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[FIRST NAME1] [LAST NAME1] [ADDRESS LINE 1] [ADDRESS LINE 2][ADDRESS LINE 3] [CITY], [STATE] [ZIP]
2016 [APPLICATION ID]
[DATE PRINTED]
BlueEssentialsSM
BlueCross® BlueShield® of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
IMPORTANT: Take action by Dec. 15, 2016, or you’ll be automatically re-enrolled in similar coverage.
Thank you for choosing BlueCross BlueShield of South Carolina for your health care needs.
WHY WE ARE WRITING:Your health insurance coverage is still being offered in 2017, but some details may have changed. Read this letter carefully and decide if you want to keep this plan or choose another one. Also, make sure to update your information with the Marketplace.
CHANGES YOU’LL SEE TO YOUR PLAN IN 2017:
Your new premium• Your 2016 monthly payment is $[CURRENT SUBSCRIBER PAYS AMOUNT].This reflects a monthly
premium of $[CURRENT TOTAL PREMIUM AMOUNT] minus $[2016 APTC AMOUNT] of financial help per month.
• Starting in January, your estimated monthly payment will be $[SUBSCRIBER PAYS AMOUNT].This reflects a 2017 monthly premium of $[TOTAL PREMIUM AMOUNT] minus $[2017 APTC AMOUNT] of your estimated financial help for 2017. You’ll see your new monthly payment when you receive your January bill.
Important: This is only an estimate based on the amount of financial help you got in 2016 and the 2017 premium rates for the second lowest silver plan in your county. It also doesn’t reflect any changes to your enrollment, such as adding additional members to your coverage. To find out how much financial help you qualify for in 2017 and your new premium amount, update your Marketplace application. See the “What You Need to Do” section in this letter for more information.
Other changes• Services outside the BlueEssentials Network are only covered for urgent or emergency care performed
in an urgent treatment center or emergency room.• Introduction of the Advanced Choice NetworkTM , which includes access to CVS, Walmart, Sam’s
Club, Costco, Kroger, Publix, K-Mart, Longs drugs, Bi-Lo, and Winn-Dixie pharmacies plus various other grocers and independent pharmacies. The network does not include Walgreens or Rite Aid pharmacies. Visit www.SouthCarolinaBlues.com/links/pharmacy/BlueEssentials to find an Advanced Choice Network pharmacy near you.
• Refer to your Member Schedule in this package for more information.• You can review more details about your plan by visiting www.SouthCarolinaBlues.com and logging on
to My Health Toolkit® to view your 2017 Summary of Benefits and Coverage.
18879-9-2016
•WHAT YOU NEED TO DO
1. Update your Marketplace application by Dec. 15, 2016. Review your Marketplace application to make sure the information is still current and correct and to see if you qualify for more or less financial help than in 2016. This may result in a lower monthly premium payment or lower out-of-pocket costs. Plus, you can help avoid paying money back when you file your taxes.
2. Decide if you want to enroll in this plan or choose another one. I want to enroll in this plan. Update your information in step #1, and then select [PLAN NAME AND QHP ID] to enroll.
I want to pick a different plan. You can choose a new plan between Nov. 1, 2016 - Jan. 31, 2017. Enroll by Dec. 15, 2016, for coverage to start on Jan. 1, 2017.
Here are some ways to look at other plans and enroll:• Check with BlueCross BlueShield of South Carolina to see what other plans may be available. Remember,
you won’t get financial help unless you qualify and enroll through the Marketplace.• Visit www.Healthcare.gov to see Marketplace plans. Consumers who shop can save hundreds of dollars
per year and can find a plan that best meets their needs and budget.
Note: If you got financial help in 2016 to lower your monthly premium, you’ll have to “reconcile” when you file your federal taxes. This means you’ll compare the amount of premium tax credit you used in advance during 2016 with the amount you actually qualify for based on your final 2016 household income and eligibility information. If the numbers are different, you may get more or less tax refund, or you may owe.
BlueEssentialsSM
HOW TO CONTACT US:
Manny Licata Vice President, Group & Individual Operations 855-404-6752 [email protected]
Call [Agent First Name] [Agent Last Name] at [Agent Phone No].Or, call BlueCross BlueShield of South Carolina at 855-404-6752 or visit www.SouthCarolinaBlues.com.
Visit www.Healthcare.gov or call 800-318-2596 (TTY: 855-889-4325) to learn more about the Marketplace and to see if you qualify for lower costs.
Find in-person help from an assister, agent or broker in your community at www.LocalHelp.Healthcare.gov.
Call 855-404-6752 to request a reasonable accommodation at no cost to you if you have a disability.
