Understanding Your Blue Cross Blue Shield of Illinois
Coverage: 5 Things Every CCSD #59 Employee Needs to
Know
1. How do I stay within the PPO Network?
• It is YOUR responsibility to stay
within the PPO network.
• How do I know if my...
The BCBS IL Network is important!
If you are an HMO Member, your
network is either the the Blue
Advantage HMO Network or t...
Blue Distinction Centers
Blue Distinction® Centers
Complicated surgeries – and their results – can vary
significantly from...
2. BCBS IL Has Tools for your Reference

5
Your Life is Mobile…
Secure Site – Log-in required

•ID Card. Instant digital membership
•Coverage. Benefits and eligibili...
Integrated Provider Finder

Use the Integrated Provider Finder tool to:
Find a network primary care physician, specialist...
Integrated Provider Finder

8
Schedule Appointments Online
BCBS IL Customer Service
 Service that Takes You Out
of the Middle

Call your BCBS customer service team for:
• Claim que...
3. Know Your Preventive Guidelines and
Wellness Tools
Certain services can be billed as preventive or diagnostic. Preventi...
Adult Preventive Care Guidelines

12
Children’s Preventive Care Guidelines

13
BCBS IL Well onTarget
Health & Wellness Interactive Tools and Resources
Well onTarget is designed to give you
the support ...
BCBS IL Wellness onTarget
Health & Wellness Interactive Tools and Resources
Articles & Tools
Interactive tools to help edu...
BCBS IL Fitness Programs
The BCBS IL Fitness Program offers
membership to a national network
of leading national, regional...
Life Points
 Offerings that earn points
− Health Assessment
− Self-directed courses
(5 courses)
− Fitness Programs
− Trac...
Blue365

Davis VisionSM (877) 393-8844, TruVision (877) 882-2020

Save on eyeglasses, as well as contact lenses, laser vis...
4. Understand Your Prescription Drug Plan
Generic Drugs: These are drugs where the patient has expired and competing pharm...
Save Money on Prescription Drugs
 Save Money on Prescriptions- ask about lower cost/no cost drugs;
ask for samples; shop ...
Mail Order Prescriptions

21
5. Read and Understand your Explanation of
Benefits

22
Sample Explanation of Benefits

23
CCSD #59

Questions

24
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Ccsd #59 employee education slides 10 23-2013

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  • Rev. 5-2013
  • Certain services can be done for preventive or diagnostic reasons.  When a service is performed for preventive screening reasons and is appropriately reported it will be adjudicated under the Preventive Care Services benefit.
    Preventive services are done on a person who:
    has not had the preventive screening done before and does not have symptoms or other abnormal studies suggesting abnormalities; or
    has had screening done within the recommended interval with the findings considered normal; or
    has had diagnostic services results that were normal after which the physician recommendation would be for future preventive screening studies using the preventive services intervals.
    has a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g. polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service.
    Examples: Preventive services
    A woman had an abnormal finding on a preventive screening mammography and the follow up study was found to be normal, and the woman was returned to normal mammography screening protocol, then future mammography would be considered preventive.
    If a polyp is encountered during a preventive screening colonoscopy, the colonoscopy, removal of the polyp, and associated facility, lab and anesthesia fees done at the same time as the preventive colonoscopy, are covered under the Preventive Care Services benefit.
  • Rev. 6-2012
  • Rev. 8-2012
  • Rev. 8-2012
  • Ccsd #59 employee education slides 10 23-2013

