Consumer Health Insurance
Plans 2014
For People Who Buy
Their Own Insurance
NORTHERN VIRGINIA
Welcome
Dear
In our 75 years of service to your family, friends and neighbors, this is
the first time that all of the plans we’re offering from CareFirst BlueCross
BlueShield and CareFirst BlueChoice, Inc. (CareFirst) are brand-new. That’s
because all 15 of our plans were designed to meet—and have met—the
new guidelines of the Affordable Care Act (ACA), or, health care reform.
Because the ACA is new, we know this is the first time anyone will be
buying an ACA plan. Everyone will benefit from learning the ACA terms and
ideas in the short overview section following this one.
That’s why we recommend you read this brief, step-by-step guide from
front to back. Written in an easy-to-understand style, it will:
■■ Explain ACA and how it will affect you
■■ Define basic health insurance concepts and terms
■■ Explain new financial help that can lower your costs
■■ Give you info about ACA Metal Levels
■■ Provide rate tables so you can calculate your premium
■■ Give you 3 ways to enroll today
The new ACA health care landscape may not be familiar, but CareFirst is.
We’ve always been committed to making sure you have the
best information, when you need it. If you need more than
you find in this book and the accompanying charts, visit
www.CareFirst.com/individual or call us at 800-544-8703,
7 days a week, 8:00 am – 8:00 pm. You can use the same
number for our no-charge bi-lingual services, too.
As always, we’re here for you.
Ready to go shopping?
You can also visit us online at
www.CareFirst.com/individual
to research and compare plans.
Sincerely,
Vickie S. Cosby
Senior Director, Consumer Direct Sales
1
Consumer Health Insurance Plans 2014
Northern Virginia
What’s Inside…
Get to know the basics
How health care reform will affect you . . . . . . . . . . . . . . . . . . . . . . . 3
What you need to know before you shop . . . . . . . . . . . . . . . . . . . . . 5
Choosing your CareFirst health care plan
Understanding your plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Calculating your total monthly premium . . . . . . . . . . . . . . . . . . . . . 15
Dental and vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
The rewards of enrolling in HealthyBlue plans . . . . . . . . . . . . . . . . 25
Taking your health to the next level . . . . . . . . . . . . . . . . . . . . . . . . . 27
Enroll today
Three ways to enroll in your new CareFirst plan . . . . . . . . . . . . . . . 29
Additional information
Our commitment to you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison
purposes only and does not create rights not given through the benefit plan.
2
Get to know the basics
How health care reform
will affect you
The Affordable Care Act (ACA), or health care reform, became law in 2010 and will affect the majority of
people who buy their own insurance. In addition to requiring nearly everyone to buy health insurance
starting in 2014, the ACA will have an impact on almost every other aspect of your health care. That’s
why you should understand the following basics about the law as you choose your new CareFirst health
insurance plan.
■■ The ACA guarantees that no one can be denied coverage or be charged
more because they’re sick or because they have a pre-existing
medical condition.
■■ The law also requires that each state’s plans all cover the same core
benefits. So all of the plans you’re about to review will offer these
Essential Health Benefits:
Ambulatory patient services
Emergency services
Maternity & newborn care
Hospitalization
Prescription drugs
Mental health/substance abuse services
Laboratory services
Rehabilitative/habilitative services & devices
Preventive/wellness care
Pediatric dental & vision services
■■ All plans (except Young Adult Catastrophic) must fit into one of 4 Metal
Levels. Bronze, Silver, Gold & Platinum plans all cover the same benefits,
but each level differs in how much of your care you’ll pay. You’ll find
details about all plan types in the next section.
■■ To help make health insurance more affordable, the federal government
offers Financial Assistance, called Subsidies. You may qualify if your
projected 2014 household income is:
less than $45,960 for an Individual
less than $62,040 for a Family of 2
less than $78,120 for a Family of 3
less than $94,200 for a Family of 4
less than $110,280 for a Family of 5
We used 2013 income levels above to give you an idea of the income
levels that may qualify for Subsidies. These levels change slightly each year.
