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Benefit BookletFor Employees ofDuke University and Duke University Health System2022An Independent Licensee of the Blue Cross and Blue Shield AssociationL1338, 7/13Blue Care / AC000389
BENEFIT BOOKLETThis benefit booklet describes the Duke University and Duke University Health SystemEMPLOYEE health plan (the PLAN). Blue Cross and Blue Shield of North Carolina providesadministrative claims payment services only and does not assume any financial risk orobligation with respect to claims.Please read this benefit booklet carefully.The benefit plan described in this booklet is an EMPLOYEE health benefit plan, subject to theEmployee Retirement Income Security Act of 1974 (ERISA) and the Health InsurancePortability and Accountability Act of 1996 (HIPAA). A summary of benefits, conditions,limitations and exclusions is set forth in this benefit booklet for easy reference.In the event of a conflict between this benefit booklet and the terms in the PLAN document,the PLAN document will control.Amendment and/or Termination of the PLANThe PLAN SPONSOR expects this PLAN to be continued indefinitely, but the PLAN SPONSORreserves the right to terminate the PLAN at any time with respect to its EMPLOYEES by awritten instrument signed by an officer of the PLAN SPONSOR. Such termination may be madewithout the consent of the MEMBERS, or any other persons. The PLAN SPONSOR also reservesthe right to amend the PLAN, including reduction or elimination of benefits or COVEREDSERVICES. Amendments shall be made only in accordance with the provisions of the PLAN.The PLAN ADMINISTRATOR will provide notice to MEMBERS within sixty days of the adoption ofany amendment that results in a material reduction in COVERED SERVICES or benefits.Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue ShieldAssociation.
TABLE OF CONTENTSRECENT CHANGES . 1GETTING STARTED WITH BLUE CARE. 2GETTING STARTED . 2NOTES ON WORDS . 2THIS BOOKLET . 2PRIOR REVIEW AND CERTIFICATION . 2EXCLUSIONS AND LIMITATIONS. 3NO ASSIGNMENT OF BENEFITS . 3MORE INFORMATION UPON REQUEST . 3MEDICAL AND REIMBURSEMENT POLICIES . 3REDUCED OR WAIVED PAYMENTS . 3COMMON INSURANCE TERMS . 4FOR HELP IN READING THIS BENEFIT BOOKLET . 4WHO TO CONTACT? . 5TOLL-FREE PHONE NUMBERS, WEBSITE AND ADDRESSES . 5VALUE-ADDED PROGRAMS . 6SUMMARY OF BENEFITS . 8HOW BLUE CARE WORKS . 17MOST COST-EFFECTIVE BENEFIT LEVEL. 17NONPARTICIPATING BENEFIT EXCEPTIONS . 19CARE OUTSIDE OF NORTH CAROLINA. 19BUNDLED CARE AND PAYMENTS PROGRAM. 20CARRY YOUR IDENTIFICATION CARD. 20THE ROLE OF A PRIMARY CARE PROVIDER (PCP) OR SPECIALIST . 20COVERED SERVICES . 22OFFICE SERVICES. 22PREVENTIVE CARE . 23ROUTINE PHYSICAL EXAMINATIONS AND SCREENINGS . 24
TABLE OF CONTENTS (cont.)WELL-BABY AND WELL-CHILD CARE . 24WELL-WOMAN CARE . 24IMMUNIZATIONS . 24NUTRITIONAL COUNSELING . 24TOBACCO CESSATION. 24ROUTINE EYE EXAMS . 25BONE MASS MEASUREMENT SERVICES . 25COLORECTAL SCREENING . 25GYNECOLOGICAL EXAM AND CERVICAL CANCER SCREENING. 26NEWBORN HEARING SCREENING . 26OVARIAN CANCER SCREENING . 26PROSTATE SCREENING . 26SCREENING MAMMOGRAMS . 26PREVENTIVE CARE EXCLUSIONS . 27OBESITY TREATMENT/WEIGHT MANAGEMENT . 27EMERGENCY AND AMBULANCE SERVICES . 27WHAT TO DO IN AN EMERGENCY . 28AMBULANCE SERVICES . 29AMBULANCE SERVICE EXCLUSIONS (GROUND OR AIR) . 29URGENT CARE . 29HOSPITAL (INPATIENT) AND OTHER FACILITY CARE . 29ALTERNATIVES TO HOSPITAL STAYS . 30HOME HEALTH CARE . 30HOSPICE SERVICES . 30PRIVATE DUTY NURSING . 31FAMILY PLANNING. 31MATERNITY CARE . 31TERMINATION OF PREGNANCY (ABORTION) . 33
