2. STUDY UP.
IT’LL
PAY OFF
LATER.
Learning these key terms will help you
better understand your health plan
choices so you can choose the coverage
that’s best for you.
Deductible
This is the amount you pay before your
health plan starts to pay for certain medical
bills. It resets January 1st.
Out-of-pocket maximum
This protects you against large medical
expenses by capping the total amount you
could pay in a plan year. (Please note: This
amount is different depending on whether
you see in-network or out-of-network
providers, and copayments do not apply to
the out-of-pocket maximum.)
Coinsurance
This is a percentage of the total medical bill
that you have to pay. For example, some
plans have a 20 percent coinsurance charge
for physical therapy. So if the total bill is
$100, the coinsurance would be $20.
Copayment
This is a fixed amount (not a percentage)
charged each time you receive a healthcare
service. For example, your plan may
have a copayment for doctor visits or
prescription drugs.
2
3. THESE PROGRAMS WILL
HELP YOU SAVE
You may be eligible to have part of your monthly premium
paid through our AccessBlue program. The charts below show
how much AccessBlue will pay each month, depending on your
household income, if you qualify. Information about AccessBlue,
including rates for families, can be found at BCBSRI.com.
AccessBlue pays:
LEVEL ONE
LEVEL TWO
Individual
Individual
$82
$54
Qualifying Household Income**
Family Size
1
You qualify for
You qualify for
LEVEL ONE
LEVEL TWO
$0-$22,340
$22,341-$39,095
if your income falls in the range below: 1 if your income falls in the range below :2
** ualifying household income is based on federal poverty levels for 2012.
Q
Level One: Gross annual household income at or below 200 percent of the federal poverty level.
NEW!
Diminishing Deductible
Reward Yourself for
Being Healthy.
With our Diminishing Deductible
Program, you get a 20 percent
deductible reduction following
the first year you don’t meet
your deductible, and a 40 percent
reduction in the second year. If
you don’t meet your deductible
for three years in a row, your
deductible amount is cut in
half—50 percent—in year four
and stays at that level until you
reach your deductible.*
1
Level Two: Gross annual household income between 201 and 350 percent of the federal poverty level.
2
YEARLY SAVINGS
WHEN YOUR DEDUCTIBLE
IS NOT MET.
20%
40%
50%
SAVINGS
Get a Great Rate
You may qualify for our preferred rate, which is a discounted rate based on
your health status, age, and gender. To apply for our preferred rate, you’ll
need to complete the enclosed Direct Pay Medical Underwriting Addendum
and return it with your application.
1st Year
Deductible
SAVINGS
SAVINGS
2nd Year
Deductible
3rd Year
Deductible
4th Year
Deductible
*To be eligible you must have paid your
Blue Cross Blue Shield of Rhode Island Direct Pay
premium for six consecutive months of coverage.
If you reach your deductible in any year, your
deductible will automatically reset to your original
deductible amount January 1st of the following year.
You can work toward reducing your deductible again
for the next year.
3
4. 2013 BlueValue Direct 2500 PLAN BENEFITS*
Your Medical Benefits
HOOK UP
WITH A
HEALTH
PLAN YOU
DESIGNED FOR
BlueValue Direct offers
benefits that can help you
feel and look your best
without draining your
bank account. With
BlueValue Direct, you get:
• ur lowest available
O
premium rates
• 00 percent coverage
1
for preventive medical
and dental services
(one cleaning and one
set of bitewing X-rays
per year)
• 4 copayments for
$
most generic drugs
Your Cost
Deductible per calendar year (resets every January 1) – The amount that you must pay each
calendar year before BCBSRI begins to pay for certain services.
Individual Deductible
$2,500
Family Deductible
Not applicable
Out-of-pocket Maximum per calendar year (resets every January 1) – The maximum amount
a member pays in a calendar year. IMPORTANT: Once the out-of-pocket maximum (OOP) is met, most
benefits are covered in full by BCBSRI.
Individual Out-of-pocket Maximum
$7,500
Family Out-of-pocket Maximum
Not applicable
Coinsurance – The percentage amount a member pays after the deductible is met.
