Individual Plans Overview
Table of Contents
Introduction ..................................................................................................................... 1
Cost Sharing ................................................................................................................... 2
Deductible.................................................................................................................... 2
Benefit Percentage ...................................................................................................... 2
Copayment .................................................................................................................. 2
Annual Maximum Out-of-Pocket .................................................................................. 3
Eligibility .......................................................................................................................... 3
Premium Payment ........................................................................................................... 5
Grace Period ................................................................................................................... 5
Grace Period for Coverage with an Advance Premium Tax Credit (APTC) ................. 5
Grace Period for All Other Coverage ........................................................................... 5
Exchanges for Individual Consumers .............................................................................. 6
Federally Facilitated Marketplace (FFM) ..................................................................... 6
Multi-State Plan Program ............................................................................................. 9
eDirect ......................................................................................................................... 9
MyChoiceSC.com ........................................................................................................ 9
Subsidies......................................................................................................................... 9
Cost-Sharing Subsidies ................................................................................................. 11
Benefit Information ........................................................................................................ 12
Essential Benefits ...................................................................................................... 12
BlueEssentials Product Comparisons ........................................................................... 12
MyChoice Advantage Product Comparisons ................................................................. 12
Reviews and Preauthorizations ..................................................................................... 13
BlueEssentials and MyChoice Advantage Network ....................................................... 14
What Is the BlueEssentials and MyChoice Advantage Network? .............................. 14
BlueEssentials and MyChoice Advantage Network Provider Credentialing ............... 14
BlueEssentials and MyChoice Advantage Network Provider Responsibilities ........... 15
The BlueCard Program .............................................................................................. 15
BlueCard Worldwide .................................................................................................. 16
BlueCard Worldwide Expat Programs ....................................................................... 16
BlueCross BlueShield of South Carolina
is an independent licensee of the
Blue Cross and Blue Shield Association.
BlueCross and BlueChoice Individual Health Plans
Overview
Introduction
On March 23, 2010, President Obama signed comprehensive health reform, known now
as the Affordable Care Act (ACA) into law. Health care reform builds on our current
health insurance system to provide more people with access to health care benefits,
establish legal protections for consumers and set up mechanisms for consumers to
shop knowledgeably for insurance.
Health care reform includes (but is not limited to) these key reforms:

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
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

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Expand Medicaid to allow more people at the lowest income levels to qualify for
coverage.
Encourage employers to offer health insurance.
Provide credits to purchase private health insurance coverage to moderateincome Americans who do not qualify for Medicaid.
Streamline the purchase of health insurance through the establishment of the
Health Insurance Exchange.
Strengthen consumer protections and require transparency.
Impose protections to guard against unreasonable rate increases.
Encourage primary and preventive care.
Require most Americans to purchase health insurance.
Many changes over the past three to four years have impacted the way insurance
companies conduct business and develop products. Some of the changes are:

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Web portal: The U.S. Department of Health and Human Services (HHS)
developed a website (www.HealthCare.gov) where individuals and small
businesses can identify affordable health insurance coverage options and
provides information on:
o Private health insurance coverage
o Medicaid
o CHIP (Children’s Health Insurance Pool)
o Pre-Existing Condition Insurance Plan
o Small group coverage
Removal of lifetime coverage limits: The law prohibits health insurance
companies from placing lifetime caps on the total amount of insurance coverage
that an individual or family can receive.
Banning rescissions: This provision bans insurance companies from dropping
people from health insurance coverage after they get sick due to an unintentional
mistake on their application. This applies to all policies.
Guaranteed Issue: The law prohibits health plans from denying coverage for
requiring waiting periods for children under age 19 with pre-existing conditions.
Beginning 2014, this will apply all people.
Page 1
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
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Regulation of annual dollar limits: The law restricts insurance companies from
placing annual dollar limits on benefits provided. This will ensure access to
needed care.
No cost-sharing preventive care: For policies sold on or after September 23,
2010, health plans are required to cover preventive services without applying
copayments, coinsurance or deductibles.
Adjusted community rating: This permits insurers limited differences in rating
based on age and tobacco use.
Cost Sharing
Cost sharing means any expenditure required by or on behalf of a member with respect
to essential health benefits. Cost sharing includes the terms deductible, coinsurance,
copayment or similar charges but does not include premiums, balance billing for out-ofnetwork providers (which does not apply to BlueCross of South Carolina or BlueChoice
HealthPlan of South Carolina [As we move through this training, these two companies
will be referred to together as “Company.”] individual policies) or spending for noncovered services.
Deductible
The amount the member will pay for health care services that the company covers
before the plan begins to pay. The deductible may not apply to all services — for
example, preventive services.
Benefit Percentage
Both the company and its members pay a percentage of the allowable medical charges
the member incurs each benefit period. The part the member pays is the “coinsurance
percentage” and the part the company pays is the “benefit percentage.”
Copayment
The member may be responsible for an office visit copayment (for product specifics,
please refer to the product comparison chart documents). These services are covered
under the office visit copayment:

Office charges including surgical services for the treatment of an accident or
injury

Injections for allergy, tetanus and antibiotics

Diagnostic lab and diagnostic 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
Page 2
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
All other services that are provided during an office visit that are not covered by the
office visit copayment are subject to the member’s deductible and coinsurance unless
otherwise specified in the Schedule of Benefits.
For example, a member has a plan that has a $20 copayment then 50 percent. The
member has been experiencing heart palpitations and shortness of breath. The office
visit will be covered by the copayment, but the tests performed by the doctor, in this
case an EKG, is covered by the coinsurance (50 percent).
All copayments apply to the member’s annual maximum out-of-pocket limit. The
member will no longer be subject to copayments once he or she has met the annual
maximum out-of-pocket amount.
Annual Maximum Out-of-Pocket
This is the total dollar limit the member will pay out of his or her pocket each benefit
period. Anything the member pays will contribute to the maximum out-of-pocket amount,
including deductibles, coinsurance and copayments (including prescription drug
copayments). Once the member reaches his or her out-of-pocket maximum, the
company pays 100 percent of eligible medical expenses for most covered services for
the remainder of the benefit period.
Eligibility
All individuals regardless of age or medical status are eligible to apply for an individual
policy during open enrollment. Open enrollment for 2014 is October 1, 2013, through
March 31, 2014. Open enrollment for subsequent years will be October 15 through
December 7 of each year. The only age restriction is for the catastrophic plan. Only
individuals under age 30 and individuals for whom other coverage has been deemed
unaffordable may purchase a catastrophic plan.
The company provides single only coverage. Dependents cannot be added to existing
policies. Gaining or losing a dependent in a household may affect eligibility for premium
tax credits and eligibility for a special enrollment. Every qualified individual who applies
for coverage during a special or open enrollment period will be accepted for coverage. If
members are determined to be no longer eligible for coverage, their coverage in the
plan will end on the last day of the month following the month in which they received
notice of their ineligibility.
Page 3
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
The date on which coverage for a member is received is called the effective date.
Request for Enrollment Is Received
October 1 to December 15
December 16 through January 15
January 16 through February 15
February 16 through March 15
March 16 through March 31
Effective Date
January 1
February 1
March 1
April 1
May 1
Applicants may enroll in coverage every year during the annual Open Enrollment. They
may enroll at other times during the year only if they have a special enrollment event. A
special enrollment must be requested within 60 days of the qualifying event.
Special enrollment events include, but are not limited to these situations:
 Loss of minimum essential coverage.
 Birth or adoption of a dependent or becoming a dependent through marriage,
birth, adoption or placement for adoption.
 Becoming a lawful United States citizen.
 Enrollment or non-enrollment in a Qualified Health Plan was unintentional,
inadvertent, or erroneous and was the result of the error, misrepresentation,
or inaction of an officer, employee, or agent of the Health Insurance
Marketplace or Health and Human Services (HHS), as evaluated and
determined by the Health Insurance Marketplace. In such cases, the Health
Insurance Marketplace may take such action as may be necessary to correct
or eliminate the effects of such error, misrepresentation, or inaction.
 The health plan previously/currently enrolled violated a material provision of
its contract.
 Determined to be newly eligible or ineligible for advance payments of the
premium tax credit or have a change in eligibility for cost-sharing reductions,
regardless of whether you were already enrolled in a Qualified Health Plan.
We must permit you to access this special enrollment period prior to the end
of your current coverage if your existing coverage through an eligible
employer-sponsored plan will no longer be affordable or provide minimum
value.
 Gaining access to a new Qualified Health Plan as a result of a permanent
move.
 An Indian, as defined by Section 4 of the Indian Health Care Improvement
Act, may enroll in a Qualified Health Plan or change from one Qualified
Health Plan to another no more often than one time per month.
 Applicant demonstrates that he or she meets certain exceptional
circumstances as the Health Insurance Marketplace may provide.
Page 4
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
The effective date for qualifying events, except birth, adoption, placement for adoption,
marriage or loss of minimum essential coverage is:
Qualifying Event Occurs
Between the first and 15th of the month
(example you lose coverage on February 2)
Between the 16th and the end of the month
(example you lose coverage on February
18)
Effective Date
The first of the next month
(Coverage is effective March 1)
The first of the month following
next month
(Coverage is effective April 1)