TABLE OF CONTENTS (cont.)COMPLICATIONS OF PREGNANCY . 33INFERTILITY SERVICES. 33STERILIZATION . 33CONTRACEPTIVE DEVICES . 34FAMILY PLANNING EXCLUSIONS . 34SPECIFIC THERAPIES AND TESTS . 34HOME INFUSION THERAPY SERVICES . 34REHABILITATIVE THERAPY AND HABILITATIVE SERVICES . 35OTHER COVERED THERAPIES . 35DIAGNOSTIC SERVICES . 35DIAGNOSTIC SERVICES EXCLUSIONS . 36OTHER SERVICES . 36BLOOD . 36CERTAIN DRUGS COVERED UNDER YOUR MEDICAL BENEFIT . 36GENE AND CELLULAR THERAPY . 37CLINICAL TRIALS. 37DENTAL TREATMENT COVERED UNDER YOUR MEDICAL BENEFIT. 38TEMPOROMANDIBULAR JOINT (TMJ) SERVICES . 39DIABETES-RELATED SERVICES . 39EQUIPMENT AND SUPPLIES . 40DURABLE MEDICAL EQUIPMENT . 40HEARING AIDS . 40LYMPHEDEMA-RELATED SERVICES . 40MEDICAL SUPPLIES . 41ORTHOTIC DEVICES . 41PROSTHETIC APPLIANCES . 41SURGICAL BENEFITS . 41ANESTHESIA . 42
TABLE OF CONTENTS (cont.)GENDER AFFIRMATION SURGERY . 43TRANSPLANTS . 43TRANSPLANTS EXCLUSIONS . 43BLUE DISTINCTION CENTERS . 44MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES . 44HOW TO ACCESS MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES . 45WHAT IS NOT COVERED?. 46WHEN COVERAGE BEGINS AND ENDS . 54ENROLLING IN THE PLAN . 57TIMELY ENROLLEES . 57LATE ENROLLEES. 58ADDING OR REMOVING A DEPENDENT . 58QUALIFIED MEDICAL CHILD SUPPORT ORDER . 59TYPES OF COVERAGE . 59REPORTING CHANGES . 59CONTINUING COVERAGE . 59MEDICARE . 60THE PLAN AS YOUR PRIMARY COVERAGE - ACTIVE EMPLOYEES AGE 65 OR OVER . 60MEDICARE AS YOUR PRIMARY COVERAGE . 60MEDICARE AND DISABILITY. 60MEDICARE AND TERMINATION OF EMPLOYMENT. 60MEDICARE AND END-STAGE RENAL DISEASE . 60WHO TO CONTACT ABOUT MEDICARE. 61RETIREMENT . 61MEDICARE AND COBRA . 61ELIGIBILITY REQUIREMENTS FOR DUKE UNIVERSITY EMPLOYEES (COMPANY CODE 10). 61ELIGIBILITY REQUIREMENTS FOR DUKE UNIVERSITY HEALTH SYSTEM (DUHS) EMPLOYEES(COMPANY CODES OTHER THAN 10). 62
TABLE OF CONTENTS (cont.)ELIGIBILITY ENDS. 63CONTINUING COVERAGE . 63CONTINUATION UNDER FEDERAL LAW . 63HEALTH INSURANCE AND LONG TERM DISABILITY . 64TERMINATION OF MEMBER COVERAGE . 65TERMINATION FOR CAUSE . 65UTILIZATION MANAGEMENT . 67RIGHTS AND RESPONSIBILITIES UNDER THE UM PROGRAM . 67YOUR MEMBER RIGHTS . 67BLUE CROSS NC’S RESPONSIBILITIES . 68PRIOR REVIEW (PRE-SERVICE) . 68URGENT PRIOR REVIEW . 69CONCURRENT REVIEWS . 69URGENT CONCURRENT REVIEW. 70RETROSPECTIVE REVIEWS (POST-SERVICE) . 70CARE MANAGEMENT . 71CONTINUITY OF CARE . 71DELEGATED UTILIZATION MANAGEMENT . 72NEED TO APPEAL A DECISION? . 73STEPS TO FOLLOW IN THE APPEALS PROCESS . 73TIMELINE FOR APPEALS . 74FIRST LEVEL APPEAL . 75QUALITY OF CARE COMPLAINTS . 75SECOND LEVEL APPEAL . 75NOTICE OF DECISION . 76EXPEDITED APPEALS (AVAILABLE ONLY FOR NONCERTIFICATIONS) . 77EXTERNAL REVIEW . 77EXPEDITED EXTERNAL REVIEW . 78