You’ll find detailed information on www.CareFirst.com/healthreform.
3
The next section
outlines some
other things you
should understand,
to make choosing
your health
insurance
plan easier.
What you need to know
before you shop
Now that you have a basic understanding of health care reform (ACA), you should also understand
some of the ways it will affect the plans you’re about to compare, and what you’ll pay.
Before you actually start comparing, spend a few minutes now to make sure you’re comfortable with
the terms used to describe how plans provide coverage. We’ve broken it down into two sections: terms
related to plans and providers, and financial-related terms.
Plans & providers
Provider Network—CareFirst has a large group or “network” of providers—
doctors, hospitals and pharmacies—you receive benefits and services from.
Plan Types—(HMO, PPO, POS) refer to how your plan provides coverage and
which network of providers you receive care from. The differences have to do
with how much freedom you have when choosing providers, balanced with how
much of that provider’s costs you will have to pay.
■■ CareFirst’s HMO plans use the BlueChoice network. When you see
any of our more than 28,000 participating providers, you’ll save the
most money. Except for emergency services, if you go outside of the
BlueChoice network, your medical services will not be covered.
■■ CareFirst’s PPO plans offer the most choice. You can receive care
from the PPO network of more than 34,000 providers locally and
thousands nationally. In addition, you can pay slightly more to go
out-of-network.
■■ With our more flexible POS plans, your cost depends
on which network you get your services in. POS
policyholders can see providers:
in the HMO network for the most savings
in the PPO network and pay slightly more
What’s in a name?
outside of CareFirst’s networks, where you’ll
likely pay charges that exceed CareFirst’s
Allowed Amount.
Our 4 plan names tell you what type of
plan it is.
■■ BlueChoice plans are HMO plans
■■ BluePreferred plans are PPO plans
■■ HealthyBlue and BlueChoice Plus
plans are POS plans
5
Consumer Health Insurance Plans 2014
Northern Virginia
Paying for coverage & care
Premium—the money you pay each month for your plan, or
policy, is your premium. Premiums are based on your age,
where you live, the family members the plan will cover, and
how much of your health care costs the plan pays.
Look closely at the plan options you are considering.
All of them offer no charge preventive care that is not
subject to a deductible. Some even cover all primary
care visits, urgent care and generic drugs without
needing to meet a deductible first.
Allowed Amount—is the fee that providers in CareFirst’s
network have agreed to accept for a particular medical
service. CareFirst has negotiated very favorable discounts
on medical services for the people we insure. If you see
a doctor who is not on your plan’s network who charges
more, the difference is your responsibility.
■■ Copayment—or “copay” is a fixed-dollar amount
you pay when you visit a provider, like $25
when you visit a doctor, or $100 for a trip to
the emergency room. Depending on the plan,
you may pay copays before or after you meet
your deductible.
Cost Sharing—the portion of your health care costs that
your plan doesn’t pay is your share. Generally, the more
costs you’re willing to pay, the lower your premiums. The
less cost sharing you want to be responsible for, the higher
your premiums will be.
■■ Coinsurance—is the percentage you pay
of the Allowed Amount after you’ve met
your deductible. So if your plan has “20%
coinsurance,” you would pay $20 for a
$100 charge, and CareFirst would pay the
remaining $80.
Cost sharing is different from your premium. It’s made up
of three things:
Out-of-Pocket Maximum—is the most you will have to pay
in deductibles, copays, coinsurance and prescription drug
costs in a calendar year. After that, CareFirst will pay 100%
of the Allowed Amount for covered services—except for
your premiums—for the rest of that year.
■■ Deductible—is the amount of money you must
pay each calendar year before a plan begins
paying its portion of your costs. “Meeting your
deductible” of $1,500, for example, means you’ll
pay the first $1,500 for health care services
covered by your plan, and then CareFirst will
start paying for part or all of the services after
that. Only costs based on CareFirst’s Allowed
Amount will count toward your deductible.
