My Medical  Benefits

Benefit Questions for the Consumer-Directed Health Plan, Enhanced 80/20 Plan and the Traditional 70/30 Plan

Does the office visit copay count toward the deductible?
Office visit copays do not count toward meeting the annual deductible or the annual coinsurance maximum if you are enrolled in the 80/20 Plan or the Traditional 70/30 Plan. If you are enrolled in the Consumer-Directed Health Plan (CDHP) there are no copays. However, the full cost of the office visit is applied to the deductible and then to coinsurance maximum after the deductible is met.
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If I satisfy the deductible for in-network benefits, will the amount apply to the out-of-network deductible?
In-network deductible amounts met do not apply to the out-of-network deductible limit. Amounts paid to satisfy out-of-network deductibles do satisfy the in-network deductible. The same rules apply toward meeting out-of-pocket limits (coinsurance maximums).
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If I have an outpatient surgical procedure, do I have to pay an office visit copay in addition to the deductible and coinsurance?
No, a copay is not required. Only the deductible and coinsurance are required.
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How will I know when my services are subject to deductibles and coinsurance?
Your level of coverage depends on the location where the service is provided (i.e. physician's office, outpatient facility, and inpatient hospital).
  • Copayments apply when services are received in an in-network physician's office.
  • Deductible and coinsurance apply when services are performed outside of the physician's office in an outpatient facility, and when performed in a hospital owned or operated physician's office or when services are provided by an out-of-network provider in the office.
  • For inpatient hospital services the inpatient copayment and deductible and coinsurance apply.
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I am unclear about how preventive and wellness benefits work. How many services can I receive for one copay, and what is subject to the coinsurance and deductible?
The initial copay covers services received during the preventive care physician visit. Additional services such as mammograms and lab work, even if received outside of the doctor's office, are also covered under the initial copay. If more services are required, such as x-rays, EEG or an EKG, they may be covered at 100% if performed in a physician's office. If the services are performed in an outpatient clinic setting, they may be subject to the deductible and coinsurance.
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What if I use up my 30 chiropractic visits during the year? Are there any exceptions, and will the plan approve more visits?
If the 30 visits are used up, covered members may take advantage of the BlueExtrasSM program, which offers discounts on chiropractic services.
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I'm having a baby. Do I have to pay a copay every time I go for a prenatal visit? And, how are hospital and delivery charges handled?
There is an initial copay charge for the pregnancy diagnosis (the first visit); visits thereafter are covered at no charge. The remaining maternity visit charges are covered by one global fee subject to the inpatient copay, deductible and coinsurance upon hospital admission/delivery. Charges include prenatal, delivery and postnatal care as well as circumcision. Please check out our Stork Rewards program on delivery room savings and other benefits.
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Are routine eye exams covered under the health plans?
Routine eye exams are not a covered benefit. However, you can receive discounts on prescription eyewear, including lenses, frames and nondisposable contact lenses, with BCBSNC network optometrists. Additional discounts, including discounts on eye exams are available, through Davis Vision. To learn more about the discounts, login to Member Services and select Rewards and Discounts.
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Are eye exams covered for diabetics?
Non-routine eye exams for diabetics are covered with specialist copay when seen by an in-network provider.
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I use an insulin pump rather than injecting insulin. Is the pump covered?
Insulin pumps are covered under durable medical equipment provisions.
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How is kidney dialysis covered? What if I receive in-home dialysis services?
Dialysis services are provided in an outpatient setting and are always covered by the deductible and coinsurance. In-home dialysis services are also covered with the deductible and coinsurance.
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If I am admitted into the hospital and my care includes anesthesiology and radiology services, will I have to pay out-of-network fees if the physician performing these services is not an in-network provider?
Inpatient services such as anesthesiology and radiology will always be covered as in-network, whether performed by in– or out-of-network providers, as long as services were provided at a participating hospital and you were admitted by a participating physician.
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Once I meet my out-of-pocket coinsurance maximum for out-of-network services, will I still be responsible for any difference between the billed amount and the allowable amount if I go out-of-network?
Yes. Once you meet your out-of-pocket coinsurance maximum for out-of-network services, you will still be responsible for any charges above the allowed amount.
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Do any of the services provided under the health plans have visit limits?
Yes, chiropractic care is limited to 30 visits per benefit year.
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What is the age limit for covered dependents?
Dependent children are covered up to age 26 as long as they are not eligible for their own or their spouse's employer sponsored health coverage.
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Can I order an ID card online?
You can order an ID card online by registering with Member Services, which is available via the Plan website.
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Can I obtain claim information online?
You can view your claim information online by registering with Member Services. You can also print an Explanation of Benefits from Member Services, which is available via the Plan website.
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