TABLE OF CONTENTS (cont.)ADDITIONAL TERMS OF YOUR COVERAGE. 80BENEFITS TO WHICH MEMBERS ARE ENTITLED . 80BLUE CROSS NC’S DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) . 81ADMINISTRATIVE DISCRETION . 81NORTH CAROLINA PROVIDER REIMBURSEMENT . 81SERVICES RECEIVED OUTSIDE OF NORTH CAROLINA . 82BLUE CROSS BLUE SHIELD GLOBAL CORE: . 83INPATIENT SERVICES . 84OUTPATIENT SERVICES . 84SUBMITTING A BLUE CROSS BLUE SHIELD GLOBAL CORE CLAIM . 84RIGHT OF RECOVERY PROVISION . 84RECOVERY OF OVERPAYMENT . 87NOTICE OF CLAIM . 87NOTICE OF BENEFIT DETERMINATION . 87LIMITATION OF ACTIONS . 88EVALUATING NEW TECHNOLOGY . 89MAINTENANCE OF BENEFITS (OVERLAPPING COVERAGE). 89IMPORTANT INFORMATION FOR MEMBERS ELIGIBLE FOR MEDICARE . 90FEDERAL NOTICES. 95STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH PROTECTIONACT . 95MASTECTOMY BENEFITS . 95IMPORTANT NOTICE OF SPECIAL ENROLLMENT . 96SPECIAL PROGRAMS. 97PROGRAMS OUTSIDE YOUR REGULAR BENEFITS . 97HEALTH AND WELLNESS PROGRAMS . 97HEALTH INFORMATION SERVICES . 98GLOSSARY. 99
TABLE OF CONTENTS (cont.)OTHER IMPORTANT PLAN INFORMATION . 113SUMMARY PLAN DESCRIPTION. 113ERISA RIGHTS STATEMENT . 114
Recent ChangesThis section lists recent changes, which may include additions, deletions or revisions to yourbenefit booklet. These changes supersede language that appears elsewhere in your benefitbooklet.Benefit booklet changes due to recent legislation can be viewed at:www.bluecrossnc.com/2022-recent-changes-aso.1
GETTING STARTED WITH BLUE CAREIMPORTANT INFORMATION REGARDING THE PLAN:In accordance with applicable federal law, the PLAN will not discriminateagainst any health care PROVIDER acting within the scope of their licenseor certification, or against any person who has received a break on theirpremium, or taken any other action to endorse his or her right underapplicable federal law. Further, the PLAN shall not impose eligibilityrules or variations in premiums based on any specified healthstatus-related factors unless specifically permitted by law.Getting StartedThis benefit booklet provides important information about your benefits and can help youunderstand how to maximize them. It’s important that you read the entire booklet. If youneed help or more information, it tells you how to contact us in the “Who to Contact”section.Notes on WordsAs you read this benefit booklet, keep in mind that any word you see in "small capital letters(SMALL CAPITAL LETTERS)" is a defined term and appears in the “Glossary” at the end of thisbenefit booklet.This BookletThis booklet tells you about: Your COVERED SERVICES and exclusions or services that are not covered How the PLAN works How we share expenses for COVERED SERVICES Who is eligible to be covered under the PLAN and when this coverage starts and ends Our UTILIZATION MANAGEMENT programs and the right to appeal the decision Any Special Programs that may come with the PLAN.PRIOR REVIEW and CERTIFICATIONCertain services require PRIOR REVIEW and CERTIFICATION in order for you to avoid a full denialof benefits. General categories of services requiring PRIOR REVIEW and CERTIFICATION arenoted in “COVERED SERVICES.” To determine if a specific service requires PRIOR REVIEW andCERTIFICATION, visit www.BlueCrossNC.com for the PRIOR REVIEW list, which is updated whennew services are added or when services are removed. You can also call Blue Cross NCCustomer Service. See “PRIOR REVIEW (Pre-Service)” in “UTILIZATION MANAGEMENT” forinformation about the review process.2
