatment Center
Service
Audiology Services
Chiropractic Services
$0
$0
No
Yes
$0
$0
No
No
Dental Services, including Oral Surgeons
Emergency Dental Services
Emergency Transportation/Ambulance
Early Periodic Screening, Diagnosis and
Treatment (EPSDT) Services
Family Planning Services and Supplies
$0
$0
$0
$0
FQHCs, RHCs and other Encounter Rate
Clinic Visits
Hearing Aids and Batteries
$0
Home Health Agency Visits
$0
Hospital Emergency Room Visits
Hospital Inpatient Services
Hospital Ambulatory Services
Laboratory and X-ray Services
$0
$0
$0
$0
Medical Supplies and Equipment
$0
2
$0
$0
Covered when mother’s life
is endangered, result of rape
or incest.
Provider Must Obtain
Prior Authorization
Yes
Covered for enrollees under
age 21.
Covered for enrollees under
age 21.
Including but not limited to:
• Doctor visit
• Birth Control
• Family Planning and Education
No
No
No
No
No
No
One hearing aid/ear every three
years. Batteries limited to 32 per
60 days.
For non-waiver services, coverage
is limited to post-hospitalization
care.
Hearing aids require prior
authorization; batteries do not
require prior authorization
No
No
Yes
Yes
Yes, under certain circumstances.
Genetic testing requires prior
authorization. Hi tech radiology
(MRI, CT, PET, etc.) requires prior
authorization.
Yes, under certain circumstances.
Summary of Benefits
Benefit Category
Copay ICP Benefit Limit/Exclusions
Mental Health (Behavioral Health)
Services
Nursing Care
$0
Nursing Facility Services
Optical Services and Supplies
$0
$0
Optometrist Services
Palliative and Hospice Services
Pharmacy Services and
Prescription Drugs
Physical, Occupational and Speech
Therapy Services
$0
$0
$0
Physician Services
Podiatric Services
Post-Stabilization Services
Practice Visits for Enrollees with
Special Needs to the Dentist
Prosthetics and Orthotics
Radiology Services
Renal Dialysis Services
Respiratory Equipment and Supplies
Subacute Alcoholism and Substance
Abuse Services, Day Treatment
(Residential) and Day Treatment (Detox)
$0
$0
$0
$0
Evaluation and re-evaluation do not
require prior authorization. All other
physical, occupational, and speech
therapy services require prior
authorization.
No
No
No
No
$0
$0
$0
$0
$0
No
No
Yes
Yes, under certain circumstances.
Yes, under certain circumstances.
$0
$0
Includes Inpatient, counseling,
prescription drugs.
Covered for Enrollees under age
twenty-one (21) not in the HCBS
Waiver for individuals who are
MFTD or for enrollees under 21
transitioning from a hospital to
home placement or other setting.
Provider Must Obtain
Prior Authorization
Yes, under certain circumstances.
One pair of eye glasses every
two years. (*Also, see Added
Benefits below)
One eye exam per year.
Quantity limits may apply.
Yes
No
No
Yes
Yes
3
Blue Cross Community Integrated Care Plan (ICP)
Added Benefits
The below are “Added Benefits” which are benefits you
receive in addition to your standard benefits above.
No copays
• $0 for doctor visits
• $0 for emergency room (ER) visits
• $0 for prescriptions
Cell Phone
You may qualify for a free cell phone to call your doctor, care
coordinator, or 911 emergency services.
Transportation
In addition to the standard benefit of transportation to covered
services, as an added benefit you may also get transportation
to the pharmacy after a provider appointment.
Prescriptions
• 90-day supply mailed to your home
• Medicaid’s four prescription limit per month does not apply
Dental
The following are additional dental benefits:
• Two oral exams each year
• Two preventative cleanings each year
• One set of x-rays per year
Also, eligible pregnant women can get these additional
dental services prior to the birth of their babies:
• Periodic oral examination
• Teeth cleaning
• Periodontal work
*Some limits apply to the general dentistry above.
For members with special needs, we cover practice visits
to the dentist.
4
Optical (Vision)
As part of your standard benefit, you receive one pair of
eyeglasses every two years. As an added benefit, you can
receive up to $100 towards a pair of upgraded eyeglass frames.
Healthy Incentives Program
You may qualify for gift cards for completing preventive services
or going to your doctor after certain hospital or ER visits.