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BlueChoice New England (POS)Benefit BookletThe State of New HampshireHealth Plan for RetireesWhat You Need to Know about Your Managed Health Care PlanThis BlueChoice New England Benefit Booklet describes The State of New Hampshire’s Point-of-Service(POS) Managed Health Care PlanSi necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando alnúmero de servicio al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción.Anthem Blue Cross and Blue Shield is located at1155 Elm Street, Suite 200Manchester, New Hampshire 03101-1505Anthem’s toll-free telephone number is 1-800-933-841513688NH (1/18) REV 5.30.18
Welcome!Anthem Blue Cross and Blue Shield (Anthem) welcomes you to Anthem’s family of members. Anthem thanks youfor choosing Anthem to be the administrator of your managed health care plan.Please contact Anthem whenever you have questions, concerns or suggestions. Anthem’s Member ServicesRepresentatives are available during business hours to assist you. A representative will ask for the identificationnumber listed on your identification card so that Anthem can locate your important records and assist you withoutdelay.Please call Anthem at 1-800-933-8415. Visit Anthem’s website at www.anthem.com or contact Anthem asfollows:Type of CommunicationMail toInquiries Anthem Blue Cross and Blue ShieldBenefit questions or claims statusP.O. Box 660North Haven, Connecticut 06473-0660Appeals Anthem Blue Cross and Blue ShieldReview of claims decisionP.O. Box 518North Haven, Connecticut 06473-0518Claims Anthem Blue Cross and Blue ShieldSubmission of claims for processingP.O. Box 533North Haven, Connecticut 06473-0533Anthem Blue Cross and Blue ShieldYou can visit Anthem at1155 Elm Street, Suite 200Manchester, New HampshireHow to Obtain Language AssistanceAnthem is committed to communicating with Members about their health plan, regardless of theirlanguage. Anthem employs a Language Line interpretation service for use by all of Anthem’s Member Services CallCenters. Simply call Member Services at 1-800-933-8415. A representative will be able to assist you. Translationof written materials about your Benefits can also be requested by contacting member services. TTY/TDD servicesalso are available by dialing 711. A special operator will contact Anthem to help with member needs.Please see “Get Help in Your Language” section for additional information.Lisa M. GuertinPresident and General ManagerNew HampshireImportant: This is not an insured benefit plan. Anthem provides administrative claims payment services only anddoes not assume any financial risk or obligation with respect to claims. Your employer – the State of NewHampshire assumes responsibility for funding of claims.This product is administered by Anthem Health Plans of New Hampshire, Inc., operating as Anthem Blue Cross andBlue Shield (Anthem). Anthem is licensed in the State of New Hampshire as a third party administrator. Anthem isan independent licensee of the Blue Cross and Blue Shield Association.A “Local Plan” is the affiliated New England Blue Cross and Blue Shield plan that administers written agreementsmade directly between the plan and Network Providers in a given Designated Network.2
TABLE OF CONTENTSBLUECHOICE NEW ENGLAND (POS) COST SHARING SCHEDULE . 7SECTION 1: OVERVIEW – HOW YOUR PLAN WORKS. 13I. ABOUT THIS BENEFIT BOOKLET . 13II. YOUR PRIMARY CARE PROVIDER (PCP). 13III. PRECERTIFICATION . 13IV. THE NETWORK . 14V. GROUP COVERAGE ARRANGED BY THE STATE OF NEW HAMPSHIRE . 15VI. SERVICES MUST BE MEDICALLY NECESSARY . 15SECTION 2: COST SHARING TERMS . 16I.II.III.IV.V.VI.COPAYMENTS . 16DEDUCTIBLE (OUT-OF-NETWORK BENEFITS) . 16COINSURANCE (OUT-OF-NETWORK BENEFITS) . 16DEDUCTIBLE AND COINSURANCE MAXIMUMS (OUT-OF-NETWORK BENEFITS) . 17THE OUT-OF-POCKET MAXIMUM . 17OTHER OUT-OF-POCKET COSTS . 17SECTION 3: NETWORK BENEFITS . 18I.II.III.IV.NETWORK SERVICES. 18SELECTING A PCP. 18PLAN APPROVAL FOR SPECIALIZED CARE . 18REFERRAL EXCEPTIONS FOR OUT OF NETWORK SERVICES . 19SECTION 4: OUT-OF-NETWORK BENEFITS . 20I. OUT-OF-NETWORK BENEFIT OPTION . 20II. PRECERTIFICATION FOR OUT-OF-NETWORK SERVICES . 20SECTION 5: ABOUT MANAGED CARE. 22I.II.III.IV.YOUR ROLE . 22THE ROLE OF NETWORK PROVIDERS . 22THE ROLE OF ANTHEM AND THE LOCAL PLAN . 23IMPORTANT NOTES ABOUT THIS SECTION . 25SECTION 6: URGENT CARE AND EMERGENCY CARE. 26I. URGENT CARE . 26II. EMERGENCY CARE . 26III. EMERGENCY ROOM VISITS FOR EMERGENCY CARE . 26IV. INPATIENT ADMISSIONS TO A HOSPITAL FOR EMERGENCY CARE . 27V. LIMITATIONS . 28SECTION 7: COVERED SERVICES . 29I.II.III.IV.V.VI.A.B.C.D.E.F.G.H.INPATIENT SERVICES . 30OUTPATIENT SERVICES . 30OUTPATIENT PHYSICAL REHABILITATION SERVICES . 36HOME CARE. 37BEHAVIORAL HEALTH CARE (MENTAL HEALTH AND SUBSTANCE USE CARE) . 43IMPORTANT INFORMATION ABOUT OTHER COVERED SERVICES . 49DENTAL SERVICES . 49HEARING SERVICES . 52INFERTILITY SERVICES . 52ORGAN AND TISSUE TRANSPLANTS . 56QUALIFIED CLINICAL TRIALS: ROUTINE PATIENT CARE . 58REQUIRED EXAMS OR SERVICES . 59SURGERY . 59TRANSGENDER SERVICES . 623
