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 78
 
Benefit Description

Outpatient Hospital or Ambulatory Surgical Center (cont.)

Outpatient treatment and therapy services performed and billed by a facility, limited to:

 
  • Cognitive rehabilitation therapy limited to 25 visits per person per calendar year
     
  • Physical therapy, occupational therapy, and speech therapy limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
     
  • Manipulative treatment and acupuncture services, limited to a combined 10 visits per person.

    Notes:

     
    • We provide benefits for manipulative treatment and acupuncture services as described on page 57.
       
    • See page 71 for our coverage of acupuncture when provided as anesthesia for covered surgery.
       
    • See page 75 for our coverage of acupuncture when provided as anesthesia for covered maternity care.

Note: The limitations listed above are a combined total regardless of the type of covered provider or facility billing for the services.


You Pay
Preferred facilities: $25 copayment per visit (no deductible)

Non-preferred facilities (Member/Non-member): You pay all charges

Note: You pay 30% of the Plan allowance for supplies or drugs administered or obtained in connection with your care. (See page 131 for more information about “agents.”)
 
Benefit Description

Outpatient treatment services performed and billed by a facility, are limited to:

 
  • Outpatient applied behavior analysis* (ABA) for an autism spectrum disorder performed and billed by a facility limited to 200 hours per person, per calendar year.

    Note: The limitations listed is a combined total regardless of the type of covered provider or facility billing for the services.

*Prior approval is required, see pages 19-22 for prior approval requirements.


You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member): You pay all charges
 
Benefit Description

Outpatient adult preventive care performed and billed by a facility, limited to:

 
  • Visits/exams for preventive care, screening procedures, and routine immunizations described on pages 41-46
     
  • Cancer screenings listed on page 42 and ultrasound screening for abdominal aortic aneurysm
     
Notes:
 
  • See pages 43-44 for our coverage requirements for preventive BRCA testing.
     
  • See pages 46-47 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.


You Pay
Preferred facilities: Nothing (no deductible)

Non-preferred facilities (Member/Non-Member): Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm

Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Non-preferred (Member/Non-member) facilities.
 
Outpatient Hospital or Ambulatory Surgical Center - continued on next page