The effective date for birth, adoption or placement for adoption is the date of the event.
The effective date for marriage or loss of minimum essential coverage is the first of the
following month, for example the date of marriage is on January 31, coverage will be
effective February 1.
Premium Payment
The premium is due of the first of each month. Premiums can be paid through bank
draft, cash (via BlueCross retail center), check or by credit card.
Grace Period
If the premium is not paid on or before the date it is due, it may be paid during the grace
period. If the premium has not been paid by midnight of the day following the end of the
grace period, the coverage will automatically terminate without further notice. Paying
claims after termination does not extend coverage.
Grace Period for Coverage with an Advance Premium Tax
Credit (APTC)
If the member has paid at least one’s month’s premium and received the APTC, the
grace period is three months. Benefits will be provided according to the coverage during
the first month of the grace period. Benefits are not allowed for services provided during
the second and third month of the grace period unless all of delinquent premiums are
paid in full. Premiums not paid in full by the end of the grace period will cause the policy
to terminate. Coverage will end on the first day of the second month of the three-month
grace period.
Grace Period for All Other Coverage
If the member did not receive an APTC, the grace period is 31 days. Benefits will not be
allowed during the grace period until premiums are paid. Premiums not fully paid by the
end of the 31-day grace period will cause the policy to terminate. Coverage will end on
the premium due date for the 31-day grace period.
Page 5
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
Exchanges for Individual Consumers
Exchanges will increase access to coverage by providing a single point of access for
individuals. The exchanges will allow consumers to easily compare health plans on an
apples-to-apples basis. Exchanges will increase competition among issuers and
improve the affordability of coverage. The exchanges are integral to the Affordable Care
Act’s goals of prohibiting discrimination against people with pre-existing conditions and
insuring all Americans.
Federally Facilitated Marketplace (FFM)
The ACA gave each state the opportunity to establish an Affordable Insurance
Exchange to help individuals and small employers purchase health insurance coverage.
These exchanges will allow individuals and eligible employers to compare and select
from qualified health plans (QHPs) for their families and employees. The plans meet
benefit design, consumer protection and other standards. Recognizing that all states
may elect to establish a state-based exchange, the Affordable Care Act directed the
Health and Human Services secretary to establish and operate a Federally Facilitated
Marketplace (FFM) in any state that does not elect to do so, or will not have an operable
exchange for the 2014 plan year. Sixteen states (plus the District of Columbia) have
elected to implement a state-based exchange, 27 have elected to default to the FFM
and seven are planning for a partnership exchange.
Before agents can sell through the FFM, all agents are required to complete training on
the Medicare Learning Network
(http://Marketplace.MedicareLearningNetworkLMS.com). Please make sure you have
your national producer number (NPN). To sell individual products on the FFM, you
must:
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Complete Affordable Care Act and Marketplace Basics and pass required test.
Complete Individual Marketplace and pass required test.
Read and accept the Individual Marketplace Agreements.
Page 6
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
Here is an outline of the flow of information for a consumer to apply for coverage
through the FFM.
Creates
an
account
Applies for
eligibility
Compares
plans
Submits
enrollment
Pays
premium to
insurer
If eligible for Medicaid and/or CHIP, the consumer’s
account will be transferred to the state for
enrollment
Basic
personal
information
Household
& Family
Income
Other
coverage
Signatures
&
Attestation
Eligibility
results
Applicants will access the FFM on www.Healthcare.gov. They will click on the “Get
Insurance” tab then click on “Individuals and Families.” They will answer questions
relating to these categories:
 Basic contact information
 Who will be applying for insurance?
 Family and household details
 Personal information
 Income information
 Additional information such as other coverage
Applicants will have the ability to review their application, attest they are eligible to apply
for coverage and sign the application. They will then be told whether or not they are
eligible to apply for coverage through the FFM and how much assistance, in the way of
tax credits, they will receive.
Applicants who are eligible for the Advance Premium Tax Credit (APTC) will have to
identify how they wish to use their APTC. They will have three options:
 Use ALL: Applicants can apply the entire amount of the APTC immediately to the
monthly premium therefore reducing the amount they will pay each month.
 Use SOME: Applicant can apply a portion of their APTC immediately to the
monthly premium therefore reducing the amount they will pay each month and
receive the remaining balance when they file their income tax return.
Page 7
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview

Use NONE: Applicants who do not elect to use any of their APTC will receive the
tax credit when they file the income tax return.
The applicant will be asked if they would like to use less than their entire APTC each
month. If they select “No,” they will continue with the enrollment process and the entire
monthly APTC will be applied to premium prices. If the applicant selects “Yes,” a slider
feature will appear that will allow them to adjust the amount that will be applied each
month. The default slider feature is set to the entire maximum APTC amount.
The FFM will provide educational information to help the applicant chose a plan. It
reviews the required essential benefits and plan categories (platinum, gold, silver,
bronze, and catastrophic). It will then allow applicants to select a plan category they
wish to shop. This screen will display the average premium price, average copayment,
coinsurance and out-of-pocket from all insurers on the FFM. Applicants can select more
than one category.
After they have selected the category(ies) the FFM will display all matching products.
This screen will also notify the applicant if the APTC has been applied to the premium.
Top level priority fields (i.e. name of plan, monthly premium after discount, deductible,
OOPs, copayments, dental options and links to specific benefits, provider directories,
and additional plan details) will be displayed for each matching product result. Results
can be sorted and filtered.
Applicant can select up to 12 products to compare side by side. Headings that can be
expanded on the plan comparison include:
 General Information
o Monthly premium
o Deductible
o Maximum out-of-pocket payments
 Cost of medical care
 Prescription drug coverage
 Health plan quality
 Adult dental
 Child dental
 Medical Management programs
 Other services
Applicants can select the plan they are interested in and review all plan information.
Once consumers click “Enroll” they will confirm their selection, provide attestation and
submit the enrollment. The applicant will see a confirmation screen containing plan
customer service information about where to go to arrange payment (website, phone
number, etc.).
Page 8
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
Multi-State Plan Program
This exchange was created by the ACA and developed by the Office of Personnel
Management (OPM). The MSPP will promote competition in the new health insurance
marketplace and help ensure that consumers have more high-quality, affordable health
insurance plans from which to choose. These health insurance plans, known as MultiState Plans (MSPs) will be among the health insurance options from which individuals
and small employers will be able to choose starting during the open enrollment
beginning October 2013 on the FFM.
The health care reform law directs the OPM to enter into contracts with private health
insurance issuers to provide at least two Multi-State Plans to be offered in each state’s
Marketplace beginning in 2014. At least one of these issuers must be a nonprofit entity.
These objectives guide the administration of the MSPs:
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Ensure a choice of at least two high-quality products to consumers participating
in the Marketplace.
Promote competition in the Marketplace to the benefit of all consumers.
Offer plans from the same issuer to families or small businesses that may reside
or operate in more than one state.
Provide strong, effective contractual oversight of the issuers that choose to offer
MSPs.
Work cooperatively with states and the Department of Health and Human
Services to ensure a level playing field for Qualified Health Plans (QHPs) and
MSPs.
eDirect
A private exchange called eDirect has been developed to promote and sell BlueCross
products. This exchange will be available on www.SouthCarolinaBlues.com and open to
any individual who wishes to purchase or agent who wishes to sell a BlueCross product
off the FFM.
MyChoiceSC.com
A private exchange, called MyChoiceSC.com, has been developed to promote and sell
BlueChoice products. This exchange will be available on www.MyChoiceSC.com and
open to any individual who wishes to purchase or agent who wishes to sell a
BlueChoice product off the FFM.
Subsidies
To encourage participation on health insurance and to provide affordable coverage for
individuals, the ACA includes provisions to lower premiums (subsidies in the form of tax
Page 9
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
credits) and cost-sharing requirements (i.e. deductibles, out-of-pocket, copayments,
etc.).
Citizens and legal residents of the United States with incomes between 100 percent and
400 percent of the federal poverty level who purchase coverage through the FFM are
eligible for a tax credit to help reduce premiums. People who are eligible for public
coverage (such as Medicaid) are not eligible for premium assistance through the FFM.
People offered coverage through an employer are also not eligible for premium tax
credits unless the employer plan does not have an actuarial value of at least 60 percent
(60 percent actuarial value means that on average the plan pays 60 percent of the cost
of covered benefits) or unless the person’s share of the premium for employersponsored insurance exceeds 9.5 percent of their income. People who meet these
thresholds for unaffordable employer-sponsored insurance are eligible to enroll in health