    1. 1. Understanding Your Blue Cross Blue Shield of Illinois Coverage: 5 Things Every CCSD #59 Employee Needs to Know
    2. 2. 1. How do I stay within the PPO Network? • It is YOUR responsibility to stay within the PPO network. • How do I know if my provider participates in the PPO network? • Go online at www.BCBSIL.com using the “Find a doctor” link. Or• Call the toll-free number on the back of your Medical ID card. • Talk with your provider and ask the correct questions. “Do you take BlueCross?” “Are you a participating BlueCross BlueShield PPO Provider?” 2
    3. 3. The BCBS IL Network is important! If you are an HMO Member, your network is either the the Blue Advantage HMO Network or the HMO of Illinois network. remember, all care has to be directed by your Primary Care Physician. Deductible Deductible Deductible Deductible In-Network In-Network Provider Provider Out of Out of Network Network Provider Provider 90% 90% Or 80% Or 80% 70% or 60% 70% or 60% Benefits are always better when you receive services within the BCBS IL PPO network. •Better Co-Insurance (either 90% or 80% in network, depending on which plan you are enrolled in) •Lower Out-of-Pocket Maximums Why are benefits better? •BlueCross negotiates with doctors and hospitals. If they come to an agreement/contract, the providers agree to provide services at lower costs and greater discounts. In return, the providers see greater utilization due to BlueCross’ large membership base. These lower costs and greater discounts are passed on to the member with better benefits and lower out of pocket expenses! 3
    4. 4. Blue Distinction Centers Blue Distinction® Centers Complicated surgeries – and their results – can vary significantly from one hospital to another. You need the facts so you can make smart decisions about where to go for your specialty medical care. Blue Distinction is a special, quality-based designation given to certain hospitals nationwide that deliver proven results for quality care and treatment. More than 1,600 Blue Distinction hospitals and treatment centers are available nationwide for these types of specialty care: Cardiac Care Complex and Rare Cancers Spine Surgery Knee and Hip Replacements Bariatric Surgery Transplants 4
    5. 5. 2. BCBS IL Has Tools for your Reference 5
    6. 6. Your Life is Mobile… Secure Site – Log-in required •ID Card. Instant digital membership •Coverage. Benefits and eligibility •Claims. By patient, date or status •Health and Wellness. My Care Profile Blue ExtrasSM discounts Obesity Nutrition and Fitness Metabolic Syndrome Diabetes Care Maternity Care •User Profile. Manage profile settings 6
    7. 7. Integrated Provider Finder Use the Integrated Provider Finder tool to: Find a network primary care physician, specialist or hospital Make an appointment to consult with a provider View Patient Feedback or Add your Review for a Provider View Quality, certifications and recognitions for doctors 7
    8. 8. Integrated Provider Finder 8
    9. 9. Schedule Appointments Online
    10. 10. BCBS IL Customer Service  Service that Takes You Out of the Middle Call your BCBS customer service team for: • Claim questions or status bcbsil.com Your benefit plan requires that you contact the Preauthorization number one day prior to hospitalization or within two days of an admission for emergency or maternity care. Failure to preauthorize may reduce your benefits. • Medical benefit coverage questions For questions regarding benefits, membership and claims please call the Customer Service number and select the appropriate prompt. Medical Providers: Please file all medical claims with your local Blue Cross and Blue Shield Plan. • Help with finding network providers • Membership and eligibility • ID card requests • Help with navigating online tools • Health education and transfer to other health programs 10 Customer Service BlueCard Access Preauthorization (MH/CD) Provider Locator 24/7 Nurseline 1-800-xxx-xxxx 1-800-xxx-xxxx 1-800-xxx-xxxx 1-800-xxx-xxxx 1-800-xxx-xxxx Members: If a provider does not file a claim on your behalf, please contact Customer Service. BlueCross BlueShield of Illinois, an independent licensee of the BlueCross BlueShield Association, provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.