Prescription Coverage—All prescription drug charges count
toward your out-of-pocket maximums. You’ll pay your share
in the form of coinsurance or a copay. You’ll pay different
amounts for different types of drugs, with generics costing
the least. For example, you can get a 3-month supply
of a generic maintenance drug for just 2 copays at our
participating retail stores. Learn more at CareFirst.com/rx.
How much will I pay for medical services?
Then you’ll share costs
with CareFirst
through copays and
coinsurance up to your
out-of-pocket maximum
*Depending on the plan, you may have
coverage for certain services even before
you meet your deductible
6
Your Out-of-Pocket
Maximum
Your Deductible
You pay the
Allowed Amount*
up to your deductible
Then, CareFirst will pay
100% of your costs
except for your
premiums, for the
rest of the plan year
Consumer Health Insurance Plans 2014
Northern Virginia
Again depending on the plan, you may have to meet your
plan’s deductible before prescription coverage begins (it
is “integrated” with your other medical expenses). Other
plans have a separate, lower deductible just for drugs,
which gives you drug coverage much sooner. We’ve
included an outline of prescription benefits in the fold-out
chart that came with this book. Checkout line 37 in that
chart for details.
■■ Portability—Your HSA account balance is yours
even if you change your health plan or move out
of state.
■■ Growth—Balances can grow because they earn
interest. You can also use other bank investment
services to grow your savings even more.
■■ Long-Term Access—Unused funds roll over and
accumulate year to year; there’s no “use it or
lose it” rule.
HSA-Compatible Plans—can help lower your health
care costs. HSA stands for Health Savings Account, a
tax-deductible account that works like an IRA for health
expenses. CareFirst offers five HSA-compatible plans that
can help lower health care costs for high-deductible, lowerpremium plans. By contributing tax-deductible money
(usually the money you save on lower premiums), you build
up savings in your HSA that you use to cover you, your
spouse and your dependents—even if they are not enrolled
in your medical plan.
■■ Retirement Savings—When you turn 65, you
can use money in your HSA Bank Account as
retirement savings, or continue to use it for
medical expenses.
Federal Financial Subsidies—as you saw in the ACA
overview on page 3, there is financial help available for
people with certain incomes to help make health care more
affordable. There are two kinds of Subsidies available:
Opening an HSA provides you with a number of
benefits, including:
■■ The Premium Subsidy—helps reduce monthly
premiums, so less of your income is spent on
buying health insurance. If you qualify, the
money can be sent directly to CareFirst, leaving
a smaller premium (if any) for you to pay. You
must apply for this Subsidy on Virginia’s Health
Insurance Marketplace (also known as Exchange)
and it can only be used to help you pay for a
plan purchased on the Marketplace. You can
use this Subsidy on any ACA plan except the
BlueChoice Young Adult (Catastrophic) plan,
discussed in the next section.
■■ Tax Savings—Your deposits and the interest you
earn are tax-free, as is the money you take out
to pay for qualified medical expenses.
■■ Freedom & Control—Use the money in your HSA
to pay for things like your copays, prescriptions
and dental and vision care.
■■ The Cost-Share Subsidy—lowers the maximum
Paying taxes vs. paying for health care
For example…
$3,300 without
an HSA
$3,300
in an HSA
Federal tax (25%)
$825
$0
Virginia tax (4%)
$132
$0
Social Security
& Employment
Taxes (7.65%)
$252
$0
Total taxes paid
$1,209
$0
Portion left to
pay for your
medical expenses
$2,091
$3,300
Tax savings
$0
$1,242
dollar amount you are required to pay for outof-pocket expenses. Lowering your maximum
means your plan begins paying 100% of your
costs earlier than it would have without the help.
The Cost-Share Subsidy is available only for
Silver Plans bought on the Marketplace.
If you qualify for a Subsidy, you can still purchase a
CareFirst plan; you will just have to buy it on the public
Marketplace, which, again, is the only place you can apply
for Subsidies. To get more detailed information, visit your
Health Insurance Marketplace at www.Healthcare.gov.
For illustration purposes only. Your rates may differ.