I.VISION SERVICES . 62SECTION 8: LIMITATIONS AND EXCLUSIONS . 63I.LIMITATIONS . 63A. Human Growth Hormones . 63B. Private Room . 63C. Ultraviolet Light Therapy and Laser Therapy for Skin Disorders .63II. EXCLUSIONS . 64Alternative Medicine or Complementary Medicine . 64Amounts That Exceed the Maximum Allowable Benefit . 64Artificial Insemination . 65Biofeedback Services . 65Blood and Blood Products . 65Care Furnished by a Family Member. 65Care Received When You Are Not Covered Under This Benefit Booklet . 65Care or Complications Related To Noncovered Services . 65Chelating Agents. 65Contraceptive Services . 65Convenience Services . 66Cosmetic Services . 66Custodial Care. 66Disease or Injury Sustained as a Result of War or Participation in a Riot or . 66Domiciliary Care . 66Educational, Instructional, Vocational Services and Developmental Disability Services . 67Experimental/Investigational Services. 67Food and Food Supplements . 68Foot Care (routine), Foot Orthotics and Therapeutic/Corrective Shoes. 68Free Care. 68Gene Therapy . 68Home Test Kits. 69Missed Appointments . 69Non-Hospital Institutions. 69Nonmember Biological Parents . 69Pharmacy Services . 69Premarital Laboratory Work . 69Private Duty Nurses. 69Processing Fees . 69Rehabilitation Services . 69Reversal of Voluntary Sterilization . 69Routine Care or Elective Care Outside the Service Area . 69Sclerotherapy for Varicose Veins and Treatment of Spider Veins . 70Services Not Covered and Care Related to Noncovered Services . 70Smoking Cessation Drugs, Programs or Services . 70Surrogate Parenting . 70Transportation . 70Weight Control . 70Workers’ Compensation . 70X-rays . 70SECTION 9: CLAIM PROCEDURE . 71I.II.III.IV.V.POST-SERVICE CLAIMS . 71PRE-SERVICE CLAIMS . 71NOTICE OF A CLAIM DENIAL . 72APPEALS . 73GENERAL CLAIM PROCESSING INFORMATION . 73SECTION 10: OTHER PARTY LIABILITY . 76I.COORDINATION OF BENEFITS (COB) . 764
II. DEFINITIONS . 77III. THE ORDER OF PAYMENT IS DETERMINED BY COB . 78IV. WORKERS’ COMPENSATION . 80V. SUBROGATION AND REIMBURSEMENT . 80VI. ANTHEM’S RIGHTS UNDER THIS SECTION . 82VII. YOUR AGREEMENT AND RESPONSIBILITY UNDER THIS SECTION. 82SECTION 11: MEMBER SATISFACTION SERVICES AND APPEAL PROCEDURE . 84I.II.III.IV.V.MEMBER SATISFACTION SERVICES . 84INTERNAL APPEAL PROCEDURE. 84VOLUNTARY EXTERNAL REVIEW . 87DISAGREEMENT WITH RECOMMENDED TREATMENT . 89APPEAL OUTCOMES . 89SECTION 12: GENERAL PROVISIONS. 90SECTION 13: MEMBERSHIP ELIGIBILITY, TERMINATION OF COVERAGE AND CONTINUATIONOF COVERAGE. 92I. ELIGIBILITY . 92II. TERMINATION OF COVERAGE . 96III. CONTINUATION OF GROUP COVERAGE . 97SECTION 14: DEFINITIONS. 100Adverse Determination . 100Anthem . 100Behavioral Health Care. 100Benefit Booklet (or Booklet) . 100Benefit . 100Birthing Center . 100BlueCard Provider . 100Calendar Year. 100Claim Denial. 100Contracting Provider . 100Convenience Services . 100Covered Service . 100Designated Network . 101Designated Provider . 101Developmental Disabilities . 101Home Health Agency . 101Inpatient . 101Local Plan . 101Maximum Allowable Benefit (MAB) . 102Medical Director . 102Medically Necessary or “Medical Necessity” . 102Member . 102Network Behavioral Health Provider . 102Network Birthing Center. 102Network Diabetes Education Provider . 102Network Nutrition Counselor . 102Network Primary Care Provider (PCP) . 103Network Provider . 103Network Service . 103Network Urgent Care Facility . 103Network Walk-In Center . 103New Hampshire Certified Midwife (NHCM) . 103NonBlueCard Provider . 103Out-of-Network Provider . 103Out-of-Network Service . 103Outpatient . 1035
Physical Rehabilitation Facility . 103Precertification or Precertify. 103Prior Approval. 104Referral . 104Service Area. 104Short Term General Hospital . 104Skilled Nursing Facility . 104Subcontractor . 104Subscriber . 104Urgent Care Claim . 104Urgent Care Facility. 104Walk-In Center . 104You, Your and Yours . 104IT’S IMPORTANT WE TREAT YOU FAIRLY . 105GET HELP IN YOUR LANGUAGE . 1066
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BlueChoice New England (POS) Cost Sharing Schedule This Cost Sharing Schedule is an outline of your cost sharing requirements and Benefits. Do not rely on this schedule alone. Please read your Benefit Booklet carefully, because important terms and conditions apply. Cost Sharing Summary YOUR COST Network Benefits Out-of-Network Benefits
