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.
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