7
Choosing your CareFirst
health care plan
Understanding
your plans
What you get with every CareFirst plan
As you review the details of each plan in the following pages, and in the fold-out
chart, keep in mind that all CareFirst plans feature the following benefits:
■■ A vast network of at least 28,000 providers
■■ No charge, no deductible for in-network:
adult physicals
well-child exams and immunizations
OB/GYN visits
cancer screenings including mammograms, pap tests, prostate and
colorectal screenings
routine pre-natal maternity services
preventive maternity services
■■ No referrals needed to see a specialist
■■ Over 60,000 pharmacies nationwide
■■ Vision and dental coverage for kids under age 19
■■ No charge, no deductible adult eye exam every 12 months
■■ 24-hour advice by a registered nurse with NurseLine—FirstHelpTM
■■ Discounts on contact lenses, laser vision correction surgery
and glasses
■■ Exclusive discounts on health and wellness services such as:
weight loss programs
discounted gym memberships
personal trainers & spa services
massage therapy
and more (see pages 27–28)
■■ Away From Home Care
Some Blues plans offer policyholders living temporarily in other states
the same coverage they have at home. See participating states on
page 28.
9
Consumer Health Insurance Plans 2014
Northern Virginia
Understanding metal levels
CareFirst’s plans within each Metal Level give you choices of networks, different cost-sharing arrangements and, of course
premiums. Here’s a summary of what you can expect to find in each Metal Level.
Highest annual
deductibles
Lowest monthly
premiums
Three tax-saving
HSA options
Higher annual
deductibles
Lower monthly
premiums
■■ Bronze Level Plans feature our lowest premiums for people willing to pay a larger
share of their health care costs. Offering a full range of provider networks, our
four Bronze plans feature three with a money-saving HSA option. Premium subsidy
option available.
■■ Silver Level Plans combine slightly higher premiums with modest deductibles.
Two plans have an HSA option and two cover additional medical services before
you meet the plan’s deductible. Premium and cost-share subsidies available.
Two tax-saving
HSA options
Lower annual
deductibles
Higher monthly
premiums
■■ Gold Level Plans appeal to people who want to pay a higher premium in exchange
for a plan with lower deductibles. Three of the four plans feature additional
services you can use before having to meet a deductible. Premium subsidy
option available.
Additional
no-cost services
No annual
deductibles
Highest monthly
premiums
■■ Platinum Level Plans have no deductible, so they begin paying their share of
health care costs immediately. Their higher premiums also shrink out-of-pocket
maximums to the lowest of any of our plans. Premium subsidy option available.
Additional
no-cost services
High annual
deductible
Lower monthly
premium
“Safety net” for
serious incident
■■ While not technically a Metal Level, BlueChoice Young Adult (Catastrophic
Coverage) is the affordable alternative to living without any health insurance, with
premiums of about $121 a month. Instead of having to pay tens or even hundreds
of thousands of dollars that a serious injury or illness could cost, people under
age 30* with this “safety net” plan would have those expenses capped at $6,350
for the calendar year they occurred in.
*Also available to people who have received certification from an Exchange that they are exempt from the individual
mandate because they do not have an affordable coverage option or because they qualify for a hardship exemption.
Visit your public Exchange for more details.
10
Consumer Health Insurance Plans 2014
Northern Virginia
Snapshot comparison of plans
Here you can see how each type of plan relates to annual
premiums* and individual annual deductible.
$825
As monthly premiums go up…
$628
$495
$473
$379
$360
$288
$284
$352
$202
$228
$162
$121
AGE 55
AGE 40
AGE 26
Catastrophic
AGE 26
Bronze Level Plans
AGE 55
AGE 55
AGE 40
AGE 26
AGE 40
AGE 40
AGE 26
Silver Level Plans
AGE 55
AGE 26
Gold Level Plans
Platinum Level Plans
$0 Deductible
$0 — $1,500
Deductible
$1,300 — $2,500
Deductible
…annual deductibles go down.
$3,500 — $6,000
Deductible
$6,350
Deductible
* Rates are based on the average for each plan per metal level for the age indicated.