[Plan Name]
Member ScheduleBenefits are available in-Network only, except for Emergency Services.
BlueEssentials Member Schedule (Rev. 1/2017)
Member’s Name: [First Name1] [Last Name1] Effective Date: [Cov Eff Date] Benefit Period: 1/1-12/31
Member’s ID Number: [Subscriber ID] Total Premium: [Tot Prem Amt] Type of Plan: Single/Family
Covered Dependents: [First Name2] [Last Name2], [First Name3] [Last Name3], [First Name4] [Last Name4], [First Name5] [Last Name5], [First Name6] [Last Name6]
DEDUCTIBLE
[Column D]
COPAYMENTS
[Column E]
COINSURANCE
[Column F]
MAXIMUM OUT-OF-POCKET
[Column G]
Blue Cross and Blue Shield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
[Plan Name]
Retail:
[Column H]
[Column J]
Mail-Order/Retail 90:
[Column I]
PRESCRIPTION DRUG COVERAGE
BENEFIT PERIOD MAXIMUM — Per Member Per Benefit Period
[Column K]
Services That Are Covered For You
PRIMARY CARE PHYSICIAN, SPECIALIST OR URGENT CARE CENTERS
Office Visit Services – Office charges for the treatment of an illness, accident or injury; injections for allergy, tetanus and antibiotics; diagnostic lab and di-agnostic X-ray services (such as chest X-rays and standard plain film X-rays), when performed in the physician’s office on the same date and billed by the physician (excluding maternity). Includes mental health and substance use disorder services.
[Column L]
Inpatient Physician and Surgical Services [Column M]
All Other Physician Services – Outpatient hospital; skilled nursing facility; clinics; lab, X-ray and the reading/interpretation of diagnostic lab and X-ray services; surgery, male sterilization; second surgical opinion; consultation; anesthesia; dialysis treatment, chemotherapy, radiation therapy and the administration of specialty medications.
[Column N]
Urgent Care Center – The facility must be licensed as an urgent care center. [Column O]
PREVENTIVE CARE FOR CHILDREN AND ADULTS
As outlined in the Covered Services section of your policy. Includes some contraceptive devices or services.
[Column P]
All other covered contraceptive devices or services not specifically listed above. [Column Q]
WellnessPlus+ – services related to a physical exam not included in other covered Preventive Screenings, limited to $500 per benefit period. Services may be subject to age and visit limits.
[Column R]
ROUTINE VISION SERVICES FOR MEMBERS AGE 19 AND YOUNGER
• Eye Exam – limited to one exam per benefit period.
• Eyeglasses – frames limited to once every two years and lenses every benefit period.
• Contacts only when medically necessary.
Pediatric vision services are provided through VSP. VSP is an independent company that provides pediatric vision services on behalf of BlueCross BlueShield of South Carolina. To find a VSP provider, go to www.vsp.com/advantage and enter your ZIP code. (This link leads to a third-party site. That company is solely responsible for the contents and privacy policies on its site.)
[Column S]
[Column T]
[Plan Name]
EMERGENCY SERVICES
Emergency room charges in- or out-of-network or out-of-area, including physician services in the Emergency Room (copayment applies only to Emergency Room charges)
[Column W]
Ambulance services in- or out-of-network or out-of-area, only when medically necessary [Column X]
HOSPITAL SERVICES
Inpatient and outpatient hospital (other than skilled nursing facilities, rehabilitation facilities or emergency room). Includes mental health and substance use disorder services.
[Column V]
MATERNITY
Pre- and post-partum care including physician services. Hospital services provided as shown above.
[Column Y]
NEWBORN CARE
Post-natal care, including physician services. Hospital services provided as shown above. Benefits are available only if the child is added to your policy.
[Column Z]
REHABILITATIVE AND HABILITATIVE
Durable medical equipment (DME) – purchase or rental – excludes repair of, replacement of and duplicate DME.
[Column AA]
Physical, occupational, speech and respiratory therapy [Column AB]
Rehabilitation, including cardiac and pulmonary [Column AC]
Skilled nursing and rehabilitation facilities [Column AD]
Medical supplies [Column AE]
LABORATORY AND DIAGNOSTIC SERVICES
Radiology, ultrasound and nuclear medicine; laboratory and pathology; ECG, EEG and other electronic diagnostic medical procedures and physiological medical testing; Endoscopies (such as colonoscopy, proctoscopy and laparoscopy); high technology diagnostic services such as, but not limited to, MRIs, MRAs, PET scans, CT scans, cardiac catheterizations and procedures performed with contrast or dye.