insurance through the FFM and may receive tax credits to reduce the cost of coverage.
The amount of the tax credit an individual can receive is based on the premium for the
second lowest cost silver plan in the exchange and the area where the person is eligible
to purchase coverage. A silver plan is a plan that provides the essential benefits and
has an actuarial value of 70 percent. The amount of the tax credit varies with income
such that the premium that the premium a person would have to pay for the second
lowest cost silver plan would not exceed a specified percentage of their income
(adjusted for family size), as outlined here:
Income Level
Up to 133%
133% - 150%
150% - 200%
200% - 250%
250% - 300%
300% - 400%
Premium as a Percentage of Income
2%
3 – 4%
4 – 6.3%
6.3 – 8.05%
8.05 – 9.5%
9.5%
Federal Poverty Level Table
Family
Size
1
2
3
4
5
100%
133%
150%
200%
250%
300%
400%
$11,170
$15,130
$19,090
$23,050
$27,010
$14,856
$20,123
$25,390
$30,657
$35,923
$16,755
$22,695
$28,635
$34,575
$40,515
$22,340
$30,260
$38,180
$46,100
$54,020
$27,925
$37,825
$47,725
$57,625
$67,525
$33,510
$45,390
$57,270
$69,150
$81,030
$44,680
$60,525
$76,360
$92,200
$108,040
An individual who wants to purchase a more expensive plan (such as a gold or platinum
plan), would have to pay the full difference between the cost of the silver plan and the
plan they wish to purchase.
Page 10
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
Example:
 Jackson is 31 and has an income in 2013 that is 250 percent of the poverty level
(around $27,925).
 The cost of the second lowest cost silver plan in the FFM in Jackson’s area is
about $5,733.
 According to the ACA, Jackson would not be required to pay more than 8.05
percent of his income in premiums, or about $2,248, to enroll in the second
lowest cost silver plan.
 The tax credit available to Jackson would be $3,485 (cost of premium $5,733
minus Jackson’s maximum payment $2,248)
Jackson can apply the entire amount of his tax credit to the monthly premium
(advanceable) or he could be reimbursed when he files his tax return (refundable).
Cost-Sharing Subsidies
Cost-sharing subsidies are designed to protect lower-income people from having to pay
high out-of-pocket costs at the point of service (i.e. lower deductibles, out-of–pocket
charges, copayments). Families with incomes at or below 250 percent of FPL are
eligible to enroll in health plans with higher actuarial values. The premium tax credits
are based on plans with an actuarial value of 70 percent. Health care reform provides
that people with lower incomes have their cost sharing reduced so that they plan will
pay a higher portion of the covered benefits. The actuarial value varies with income.
For non-Native Americans, insurers are required to have three cost sharing
reduction(CSR) plan variations for each silver QHP offered on the exchange.
Income Level
100 – 150% FPL
150 – 200% FPL
200 – 250% FPL
Above 250% FPL
Actuarial Value
94%
87%
73%
70% Standard Silver (No
CSR)
Self-Only
Coverage
Reduced Max
Annual Outof-Pocket
Limit
$2,250
$2,250
$5,200
$6,350
Family
Coverage
Reduced
Maximum
Annual Outof-Pocket
Limit
$4,500
$4,500
$10,400
$12,700
For Native Americans, insurers are required to have two CSR plan variations for all
QHPs offered on the Exchange (regardless of metal level): Items or services furnished
Page 11
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
directly by the HIS, an Indian Tribe, a Tribal Organization, or an Urban Indian
Organization provider or through referral under Contract Health Services (CHS) have
zero cost sharing to the member.
Income Level
Native American Plan Variation
Below 300% FPL
Zero cost-sharing plan variations for Indians with incomes
below 300% FPL regardless of provider.
Limited cost-sharing plan variations for Native Americans with
incomes above 300% FPL at an in-network provider.
Above 300% FPL
Benefit Information
The Group and Individual division of BlueCross BlueShield of South Carolina will be
offering four levels of products:
 Gold: BlueEssentialsSM Gold
 Silver: BlueEssentialsSM Silver
 Bronze: BlueEssentialsSM Bronze
 Catastrophic: BlueEssentialsSM Catastrophic
All four levels will be offered on the FFM and the BlueCross private exchange. Gold and
silver products will be offered as MSPs.
BlueChoice HealthPlan of South Carolina will be offering four levels of products:
 Gold: MyChoice Advantage Gold
 Silver: MyChoice Advantage Silver
 Bronze: MyChoice Advantage Bronze
 Catastrophic: MyChoice Advantage 6351 plan
All levels will be offered on the FFM and the BlueChoice private exchange.
Essential Benefits
Please see the separate Essentials Benefits document.
BlueEssentials Product Comparisons
Please see the separate BlueEssentials Product Comparisons document.
MyChoice Advantage Product Comparisons
Please see the separate MyChoice Advantage Product Comparisons document.
Page 12
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
Reviews and Preauthorizations
The company requires in-network providers to get permission from the company before
performing certain services. These are called reviews and preauthorizations (or
precertifications). Along with certain services needing to be medically appropriate, the
patient must be a member under this policy at the time the service is provided and the
service must be a covered service.
The following services require preauthorizations. Benefits will not be provided without
preauthorizations.