11
Consumer Health Insurance Plans 2014
Northern Virginia
Narrowing down your selection
This chart shows the features people use most often to compare plans. Use it to find your top 3 or 4 choices—based
on plan type or deductible, or specific features like the option to add an HSA account, or out-of-network coverage,
coinsurance level…whatever’s most important to you. Check the plans you want to find your rates for, which is what awaits
in the next section.
Catastrophic
Plan Name
Bronze Level Plans
Silver Level Plans
BlueChoice
Young Adult *
$6,350
BlueChoice
HSA Bronze
$6,000
BlueChoice
Plus Bronze
$5,500
BlueChoice
HSA Bronze
$4,000
BluePreferred
HSA Bronze
$3,500
BlueChoice
Plus Silver
$2,500
BlueChoice
Silver
$2,000
HMO
HMO
POS
HMO
PPO
POS
HMO
Individual Deductible
$6,350
$6,000
$5,500
$4,000
$3,500
$2,500
$2,000
Individual
Out-of-Pocket Max
$6,350
$6,000
$6,350
$6,350
$6,350
$6,350
$6,350
Coinsurance
0%
0%
20%
30%
20%
20%
20%
Copays (PCP/
Specialist)
$0
$0
$35 / $45
$30 / $40
$30 / $40
$20 / $40
$30 / $40
✓
✓
Check to
compare plans
Plan Type
(page 5)
You Pay (page 6)
Plan Features
Lower Deductible
Out-of-Network
Coverage
✓
Pay no deductible for
PCP, urgent care and
preferred generics
✓
✓
✓
No-charge and nodeductible for PCP,
labs, x-rays and
generic drugs
HSA-Compatible
(page 7)
✓
✓
✓
HealthyRewards
Program (page 25)
Non-emergency
coverage in the U.S.
(page 28)
Pediatric Dental
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
* Available to individuals under the age of 30. Also available to people who have received certification from an Exchange that they are exempt from the individual
mandate because they do not have an affordable coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
12
Consumer Health Insurance Plans 2014
Northern Virginia
Silver Level Plans
Gold Level Plans
Platinum Level Plans
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
BluePreferred
Platinum
$0
HealthyBlue
Platinum
$0
PPO
HMO
POS
HMO
PPO
HMO
PPO
POS
$1,500
$1,300
$1,500
$1,000
$500
$0
$0
$0
$5,500
$6,350
$3,450
$3,750
$3,750
$6,350
$1,800
$2,000
30%
20%
0%
10%
20%
30%
10%
0%
$30 / $40
$30 / $40
$0 / $40
$20 / $30
$30 / $40
$20 / $30
$20 / $30
$0 / $30
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
13
✓
✓
✓
✓
✓
Consumer Health Insurance Plans 2014
Northern Virginia
A variety of plans for a variety of needs
Everyone’s health insurance needs are different. We know cost is a concern when selecting the best plan for you and your
family. But we also know you have specific things you want your plan to cover. As you’ll see from these examples, and
from our plans, our plans offer the value you’ve come to expect with the choices you deserve.
Like most young
Although Amanda
people, 27-year-old
is excited to finally
Kyle didn’t think about
be running her own
health insurance much.
business at age
When he found out
39, she doesn’t get
the law was going
employer-sponsored
to require him to get
health insurance like
it, he learned about
she used to. Amanda
affordable plans that limit the medical expenses of
decided she is okay paying a little more each month
a serious injury or illness that could cost him tens or
for a low to moderate deductible similar to her old
hundreds of thousands of dollars. Kyle trusts CareFirst
plan. She is going to look at Silver and Gold plans.
and wants to buy the BlueChoice Young Adult Plan
or a Bronze plan if he qualifies for a substantial
premium subsidy.
Cheryl loves her job
Justin and Rose just
at the small event-
welcomed twins into
planning company
the world, so quality
where she’s worked for
health insurance is
two years. She trusts
even more important
the owners when they
than it was before.
say they’ll offer health
Earning a decent dual
insurance one day.
income, Justin and
For now, because she qualifies for both Subsidies,
Rose like the lower out-of-pocket and deductibles in
Cheryl is going to get a Silver plan so she can save the
the Gold plans, but are leaning toward Platinum plans
most money.
to make sure they get the best coverage for their
new family.
