FAQs

1. Q: What is a PPO?

A: A PPO is a medical plan with a large group or network of providers contracted to provide their services at reduced rates. The PPO allows participants to use physicians and hospitals in the BlueChoice network, without the use of a primary care provider for referrals to specialists and hospitals. The Plan provides benefits for both in-network and out-of-network services, although the plan pays higher benefits for services provided in-network.

2. Q: Do I have to select a primary care physician (PCP) in the PPO?

A: You may seek covered services from any physician or hospital. In order to receive the highest level of benefits, you must select a provider in the Blue Cross BlueChoice network. If you receive covered services from a provider that is not part of the BlueChoice network, they will be covered at a lower level of benefits.

3. Q: How can I find a PPO doctor?

A: Use the BCBSTX online Provider Finder at www.BCBSTX.com when in the state of Texas, or if outside of the state of Texas use www.BCBS.com. You can search by doctor name, and by zip code. New providers will continue to be added to the network and some providers may elect to discontinue their participation. BCBSTX updates the online provider-listing semi-monthly. Please check again if your provider is not included in the current week's listing.

4. Q: Does the PPO have an annual deductible?

A: Yes, and the deductible is calculated on a calendar year basis. The deductible is the amount of your medical expenses that you will pay before the plan begins paying its benefit (the coinsurance.) PPO and Out of Area plan deductibles can be used to satisfy the 2005 PPO deductible.

5. Q: How does coinsurance apply in the PPO?

A: After you meet the annual deductible, coinsurance is the 20% (in-network) or 40% (out-of-network) of your medical expenses that you are responsible for paying, if applicable. Coinsurance applies to certain plan features, and copayments apply to certain plan features. The plan will pay the other 80% (in-network) or 60% (out-of-network).

6. Q: How do copayments apply in the PPO?

A: Copayments are fixed dollar amounts that you pay for some services, usually paid at the time that services are provided. The plan requires that you always pay copayments.

7. Q: Is there an annual maximum out-of-pocket limit in the PPO?

A: Yes. The annual maximum out-of-pocket expense is calculated with a combination of deductible, coinsurance and copayment expenses. Only the prescription copayments are excluded from the calculation. See the PPO section of this document for more details regarding the Annual Maximum. You will always pay copayments for perscription drugs, office visits, inpatient hospital stays and durable medical equipment. Others may apply.

8. Q: Will my doctor know that I have met the annual PPO deductible?

A: Doctors’ records will not reflect that you have met the annual deductible. Ask your doctor to contact BCBSTX to confirm that you have met the deductible, and only charge you the coinsurance for which you are responsible.

 

9. Q: I expect to change from the HMO to the PPO plan. If I have an outstanding referral to a specialist for use after May 1, could I still use the referral and have the services covered under the HMO?

A. There is no need for a referral in the PPO. If you change to the PPO and are not confined in a hospital or have a condition for which you require approved transition care by your HMO provider, services that you receive after May 1 must satisfy PPO Plan requirements for coverage. Starting May 1, you may see specialists or other providers of choice without a referral. If you have question about transition of care, contact BCBSTX Customer Service at 1-866-757-6875.

10. Q: I live outside the state of Texas, and was a member of the Out of Area plan. Is the PPO plan my only health plan option now?

A: The Out of Area plan is designed only for employees and retirees who live outside the HMO and PPO service areas. The HMO service area is 220 counties in Texas. The PPO service area is 51,000 zip codes in 49 states. At last count, there are only 6 families that live outside the HMO and PPO service area. Those families will be allowed to enroll in the Out of Area plan. Employees and retirees in the service areas will enroll in the HMO or PPO plan.

11. Q: Do I have to pay a copayment for my weekly allergy shot if I enroll in the PPO?

A: Yes. You will pay the office visit copayment each time that the injection is given in the doctor’s office, as long as an office visit is billed. If only the injection is given and no office visit is billed, the injection will be paid after deductible and coinsurance.

12. Q: What if I have a medical question in the middle of the night?

A: Whether you are in the HMO or PPO, you can call your personal physician or call CareWise at 800-987-7597. This 24-hour, toll-free health information line allows you to have a confidential conversation about your health questions with a registered nurse anytime of the day or night.