GETTING STARTED WITH BLUE CARE (cont.)Exclusions and LimitationsExclusions and limitations apply to your coverage. Service-specific exclusions are statedalong with the benefit description in “COVERED SERVICES.” Exclusions that apply to manyservices are listed in “What Is Not Covered?” To understand the exclusions and limitationsthat apply to each service, read “COVERED SERVICES,” “Summary of Benefits” and “What IsNot Covered?”No Assignment of BenefitsThe benefits described in this benefit booklet are provided only for MEMBERS. These benefits,the right to receive payment under the PLAN, and the right to enforce any claim arising underthe PLAN cannot be transferred or assigned to any other person or entity, includingPROVIDERS. Blue Cross NC will not recognize any such assignment, and any attemptedassignment is void if performed without Blue Cross NC's prior written consent. PROVIDERS arenot considered beneficiaries under the PLAN and do not have standing to sue under ERISA.Blue Cross NC may pay a PROVIDER directly. For example, Blue Cross NC pays PARTICIPATINGPROVIDERS directly under applicable contracts with those PROVIDERS. However, anyPROVIDER’S right to be paid directly is through such contract with Blue Cross NC, and notthrough the PLAN. Under the PLAN, Blue Cross NC has the sole right to determine whetherpayment for services is made to the PROVIDER, to the SUBSCRIBER, or allocated among both.Blue Cross NC’s decision to pay a PROVIDER directly in no way reflects or creates any rights ofthe PROVIDER under the PLAN, including but not limited to benefits, payments or procedures.For more information see “Additional Terms of Your Coverage.”More Information upon RequestYou may receive, upon request, information about Blue Care, its services and DOCTORS,including printed copies of this benefit booklet with a benefit summary, and a directory ofPARTICIPATING PROVIDERS.Medical and Reimbursement PoliciesCertain services are covered pursuant to Blue Cross NC medical and reimbursement policies,which are updated throughout the plan year. These policies describe the procedure andcriteria to determine whether a procedure, treatment, facility, equipment, drug or device isMEDICALLY NECESSARY and eligible for coverage, INVESTIGATIONAL or EXPERIMENTAL, COSMETIC,or a convenience item. The most up-to-date medical and reimbursement policies areavailable at al-policy/index.htm, or call BlueCross NC Customer Service at the number listed in “Who to Contact?”Reduced or Waived Payments From time to time, MEMBERS may receive a reduced or waived copayment, deductibleand/or coinsurance on designated services, therapies, or PRESCRIPTION DRUGS inconnection with programs designed to reduce medical costs, or to encourage3
GETTING STARTED WITH BLUE CARE (cont.)MEMBERS to seek appropriate, high quality, efficient care based on Blue Cross NCcriteria.Common Insurance TermsTo help you become familiar with some common insurance terms concerning what you mayowe after visiting your PROVIDER, see the chart below and the “Glossary:"CopaymentThe fixed dollar amount you must pay for some COVEREDSERVICES at the time you receive them. Copayments are notcredited to the deductible; however, they are credited to theOUT-OF-POCKET LIMIT.DeductibleThe amount of money you must pay for COVERED SERVICES in aBENEFIT PERIOD before the PLAN begins to pay for COVEREDSERVICES. The deductible does