2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 10. Definitions of Terms We Use in This Brochure
Page 132
Congenital anomaly
A condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birth marks; ambiguous genitalia; and webbed fingers and toes. Note: Congenital anomalies do not include conditions related to the teeth or intra-oral structures supporting the teeth.

A copayment is a fixed amount of money you pay when you receive covered services. See page 28.

Core benefits
Benefits under FEP Blue Focus that have no or a low copayment. CORE benefits are not subject to deductible or coinsurance. The benefits are most commonly used to receive general care and to maintain your overall health and well-being, but also include coverage for spinal manipulations, acupuncture and accidental injury.

Cosmetic surgery
Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form, except for repair of accidental injury, or to restore or correct a part of the body that has been altered as a result of disease or surgery or to correct a congenital anomaly.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Covered services
Services we provide benefits for, as described in this brochure.

Custodial or long term care
Facility-based care that does not require access to the full spectrum of services performed by licensed healthcare professionals that is available 24 hours a day in acute inpatient hospital settings to avoid imminent, serious, medical or psychiatric consequences. By “facility-based,” we mean services provided in a hospital, long term care facility, extended care facility, skilled nursing facility, residential treatment center, school, halfway house, group home, or any other facility providing skilled or unskilled treatment or services to individuals whose conditions have been stabilized. Custodial or long term care can also be provided in the patient’s home, however defined.

Custodial or long term care may include services that a person not medically skilled could perform safely and reasonably with minimal training, or that mainly assist the patient with daily living activities, such as:

  1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube, or gastrostomy), exercising, or dressing;
  2. Homemaking, such as preparing meals or special diets;
  3. Moving the patient;
  4. Acting as companion or sitter;
  5. Supervising medication that can usually be self-administered; or
  6. Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature, and respiration; or administration and monitoring of feeding systems.

We do not provide benefits for custodial or long term care, regardless of who recommends the care or where it is provided. The Carrier, its medical staff, and/or an independent medical review determine which services are custodial or long term care.

Durable medical equipment
Equipment and supplies that are:

  1. Prescribed by your physician (i.e., the physician who is treating your illness or injury);
  2. Medically necessary;
  3. Primarily and customarily used only for a medical purpose;
  4. Generally useful only to a person with an illness or injury;
  5. Designed for prolonged use; and
  6. Used to serve a specific therapeutic purpose in the treatment of an illness or injury.