[Column U]
[Plan Name]
This Policy only provides benefits for Covered Services received in-Network. If you receive Emergency Services for an Emergency Medical Condition by an out-of-Network Provider, benefits are provided at the in-Network Coinsurance amount; the Allowed Amount will not be more than the Maximum Payment as defined in your contract, and an out-of-Network Provider can bill you for the difference between the Allowed Amount we pay and his or her actual charge.For some services to be covered, you will be required to use a provider we designate, who may or may not be a BlueEssentials provider. These services include transplants, mammography, habilitation, rehabilitation and vision care.All benefits payable on Covered Services are based on our allowed amount. All covered services must be medically necessary. Some services require preauthorization, including all hospital admissions, except maternity. See the preauthorization section of the Certificate for information concerning the preauthorization requirement.If you are an individual living with disabilities, or have limited English proficiency, we have free interpretive services available.
MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES
Inpatient and physician’s services [Column AF]
Outpatient and physician’s services [Column AG]
Residential treatment centers [Column AH]
Physician’s office [Column AI]
OTHER SERVICES
Dental services related to accidental injury – Only when such care is for treatment, surgery or appliances caused by accidental bodily injury (except dental injuries occurring through the natural act of chewing). It’s limited to care completed within six months of such accident and while the patient is still covered under this policy.
[Column AJ]
Home health care [Column AK]
Hospice care [Column AL]
Out-of-Country services including facility and physician (covered through a BlueCard® provider only).
[Column AM]
[Plan Name]
Non-Discrimination Statement and Foreign Language Access We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. If you or someone you’re assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in the materials included with this notice. Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below. If you think we have not provided these services or have discriminated in any way, you can file a grievance online at [email protected] or by calling our Compliance area at 1-800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or 1-800-537-7697 (TDD). Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de este plan de salud, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-396-0183. (Spanish) 如果您，或是您正在協助的對象，有關於本健康計畫方面的問題，您有權利免費以您的母語得到幫助和訊
息。洽詢一位翻譯員，請撥電話 [在此插入數字 1-844-396-0188。 (Chinese) Nếu quý vị, hoặc là người mà quý vị đang giúp đỡ, có những câu hỏi quan tâm về chương trình sức khỏe này, quý vị sẽ được giúp đở với các thông tin bằng ngôn ngữ của quý vị miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-389-4838 (Vietnamese) 이 건보험에 관하여 궁금한 사항 혹은 질문이 있으시면 1-844-396-0187 로 연락주십시오. 귀하의 비용 부담없이 한국어로 도와드립니다. PC 명조 (Korean) Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa planong pangkalusugang ito, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-844-389-4839 . (Tagalog) Если у Вас или лица, которому вы помогаете, имеются вопросы по поводу Вашего плана медицинского обслуживания, то Вы имеете право на бесплатное получение помощи и информации на русском языке. Для разговора с переводчиком позвоните по телефону 1-844-389-4840. (Russian)
فلدیك الحق في الحصول على المساعدة والمعلومات ،خطة الصحة ھذه إن كان لدیك أو لدى شخص تساعده أسئلة بخصوص 1-844-396-0189 (Arabic) للتحدث مع مترجم اتصل ب .الضروریة بلغتك من دون ایة تكلفة
Si ou menm oswa yon moun w ap ede gen kesyon konsènan plan sante sa a, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232. (French/Haitian Creole) Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de ce plan médical, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-396-0190 . (French) Jeśli Ty lub osoba, której pomagasz, macie pytania odnośnie planu ubezpieczenia zdrowotnego, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-844-396-0186. (Polish) Se você, ou alguém a quem você está ajudando, tem perguntas sobre este plano de saúde, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-396-0182. (Portuguese) Se tu o qualcuno che stai aiutando avete domande su questo piano sanitario, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-844-396-0184. (Italian) あなた、またはあなたがお世話をされている方が、この健康保険 についてご質問がございましたら、ご
希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳
とお話される場合、1-844-396-0185 までお電話ください。 (Japanese) Falls Sie oder jemand, dem Sie helfen, Fragen zu diesem Krankenversicherungsplan haben bzw. hat, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-396-0191 an. (German)
ی بھداشتی این برنامھ یاگر شما یا فردی کھ بھ او کمک می کنید سؤاالتی در بارهداشتھ باشید، حق این را دارید کھ کمک و اطالعات بھ زبان خود را بھ طور رایگان
تماس حاصل 6233-398-844-1 یدریافت کنید. برای صحبت کردن با مترجم، لطفًا با شماره (Persian-Farsi) نمایید.