Coinsurance Liability
50% after deductible
Copayments – The amount a member pays when receiving a service. The copayment does not apply to
the deductible or out-of-pocket maximum.
Annual Well Exam
Primary Care Physician and Specialist
First annual Foot and Eye Exam for Diabetics
Covered at 100% by BCBSRI. There is
no charge to the member for an annual well visit.
First two visits $30
additional visits 50%
coinsurance after deductible
Urgent Care
Emergency Room
50% after deductible
First visit $200
additional visits 50%
coinsurance after deductible
Dental Preventive Care
One Dental Cleaning and one set of Bitewing
X-rays per year
Covered in full
Diagnostic Tests, X-rays, Lab
Diagnostic Radiology Services (high-end
radiology services major diagnostic and nuclear
medicine including MRI, CT and PET scans)
50% after deductible
Preventive Laboratory Services
Covered in full. There is no charge to the member, i.e. cholesterol test.
Diagnostic Laboratory Services
50% after deductible
Other Covered Services
Inpatient Hospitalization
50% after deductible
Surgery in a Physician’s Office
50%
(deductible does not apply)
Physical/Occupational and Speech Therapy
50% after deductible
(30 visit limit per specialty)
Prescription Drugs
Tier 1 – ow Cost Generic Drugs
L
Tier 2 – igher Cost Generic and Preferred Brand
H
Name Drugs
Tier 3 – rand Name Drugs
B
Tier 4 – Specialty
*Note: This is not a complete list. Check page 6 for information about other plans for individuals and families, and
visit BCBSRI.com for complete plan benefit information.
$500 deductible applies to Tiers 2, 3, and 4
Once deductible is met your
prescription copays are
50%, 50%, and $200
Incentives
$100 gym membership
reimbursement
Out-of-network benefits are available.
4
Tier 1 – $4
5. Get off the
couch and
GO TO THE GYM
We can help.
Once you enroll in BlueValue Direct,
you can get $100 to use toward
a gym membership. We’ll also
guarantee that you receive the
lowest available membership rate at
more than 75 gyms in Rhode Island.
The actual exercising part, that’s
on you!
Learn more about our fitness
discount programs as well as other
health plan options at BCBSRI.com.
ADDITIONAL RESOURCES
HELP YOU SAVE
AND MORE
Once you become a Blue Cross member, you’ll have
access to resources that can help you save money
and take better care of yourself, such as:
Fitness Discount Program,
where you’ll get the lowest available
membership fees at more than 75
fitness centers in Rhode Island and a
10 percent discount on NordicTrack
fitness equipment from Sears.
Blue365, a program that offers
®
saving on health and wellness products
and services from leading national
companies, including Jenny Craig®,
Reebok, and many more.
Health Center, a website with
more than 7,000 articles as well as
interactive tools that can help you
take the best care of yourself.
SM
My Blue Community, **an online
social network that allows you to
connect with more than 30,000
Blue Cross members nationwide and
take advantage of expert advice on
fitness, nutrition, and more.
Go to BCBSRI.com
to learn more
about these
programs and
resources.
**My Blue Community is a website that enables discussions among individual users. This
website is intended solely as a forum for general information and users’ opinions; it does not
contain any advice that is intended for medical diagnosis or treatment, and does not substitute
for professional medical advice and services. Always seek the advice of your physician
or other qualified healthcare provider on any medical condition and before following any
information that may appear on My Blue Community.
5
6. Additional Health Plans. Everyone likes options.
That’s why we offer a range of plans for every stage of life.
HealthMate Coast-to-Coast®
Direct 2500/5000*
HealthMate Coast-to-Coast Direct has many traditional features, like predictable
copayments and coinsurance for certain services, as well as a Wellness Reward
Program designed to reward you for living healthy. You can get back 10 percent of
your annual paid premium by simply:
• hoosing a primary care physician for you and your family members
C
• ompleting an online personal health assessment (any dependent 18 years
C
and older)
• ompleting certain wellness requirements within the first eight months of
C
joining the program
*A Wellness Health Benefit Plan.
