2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 73

Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.
Benefit Description

Inpatient Hospital

Room and board, such as:

  • Semiprivate or intensive care accommodations
  • General nursing care
  • Meals and special diets

Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a hospital only has private rooms.

Other inpatient hospital services and supplies, such as:

  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic studies, radiology services, laboratory tests, and pathology services
  • Administration of blood or blood plasma
  • Dressings, splints, casts, and sterile tray services
  • Internal prosthetic devices
  • Other medical supplies and equipment, including oxygen
  • Anesthetics and anesthesia services
  • Take-home items
  • Pre-admission testing recognized as part of the hospital admissions process
  • Nutritional counseling
  • Acute inpatient rehabilitation

Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described on page 77. See pages 134-135 for more information about these types of services.

Here are some things to keep in mind:

  • If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See page 26 for information on requesting additional days.
  • We pay inpatient hospital benefits for an admission in connection with the treatment of children up to age 22 with severe dental caries. We cover hospitalization for other types of dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(g).

  • See pages 79 and 89 for inpatient residential treatment center.
  • See pages 74-76 for other covered maternity services.
  • For inpatient care received overseas, refer to Section 5(i) page 109.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member): You pay all charges
Inpatient Hospital - continued on next page