14
Young Adult
$6,350
HSA Bronze
$6,000
Plus Bronze
$5,500
HSA Bronze
$4,000
HSA Bronze
$3,000
Plus Silver
Young
Adult
$2,500
$6,350
Silver
HSA
Bronze
$2,000
$6,000
0-20
0-20 Consumer
$114
Consumer Health Insurance Plans 2014
Health Ins
21
21
$180
Northern Virginia
Maryland
22
22
$180
23
23
$180
24
24
$180
25
25
$181
Northern Virginia
Baltimo
26
26
$185
27
27
$189
Bronze Level Plans
Silver Le
Age
Age
28
28
$196
B
BlueChoice
BlueChoice
BluePreferred
BlueChoice
BlueChoice
BlueChoice
BlueChoice
BlueChoice
29
29
$202
Silver
Plus
Silver
Bronze
Young Adult HSA Bronze Plus Bronze HSA Bronze HSA Bronze
Young
Adult HSA
30
30
$205
$2,000
$2,500
$3,500
$4,000
$5,500
$6,000
$6,000
$6,350
$6,350
31
NA*
31
$209
NA*
0-20
$75.29
$87.62
$106.18
$91.52
$115.37
0-20
$142.33
$136.66
32
NA*
32
$213
NA*
$118.57
$137.99
$167.22
$144.12
$181.69
21
$224.14
$215.21
3321
NA*
33
$216
NA*
22
$118.57
$137.99
$167.22
$144.12
$181.69
22
$224.14
$215.21
Everyone who will be covered by your plan
has
their
own
34
NA*
34
$219
NA*
$118.57
$137.99
$167.22
$144.12
$181.69
23
$224.14
$215.21
3523
NA*
35
$220
NA*
rate, based on their age.
$118.57
$137.99Need a$167.22
$144.12
$181.69
24
$224.14
$215.21
3624
NA*
36
$222
NA*
“for instance?”
$119.04
$138.54
$167.89
$144.70
$182.42
25
$225.04
$216.07
For each plan you’re interested in:
3725
NA*
37
$223
NA*
and Sari are $147.58
married with $186.05
3 kids—Meredith,
15
$121.42
$141.30Denny $171.23
26
$229.52
$220.38
3826
NA*
38
$225
NA*
1. Go down the plan column to the row
that
Michele,
17
and
Josiah,
23.
They
live
in
Fairfax
County
27
$124.26
$144.61
$175.25
$151.04
$190.41
27
$234.90
$225.54
39
NA*
39 Consumer
$227
NA*
Consumer
Health Insurance Plans 2014
Health
Ins
matches your age when coverage40will
28 begin
$128.89
$150.00
$181.77
$156.66
$197.50
28
$243.64
$233.93
and
want
to
calculate
their
family’s
monthly
premium
for
NA*
40 Maryland
$230
NA*
Northern
Virginia
29
$132.68
$154.41
$187.12 Plus$161.27
$203.31
29
$250.81
$240.82
the BlueChoice
Silver $2,500.
NA*
41
$235
NA*
2. Circle that premium – you can add4130
it to the$134.58
top of
30
$156.62
$189.79
$163.58
$206.22
$254.40
$244.26
42
NA*
42
$239
NA*
the fold-out chart
31
NA*
31
NA*
$159.93
$193.81
$167.04
$210.58
$259.78
$249.43
43
NA*
43
$245
NA*
32
NA*
32
NA*
$163.24
$197.82
$170.49
$214.94
$265.16
$254.59
44
$252
NA*
Using the rate charts, they find
3. Repeat for all of the plans you’re 44
interestedNA*
in
Northern$217.66
Virginia
Baltimo
Northern
Virginia
33
NA*
NA*
$165.31
$200.33
$172.66
$268.52
$257.82
4533
NA*
45
$260
NA*
their plan’s
column $174.96
and find
34
NA*
NA*
$167.52
$203.01
$220.57
$272.11
$261.26
4634
NA*
46
$270
NA*
and circle:
Bronze Level
Plans
Silver Le
Age
Age
Family plan? Use the same rate 47
table.