not include coinsurance,charges in excess of the ALLOWED AMOUNT, amountsexceeding any maximum, or charges for noncovered services.CoinsuranceYour share of the cost of a covered health service, after youhave met your BENEFIT PERIOD deductible. This is stated as apercentage of the ALLOWED AMOUNT. The coinsurance listed isyour share of the cost of a COVERED SERVICE.OUT-OF-POCKET LIMITThe OUT-OF-POCKET LIMIT is the dollar amount you pay forCOVERED SERVICES in a BENEFIT PERIOD before the PLAN pays100% for COVERED SERVICES in a BENEFIT PERIOD. TheOUT-OF-POCKET LIMIT includes your deductible, coinsurance,and copayments. It does not include charges over theALLOWED AMOUNT, premiums, and charges for noncoveredservices.Please note: This health benefit plan is not a high deductible health plan (“HDHP”) under theTax Code, and therefore cannot be paired with a health savings account (“HSA”).For Help in Reading this Benefit BookletBlue Cross NC provides consumer assistance tools and services for individuals living withdisabilities (including accessible websites and the provision of auxiliary aids and services atno cost to the individual) in accordance with the Americans with Disabilities Act and section504 of the Rehabilitation Act. Blue Cross NC also provides language services at no cost to theindividual, including oral interpretation and written translations. To access these services andmore, call 1-888-206-4697. For TTY and TDD, call 1-800-442-7028.4
WHO TO CONTACT?Toll-Free Phone Numbers, Website and AddressesBlue Cross NC Website:www.BlueCrossNC.comFind PARTICIPATING PROVIDERS and get information abouttop-performing facilities and news about Blue Cross NC.Blue Connect Website:www.BlueConnectNC.comUse our secure MEMBER website to look at your plan,check benefits, eligibility, and claims status, downloadforms, manage your account, ask for new ID CARDS, gethelpful wellness information and more.Blue Cross NC Customer Service:For questions about your benefits, claims, new ID CARDrequests or to voice a complaint.1-877-275-9787TTY/TDD: 1-800-442-7028PRIOR REVIEW and CERTIFICATION:To request, MEMBERS call:1-877-275-9787PROVIDERS call: 1-800-672-7897Behavioral Health:1-800-359-2422Out of North Carolina Care:1-800-810-BLUE (2583)Some services need PRIOR REVIEW and CERTIFICATION fromBlue Cross NC. Up-to-date information about whichservices may need PRIOR REVIEW can be found online atwww.BlueConnectNC.com.For questions about your mental health and substanceuse disorder benefits and claims.For help in obtaining care outside of North Carolina orthe U.S., call this number or visit www.BCBS.com.HealthLine BlueSM:1-877-477-2424Talk to a nurse 24/7 to get timely information and help ona number of health-related issues. Nurses are on handby phone in both English and Spanish.Nurse Support:Talk to a Nurse Advocate about receiving support formanaging asthma, diabetes, congestive heart failure,coronary artery disease (CAD) and chronic obstructivepulmonary disease
The benefit plan described in this booklet is an EMPLOYEE health benefit plan, subject to the Employee Retirement Income Security Act of 1974 (ERISA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A summary of benefits, conditions, limitations and exclusions is set forth in this benefit booklet for easy reference.
