Caroline Ehrenthal is an Independent, Authorized Agent for BlueCross BlueShield of Illinois.
With more than 7 million members in Illinois, Blue Cross and Blue Shield of Illinois® (BCBSIL), is the largest health insurer in Illinois. Started in 1936, BCBSIL is committed to promoting the health and wellness of its members and its communities through accessible, cost-effective, quality health care.
Blue Cross and Blue Shield of Illinois offers multiple products in Illinois all of which can be purchased through East Coast Health Insurance including group and individual health insurance coverage, managed care products, Medicare supplement coverage, and prescription drug coverage.
The Blue Cross Blue Shield of Illinois coverage is designed to provide you with economic incentives for using designated health care providers. It provides, to persons insured, coverage for major Hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily Hospital room and board, miscellaneous Hospital services, surgical services, anesthesia services, InHospital medical services, and OutofHospital care, subject to any Deductibles, Copayment provisions, or other limitations which may be set forth in the Policy.
Although you can go to the Hospitals and Physicians of your choice, your benefits under the SelectBlue Advantage plan will be greater when you use the services of participating Hospitals and Physicians.
Lifetime Benefit $5,000,000
With your choice of deductibles.
Deductible Per individual, per calendar year. (If two or more family members receive covered services as a result of injuries received in $250* the same accident, only one Deductible will apply.)
Carryover Deductible If an insured incurs covered expenses for the Deductible in the last three months of the calendar year, we will carry over that amount as credit toward the Deductible for the following $5,000* calendar year.
Family Aggregate Deductible Per family, per calendar year. Equal to three times the individual Deductible
Hospital Admission Deductible Per admission, per individual.
Coinsurance The level of coverage provided by the plan after the calendar year Deductible has been satisfied.
OutofPocket Expense Limit The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year.
Items asterisked (*) do not apply to the outofpocket expense limit.
Family Aggregate OutofPocket Expense Limit
Equal to three times the individual outofpocket limit, per family, $9,000 $18,000 per calendar year.
Participating NonParticipating Provider Coverage Provider Coverage
Outpatient Physician Medical/Surgical Services 100% after you pay Covered services OTHER THAN surgery, therapy, and certain $30 copayment per visit*† 50% diagnostic services received in a provider’s office, which are described immediately below
Surgery, therapy, and certain diagnostic services including MRI, 80% 50% CT scan, pulmonary function studies, cardiac catheterization, EEG, EKG, ECG, and SwanGanz catheterization.
Inpatient Physician Medical/Surgical Services 80% 50%
Wellness Care From age 16. Covers services associated with both an annual physical exam and an annual gynecological exam. Includes immunizations and routine diagnostic tests received or ordered on the same day as part of the exam. ($500 calendar year maximum per person.)
When covered services are received in a provider’s office 100% after you pay 50%* $30 copayment per visit*†
When covered services are received OTHER THAN in a provider’s office
WellChild Care To age 16. Includes immunizations, physical, 100% after you pay 50%* exams and routine diagnostic tests. ($500 calendar year maximum, $30 copayment per visit† per dependent for nonparticipating provider services only.)
Inpatient/Outpatient Hospital Services Includes surgery, preadmission testing and services received in a skilled nursing facility, 80% 50%
coordinated home care program and hospice. (For mental health coverage levels, please refer to mental health benefits on the next page.)
Inpatient/Outpatient Hospital Diagnostic Testing Includes, but not limited to, Xrays, lab tests, EKGs, ECGs, pathology services, 80% 50% pulmonary function studies, radioisotope tests, and electromyograms
Physical, Occupational, and Speech Therapist Services
80%* 50%* ($3,000 maximum per therapy, per calendar year.)
Temporomandibular Joint Dysfunction
80%* 50%* and Related Disorders ($1,000 lifetime maximum.)
Optional Maternity Coverage Inpatient/Outpatient Hospital services and Physician Medical/Surgical services. When elected, maternity 80% 50% benefits will begin 365 days after the effective date of the maternity coverage.
Outpatient Emergency Care (Accident or Illness) 80% after you pay For both Hospital and Physician. $75 copayment†
Additional Surgical Opinion Program Following a recommendation for elective surgery, provides additional consultations 100%† and related diagnostic service by a Physician, as needed.
Participating NonParticipating Provider Coverage Provider Coverage
Mental Health Unit In order to maximize your benefits, the Policyholder is responsible for notifying the Mental Health Unit for ALL care related to mental health and substance abuse. In the event of an admission, for either mental illness or substance abuse, notification is required three days prior for nonemergencies and within 24 hours or as soon as reasonably possible for emergencies. Failure to contact the Mental Health Unit may result in a reduction of benefits of up to $1,000.*
Other Covered Services Ambulance services; services of a private duty nursing service ($1,000 per month maximum*); naprapathic services rendered by a Naprapath ($1,000 per calendar year maximum*); oxygen 80% and its administration; blood plasma; surgical dressings; casts and splints.