35
NA*
35
NA*
$168.62
$204.34
$176.11
$222.03
$273.90
$262.99
NA*
47
$282
NA*
36
NA*
36
NA*
$169.73
$205.68
$177.27
$223.48
$275.69
$264.71
BlueChoice BlueChoice BlueChoice BluePreferred
BlueChoice B
BlueChoice
BlueChoice
48 andBlueChoice
NA*
48
$295
NA*
1. Find the age rows in the plan column
circle
■■ Meredith and Michele’s
Bronze
Bronze HSA
Bronze HSA
Bronze Plus
Bronze
Young
Young
Plus
Silver
Adult HSA
Silver
37
NA*
NA*Adult HSA
$170.83
$207.02
$178.42
$224.93
$277.49
$266.43
4937
NA*
49
$307
NA*
the rates for:
rate
in their age
row
$3,50038
$4,000
$5,500
$6,000
$6,000
$6,350
$2,500
$6,350
$2,000
NA*
38
NA*
$171.94
$208.36
$179.57
$226.39
$279.28
$268.15
50
NA*
50
$322
NA*
(0-20)
– they $181.88
make
39
NA* x2 $271.60
39
NA*
$174.14
$211.03
$229.29
$282.86
0-20
$75.29
$87.62
$106.18
$91.52
$115.37
0-20
$142.33
$136.66
You
51
NA*
51
$336
NA*
a$213.71
note to add$184.19
that
40
NA*
NA*
$176.35
$232.20
$286.45
$275.04
21
$118.57
$137.99
$167.22
$144.12
$181.69
21
$224.14
$215.21
5240
NA*
52
$352
NA*
Your spouse
41
NA*
41
NA*
$179.66
$217.72
$187.64
$236.56
$291.83
$280.20
$118.57
$137.99
$167.22
$144.12
$181.69
22
$224.14
$215.21
rate
twice, once
for
5322
NA*
53
$368
NA*
42
NA*
42
NA*
$182.84
$221.57
$190.96
$240.74
$296.99
$285.15
23
$118.57
$137.99
$167.22
$144.12
$181.69
23
$224.14
$215.21
Your 3 oldest kids under 21 (all
are
covered,
54
NA*
54
$385
NA*
each daughter
43
NA*
43
NA*
$187.25
$226.92
$195.57
$246.55
$304.16
$292.04
24
$118.57
$137.99
$167.22
$144.12
$181.69
24
$224.14
$215.21
but only 3 count toward overall55rate) NA*
55
$402
NA*
44
NA*
NA*
$192.77 ■■ Josiah’s
$233.61
$201.34
$253.82
$313.12
$300.65
his age
25
$119.04
$138.54
$167.89 rate in
$144.70
$182.42
25
$225.04
$216.07
5644
NA*
56
$420
NA*
All kids 21-25
45
NA*
45
NA*
$199.26
$241.47
$208.11
$262.36
$323.66
$310.76
$121.42
$141.30
$171.23
$147.58
$186.05
26
$229.52
$220.38
row
(23)
5726
NA*
57
$439
NA*
46
NA*
46
NA*
$206.99
$250.83
$216.18
$272.54
$336.21
$322.82
27
$124.26
$144.61
$175.25
$151.04
$190.41
27
$234.90
$225.54
58
NA*
58
$459
NA*
2. Add up everyone’s rate
rate in $156.66
her age
47
NA*
$215.68
$261.36
$225.26
$283.98
47
$350.33
NA*
$336.37
$128.89
$150.00 ■■ Sari’s
$181.77
$197.5028
$243.64
$233.93
5928
NA*
59
$469
NA*
48
NA*
$225.61
$273.40
$235.64
$297.06
48
$366.47
NA*
$351.87
29
$132.68
$154.41
$187.12
$161.27
$203.31
29
$250.81
$240.82
row
(48)
3. Transfer that total premium to the60top of the
NA*
60
$489
NA*
49
NA*
$235.41
$285.28
$245.87
$309.96
49
$382.38
NA*
$367.15
30
$134.58
$156.62
$189.79
$163.58
$206.22
30
$254.40
$244.26
61
NA*