13. Q: Does the PPO cover routine physical exams and immunizations?

A: Yes. The Plan covers those services, both in –network and out-of-network with the applicable copayments and coinsurance.

14. Q: If my doctor does not participate in the PPO Network, can I still have my routine physical with him or her and just pay the out-of-network costs?

A: Yes. You might also ask your doctor if she/he is a ParPlan provider. A ParPlan provider is outside the official network, but has a special arrangement with BCBSTX to provide reduced rates to BCBSTX’s members. The provider agrees to accept BCBSTX’s allowable amount and will file the claim on the member’s behalf. The provider also agrees to not balance bill the member. Then your 40% coinsurance will be based on a lower billed charge.

15. Q: Does the PPO Plan cover emergency care?

A: The PPO provides benefits for the treatment of an emergency. If you go to an emergency room for treatment of an emergency within 48 hours after the incident that caused the emergency, your benefits will be the same regardless of whether you use an in-network or out-of-network provider. After 48 hours, the in-network benefit will be the same; the out-of-network benefit requires you to meet the annual deductible.

If you are admitted to the hospital from the emergency room or held for observation, your emergency copayment will be waived. If are admitted as a hospital inpatient, your benefits will be paid like any other inpatient facility or professional charges. If you are admitted to an out-of-network hospital, you may need to transfer to a participating hospital once your condition has been stabilized in order to continue receiving in-network benefits.

16. Q: Does the PPO plan cover urgent care visits?

A: The PPO plan provides an urgent care benefit when services are provided by a PPO urgent care facility.

17. Q: What happens to my coverage if I am temporarily out of the PPO service area?

A: Remember, Montana is the only state that does not have a PPO network. There are also 35 states that have participating HMO networks. Blue Cross and Blue Shield's BlueCard program offers cost-effective, quality health care for covered members across the United States. BlueCard is a valuable program that provides you network access and provider discounts across the United States. Use www.BCBSTX.com to locate a provider or call BCBSTX Customer Service at 1-866-757-6875. To contact BlueCard directly call 1-800-810-BLUE. Refer to your ID card for the phone numbers, and the suitcase symbol that indicates you are a BlueCard member.

18. Q: Can I cover a dependent who lives out-of-state, or my child away at school?

A: Your dependent(s) residing out-of-state will continue to be covered until their 25th birthday, if they are unmarried and still qualify as your dependent according to IRS rules. Refer to the BlueCard program for coverage options outside the service area.

If your dependent needs to fill a prescription, BCBSTX offers a comprehensive pharmacy network within the 50 United States and you will receive the in-network level of prescription drug benefits at any participating pharmacy. Call BCBSTX Customer Service or go online at BCBSTX.COM under pharmacy finder to identify participating pharmacies in the 50 United States. For non-participating pharmacies you will receive out-of-network benefits.

19. Q: Do I need preauthorization for a PPO hospital confinement?

A: Your in-network participating physician or specialist will coordinate preauthorization for hospital admissions for you. You may want to check with your participating provider to make sure preauthorization has been obtained.

If you use an out-of-network facility, preauthorization is still required for the confinement, private duty nursing, and skilled nursing facility admissions, and you are required to obtain it. You will pay an additional $250 copayment for failure to obtain preauthorization for admissions.

20. Q: Can I get reimbursed for drugs I got from a pharmacy outside of the network?

A: Yes. You may be reimbursed for prescription drugs that you received from an out-of-network pharmacy, but you may have to pay full charges at the pharmacy and file the claim. You will receive out-of-network benefits and be responsible for paying the copayment amount. Check www.BCBSTX.com to find a network pharmacy or call the customer service number that is on your ID card. Refer to BCBSTX.COM for the preferred drug list associated with your medical plan.


 
 
   

 

 
City of Houston
Health Fair

Thursday
April 21, 2005
9 a.m. to 2 p.m.

 
 

 

 

Important note:
If you are enrolled in the medical, dental or supplemental insurance plans and don’t want to make any changes - don’t do anything. Your coverage will remain in effect through April 30, 2006.

Important note: For medical and dental plans, only new enrollees will receive new ID cards for May 1, 2005. Your current ID card has no expiration date. If you need additional or replacement ID cards, order them through the provider, as usual.

 
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   
     

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