Mental IllnessTreatment and Substance Abuse RehabilitationTreatment
Inpatient Care (30 Inpatient Hospital days per calendar year.) Physician 80%* 50%* Hospital First 14 days 60%* 50%*
Thereafter 50%* 50%*
Outpatient Care (30 visits per calendar year combined annual maximum and 100 visits per lifetime maximum.) Physician and Hospital 50%* 50%*
Medical Services Advisory (MSA®´) In order to maximize your benefits, the Policyholder is responsible for notifying the MSA for Hospital admissions at NonParticipating and NonPlan Hospitals. (MSA notification by the Policyholder is NOT required when services are rendered in a Participating Hospital.) MSA notification is required within three business days for nonemergencies and within one business day or as soon as reasonably possible for emergencies and maternity admissions. Failure to contact the MSA will result in a reduction of Hospital benefits of $1,000.*
Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility.
Durable Medical Equipment (DME) providers, Orthotic providers and Prosthetic providers are participating providers. Please refer to your Policy Book for details.
* Does not apply to outofpocket expense limit.
† Deductible does not apply.
†† Benefits will be significantly reduced if you use a nonparticipating pharmacy.
IF USING A NONPLAN PROVIDER…
A $300 per Hospital admission Deductible will apply.* If using a NonPlan Provider, benefits are reduced to 50%. However, Outpatient Hospital emergency care is paid at 80% after you pay a $75 copayment, regardless of your coverage level or whether services were received from a Participating, NonParticipating or NonPlan Provider.
PREEXISTING CONDITIONS LIMITATION Preexisting Conditions are those health conditions which were diagnosed or treated by a Provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment. Any Preexisting Condition will be subject to a waiting period of 365 days.
PREMIUMS We may change premium rates only if we do so on a class basis for all DB48 HCSC policies. Premiums can be changed based on age, sex, and rating area.
GUARANTEED RENEWABILITY Coverage under this Policy will be terminated for nonpayment of premiums. In addition, Blue Cross and Blue Shield may terminate or refuse to renew this Policy only for the following reasons:
1. If every Policy that bears this Policy form number, DB48 HCSC, is not renewed. If this should occur:
- Blue Cross and Blue Shield will give you at least 90 days prior to written notice.
- You may convert to any other individual policy Blue Cross and Blue Shield offers to the individual market.
- In the event of fraud or an intentional misrepresentation of material fact under the terms of this Policy. In this case, Blue Cross and Blue Shield will give you at least thirty (30) days prior written notice.
- If you no longer reside, live or work in an area for which Blue Cross and Blue Shield is authorized to do business. Blue Cross and Blue Shield will never terminate or refuse to renew this Policy because of the condition of your health. Blue Cross and Blue Shield may uniformly modify coverage provided by every Policy which bears this Policy form number only on the coverage Renewal Date.
Exclusions and Limitations:
- Hospitalization, Services, and supplies which are not Medically Necessary; Services or supplies that are not specifically mentioned in this Policy;
- Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers’ Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits except where not required by law;
- Services or supplies that are furnished to you by the local, state, or federal government; Services and supplies for any illness or injury occurring on or after your Coverage Date as a result of war or an act of war;
- Services or supplies that do not meet accepted standards of medical or dental practice;
- Investigational Services and Supplies, including all related services and supplies;
- Custodial Care Service;
- Routine physical examinations, unless specifically stated in this Policy;
- Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline, or other antisocial actions which are not specifically the result of Mental Illness;
- Cosmetic Surgery and related services and supplies, except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases;
- Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage; Charges for failure to keep a scheduled visit or charges for completion of a Claim form;
- Personal hygiene, comfort, or convenience items commonly used for other than medical purposes, such as air conditioners, humidifiers, physical fitness equipment, televisions, and telephones; Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery controlled implants, except as specifically mentioned in this Policy;
- Eyeglasses, contact lenses, or cataract lenses and the examinations for prescribing or fitting of glasses or contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this Policy;
- Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot or routine foot care;
- Immunizations, unless otherwise stated in this Policy; Maintenance Occupational Therapy, Maintenance Physical Therapy, and Maintenance Speech Therapy;
- Speech Therapy when rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorder, conceptual handicap, or mental retardation; Hearing aids or examinations for the prescription or fitting of hearing aids;
- Diagnostic Service as part of routine physical examinations or checkups, premarital examinations, determination of the refractive errors of the eyes, auditory problems, surveys, casefinding, research studies, screening, or similar procedures and studies, or tests which are Investigational, unless otherwise specified in this Policy;
- Procurement or use of prosthetic devices, special appliances, and surgical implants which are for cosmetic purposes, or unrelated to the treatment of a disease or injury;
- Services and supplies provided for the diagnosis and/or treatment of infertility including, but not limited to, Hospital services, Medical Care, therapeutic injection, fertility and other drugs, Surgery, artificial insemination, and all forms of invitro fertilization;
- Maternity Service, including related services and supplies, unless selected as an option (Complications of Pregnancy are covered as any other illness). Long Term Care; Inpatient Private Duty Nursing Service; Maintenance Care;
- Wigs (also referred to as cranial prosthesis);
- Services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this Policy.
* Does not apply to outofpocket expense limit.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association