VantageBlue Direct 1000/2000
VantageBlue Direct 1500/3000
These plans offer benefits and features that keep you focused on your health,
including:
• $50 incentive for completing an online personal health assessment
A
• o copayment for the first foot and eye exam for members with diabetes
N
• 2 prescription drug copayments for certain drugs that treat diabetes,
$
asthma, and chronic obstructive pulmonary disease**
* You are required to participate in a health management program or
*
choose a doctor who is part of a patient-centered medical home to receive
this benefit.
BlueSolutions for HSA Direct 3000/6000
BlueSolutions for HSA Direct 5000/10000
These high-deductible health plans are for people who want to take on
additional responsibility for their healthcare and feature:
• ome of our lowest available monthly premiums
S
• opayments and coinsurance for certain services
C
• he chance to open a tax-advantaged health savings account (HSA), which
T
you can use to save for current and future medical expenses
All plans offer access to special programs that can help you quit smoking, lose weight, manage your asthma, and more.
For more information about our plans, including complete plan benefit information, their actuarial value,
and examples of how they work, please visit BCBSRI.com.
6
7. SMILE
WE’VE GOT
. DENTAL PLANS
No Deductible. No Annual Membership Fee.
No Problem.
Blue Cross Dental Direct Basic
Basic Benefits
Coverage
Calendar Year Maximum
Oral exams, X-rays, two cleanings per year, fluoride,
sealants
$1,000
100%
2013 Monthly Rates
50%
Night guards
Individual
Enrollee and spouse
$25.97
$51.94
50%
Fillings, simple extractions, denture/bridge repairs,
root canal therapy, space maintainers, oral surgery
Enrollee and child(ren)
Family
$51.68
$82.33
Blue Cross Dental Direct Essential
Essential Benefits
Coverage
Calendar Year Maximum
Oral exams, X-rays, two cleanings per year, fluoride,
sealants
Fillings, simple extractions, denture/bridge repair,
root canal therapy, space maintainers, oral surgery
$1,000
100%
80%
Crowns over natural teeth*
Individual
Enrollee and spouse
Enrollee and child(ren)
Family
$39.99
$79.98
$79.59
$126.77
50%
Night guards
2013 Monthly Rates
50%
Blue Cross Dental Direct Plus
Plus Benefits
Coverage
Calendar Year Maximum
Oral exams, X-rays, two cleanings per year, fluoride,
sealants
Fillings, simple extractions, denture/bridge repair, root
canal therapy, oral surgery
Crowns, bridges, single tooth implants, partial
and complete dentures*
Night guards
$1,750
100%
80%
2013 Monthly Rates
Individual
Enrollee and spouse
Enrollee and child(ren)
Family
$49.84
$99.69
$99.20
$158.02
50%
50%
* Note: This a partial list of benefits and a 12-month waiting period applies to some services.
All plan rates listed above are in effect through December 31, 2013.
7
8. LET’S GET
STARTED
Just follow these simple steps to enroll:
1. Complete the Health Plan Application.
2. Complete the Direct Pay Medical Underwriting Addendum to
apply for our preferred rates.
3. Obtain a Certificate of Creditable Coverage, which you should
have received from your most recent health insurance provider.
4. Complete the AccessBlue application, if your household income
qualifies (see chart on page 3).
5. Enclose these documents in the provided envelope and send to
the address below:
Blue Cross Blue Shield of Rhode Island
Individual Sales Department
500 Exchange Street
Providence, RI 02903-2699
Important note: Your application cannot be processed until
all the required documents are provided. If you do not have a
Certificate of Creditable Coverage, please contact your previous
health insurance provider.
Looking for More
Information?
You can always visit
BCBSRI.com/BlueValue
to find out more about
your plan options.
Need Help Choosing
Coverage?
Call us at (401) 351-BLUE
(2583). We’d be happy to
help you choose the best
plan.
Interested in Dental
Coverage?
We now offer three
comprehensive dental
plans. Go to:
BCBSRI.com/dentaldirect
or call us at:
(401) 351-BLUE (2583) to
learn more.
500 Exchange Street • Providence, RI 02903-2699
Blue Cross Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
12/12
DPAY-12525.3165