Hospital admissions, including maternity

Skilled nursing facility (SNF) admission

Continuation of a hospitalization stay review (a stay in an inpatient hospital or
SNF longer than what the company originally approved)

Outpatient chemotherapy or radiation therapy

Outpatient hysterectomy or septoplasty

Home health or hospice care

Durable medical equipment (when the purchase or rental price is over $500)

Admissions for habilitation, rehabilitation and/or human organ and/or tissue
transplants (must also use a designated provider)

Treatment for hemophilia (care must be coordinated through a Centers for
Disease Control and Prevention (CDC) hemophilia treatment center at least once
per benefit period)

Certain prescription drugs

Specialty drugs (must also use a designated provider)

Outpatient and office MRI, MRA, PT scan and CT scan (National Imaging
Associates provides utilization management for these radiological procedures.
Because NIA is an independent company from BlueCross and BlueChoice, NIA
will be responsible for all services related to these procedures.)

Mental health and substance use services (CBA is a separate company that
manages behavioral health and substance abuse benefits for most BlueCross
and BlueChoice members and their dependents.)

Emergency admission review — if a member has a life-threatening emergency
and he or she is admitted to the hospital directly through the emergency room,
then the member or provider needs to contact the company within 24 hours or by
5 p.m. the next business day or as soon as reasonably possible.
Page 13
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
BlueEssentials and MyChoice Advantage Network
BlueCross members enrolled in a BlueEssentials product will use the BlueEssentials
network. BlueChoice members enrolled in a MyChoice Advantage product will use the
MyChoice Advantage network.
What Is the BlueEssentials and MyChoice Advantage
Network?
The BlueEssentials and MyChoice Advantage network is an exclusive provider
organization (EPO). An EPO is an organization of medical providers who agree to
provide their services at a discount. These providers make up the exclusive provider
network. As an incentive for covered individuals to use network providers, the plan plays
a higher percentage of the approved allowance for procedures/services.
Some advantages of the BlueEssentials and MyChoice Advantage network are the
negotiated discounts for covered services with in-network providers. This means big
savings to members. Members will receive a higher level of benefits for covered
services. Members also have the freedom to “self-refer” to a network specialist. This
means they may schedule an appointment without a referral from a primary care
physician. However, not all specialists accept self-referrals.
BlueEssentials and MyChoice Advantage Network Provider
Credentialing
Before a provider can qualify to participate in the BlueEssentials or the MyChoice
Advantage network, physicians must go through an initial credentialing process. We
repeat the credentialing process every three years to determine if physicians still meet
specific criteria. This credentialing process is the same as the Preferred Blue or
MyChoice credentialing process.
Here are the criteria we require for a physician to participate in the Blue Essential or the
MyChoice Advantage network:

Have a current state license, registration and/or certification.

Maintain adequate levels of professional liability insurance.

Provide a five-year work history.

Verify in writing his/her hospital admitting privileges.

Complete and submit the South Carolina Uniform Managed Care Credentialing
Application.
In addition to meeting these requirements, board certification in a specialty is highly