    11. 11. 3. Know Your Preventive Guidelines and Wellness Tools Certain services can be billed as preventive or diagnostic. Preventive services are covered 100% In-Network – make sure billed as preventive! Covered preventive services performed specifically for preventive screening, with no known symptoms, illnesses, or history, are generally covered as Preventive Care, subject to age and gender guidelines, and health status. Preventive services are usually covered when performed on a person who: • has not had the preventive screening done before • does not have symptoms or abnormalities • has had a screening done within the recommended age/gender guidelines with the findings considered “normal” • has had previous diagnostic services with the results being “normal” • has a preventive service done that results in a therapeutic service done at the same time, and as an integral part of the preventive service (e.g. polyp removal during a preventive colonoscopy), the therapeutic service would still be considered 11 preventive service
    12. 12. Adult Preventive Care Guidelines 12
    13. 13. Children’s Preventive Care Guidelines 13
    14. 14. BCBS IL Well onTarget Health & Wellness Interactive Tools and Resources Well onTarget is designed to give you the support you need to make healthy choices. All while rewarding you for your hard work. Well onTarget Member Wellness Portal • Onmytime Self-Directed Courses • Health and Wellnes Library • Tools and Trackers • Onmyway Health Assessment • Life Points Program 14 14
    15. 15. BCBS IL Wellness onTarget Health & Wellness Interactive Tools and Resources Articles & Tools Interactive tools to help educate you on a topic of interest Food & Exercise Diary Tool indicating calories consumed, Calories burned &daily calorie budget. Symptom Checker 15 A resource for you designed to assess your medical symptoms.
    16. 16. BCBS IL Fitness Programs The BCBS IL Fitness Program offers membership to a national network of leading national, regional and local fitness centers for one low monthly price of $25 and no contract. There are more than 8,600 fitness centers in the Fitness Program Network. Chains Include; • • • • • Snap Fitness Anytime 24 Hour Fitness Gold’s Gym Some YMCA’s 16 Buy-up option with BCC Enhanced or Custom
    17. 17. Life Points  Offerings that earn points − Health Assessment − Self-directed courses (5 courses) − Fitness Programs − Tracking  Life Points Redemption − # of levels − Amazon Like store − Buy Ups are available 17
    18. 18. Blue365 Davis VisionSM (877) 393-8844, TruVision (877) 882-2020 Save on eyeglasses, as well as contact lenses, laser vision correction services, examinations and accessories. Find out more when you log in to BAM. Jenny Craig® (877) JENNY70 (877-536-6970) Jenny Craig can help you reach your weight loss goals. You will get one-on-one support given by a trained weight loss expert. Life Time® Fitness Life Time Fitness offers a total health fitness experience no matter your fitness level, interests, schedule or budget. Procter & Gamble (P&G) Dental Products (877) 333-0121 Get savings on dental packages containing the latest in Oral B® power toothbrushes and Crest® products. Seattle Sutton’s Healthy Eating® (800) 442- DIET (800) 442-3438 These freshly prepared, calorie-controlled meals are designed to help with weight loss and managing certain health problems. TruHearing® (800) 687-4617 Save on digital hearing aids through TruHearing. Get a hearing test at no extra charge when performed to fit a hearing aid.
    19. 19. 4. Understand Your Prescription Drug Plan Generic Drugs: These are drugs where the patient has expired and competing pharmaceutical manufactures can no produce and sell that formulary. plan to pass the savings onto you with a lower copay. These lower cost generics allow the Brand Name Drugs: Brand name drugs are still within the patient. These drugs are heavily advertised and cost considerably more than generic alternatives. A Formulary is a list created by your insurance carrier BlueCross BlueShield of Illinois. They will negotiate with drug companies for discounted rates. These drugs are put on a formulary list and some of the savings is passed to the consumer at a lower copay. Non Formulary are brand name drugs that do not fall onto the formulary list. These drugs have the highest copayments. A copy of the formulary list can be found on www.bcbsil.com
    20. 20. Save Money on Prescription Drugs  Save Money on Prescriptions- ask about lower cost/no cost drugs; ask for samples; shop different pharmacies for discount drug programs (www.walmart.com , www.target.com, www.meijer.com, www.costco.com, www.samsclub.com) 20
    21. 21. Mail Order Prescriptions 21
    22. 22. 5. Read and Understand your Explanation of Benefits 22
    23. 23. Sample Explanation of Benefits 23
    24. 24. CCSD #59 Questions 24

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