desirable.
Page 14
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
BlueEssentials and MyChoice Advantage Network Provider
Responsibilities
Once a physician contracts with the company to be a BlueEssentials or MyChoice
Advantage provider, there are certain responsibilities he or she must uphold:

The provider agrees to file all claims for covered services for our members.

The provider agrees to refer members who need specialty care to other
BlueEssentials or MyChoice Advantage providers.

The provider agrees to accept our fees and any required member payments for
covered services they provide. Member payments include:
o Deductibles – The amount of covered expenses that the member pays
before benefits become payable by the plan.
o Copayments – The amount the member pays each time he/she visits a
BlueEssentials or MyChoice Advantage doctor’s office after which we pay
100 percent.
o Coinsurance – The percentage of covered expenses the member must
pay, after meeting the deductible.
The in-network provider may not bill the member for covered service charges exceeding
the allowable charge as negotiated by the company. This is a practice known as
“balance billing.” Members are only responsible for any deductibles, copayments or
coinsurance amounts. They will never have to pay more than the company’s allowed
amount.
The BlueCard Program
The BlueCard program is a national program in which all Blue Cross and Blue Shield
plans participate. This national program benefits BlueCross BlueShield of South
Carolina and BlueChoice Health Plan of South Carolina members who received covered
services outside of our service area (national and international), even if it is a nonemergency. The member simply calls the 800 number on the back of his or her ID card
(or at www.SouthCarolinaBlues.com or www.BlueChoiceSC.com) to find participating
providers in the local area they are visiting.
When a member visits a preferred provider, the member must show his or her ID card.
The provider will then verify membership and coverage information. After providing the
medical services the member requires, the provider will submit the member’s claim to
the local Blue Plan. This claim is then electronically routed to the appropriate company.
The member will receive the local Blue Plan’s provider discounts and is only responsible
for any required deductibles, coinsurance and/or copayments.
Page 15
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association
BlueCross and BlueChoice Individual Health Plans
Overview
BlueCard Worldwide
BlueCross and BlueChoice processes claims for all 41 Blue Plans’ members traveling or
living outside of the United States.
BlueCard Worldwide gives members access to doctors and hospitals in more than 200
countries and territories and to a wide range of medical assistance services around the
world. Claims are sent to us to process. Then, we route the claim to the member’s home
plan with U.S. dollars and text already translated. Procedures also are in place if the
member pays the bill and requests reimbursement in a foreign currency.
BlueCard Worldwide Expat Programs
BlueCard Worldwide Expat provides comprehensive major medical health care
coverage for employees of U.S.-based overseas companies and their families. If these
employees and their dependents need health care while living in a foreign country or
visiting the United States, they receive access to doctors and hospitals through the
BlueCard program. Providers file claims with the local Blue Plan and the local Blue Plan
forwards the claim to the appropriate company for processing.
Page 16
BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan are independent licensees of
the Blue Cross and Blue Shield Association