61
$506
NA*
fold-out chart
his age
NA*
$246.45
$298.65
$257.40
$324.50
50
$400.31
NA*
$384.37
31
$159.93 ■■ Denny’s
$193.81 rate in
$167.04
$210.58
31
$259.78
$249.43
6250
NA*
62
$518
NA*
row
(53)
51
$257.35
$311.87
$268.78
$338.85
51
$418.02
NA*
$401.37
32
NA*
$163.24
$197.82
$170.49
$214.94
32
$265.16
$254.59
4. Repeat for each plan you want to63
consider
NA*
63
$532
NA*
52
$269.36
$326.41
$281.32
$354.66
52
$437.52
$420.09
33
NA*
$165.31
$200.33
$172.66
$217.66
33
$268.52
NA*
$257.82
64
NA*
64
$541
NA*
53
$281.50
$341.13
$294.00
$370.65
53
$457.25
$439.03
34
NA*
$167.52
$203.01
$174.96
$220.57
34
$272.11
NA*
$261.26
65+**
NA*
65+**
$541
NA*
54
$294.61
$357.01
$307.70
$387.91
54
$478.54
$459.47
35
NA*
$168.62
$204.34
$176.11
$222.03
35
$273.90
NA*
$262.99
Then they
just:
55
$307.72
$372.90
$321.39
$405.17
55
$499.83
$479.92
36
NA*
$169.73
$205.68
$177.27
$223.48
36
$275.69
NA*
$264.71
$ $321.93
$ $423.88
$ 1,334.30
$$$266.43
56
$390.12
56
$522.92
$502.08
37
NA*
$170.83
$207.02
$178.42
$224.93
37
$277.49
NA*
Add$it up
and… $ $336.23
57
$336.28
$407.52
$351.22
$442.78
57
$546.23
$524.47
38
NA*
$171.94
$208.36
$179.57
$226.39
38
$279.28
NA*
$268.15
* If you
or older, you can
only apply if $426.08
you
are NOT eligible
for Medicare. $462.95
* If 58
you are age
65
or older, you
can only app
58
$351.60
$367.22
$571.11
$548.36
39are age 65NA*
$174.14
$211.03
39
NA*
$181.88
$229.29
$282.86
$271.60
** Also available to people who have received certification from an Exchange that they are
** Also
exempt
available
from the
to people
individual
whomandate
have receive
beca
59
$359.19
$435.27
$375.14
$472.94
59 to
$583.44
$560.19
40
NA*
40
$176.35
$213.71
$232.20
$286.45
Write
in at the
top$184.19
ofVisit
theyour
fold-out
chart
indetails.
optionNA*
or because they
qualify
for ait
hardship
exemption.
public
Exchange
foruse
more
option
or because$275.04
they qualify f
coverage
coverage
60
NA*
$374.50
$391.14
$493.11
60
$608.32
$584.08
41
NA*
41
$179.66making$453.84
$217.72
$187.64
$291.83
$280.20
their final decision.
18$236.56
61
NA*
$387.75
$469.89
$404.98
$510.5542
61
$629.83
$604.74
NA*
42
$182.84
$221.57
$190.96
$240.74
$296.99
$285.15
62
NA*
$396.45
$480.42
$414.06
$522.00
62
$643.95
NA*
$618.30
43
43
$187.25
$226.92
$195.57
$246.55
$304.16
$292.04
63
NA*
$407.35
$493.63
$425.44
$536.35
63
$661.66
$635.30
44
NA*
44
$192.77
$233.61
$201.34
$253.82
$313.12
$300.65
64
NA*
$413.97
$501.66
$432.36
$545.07
64
$672.42
$645.63
45
NA*
45
$199.26
$241.47
$208.11
$262.36
$323.66
$310.76
65+**
NA*
$413.97
$501.66
$432.36
$545.07
65+**
$672.42
$645.63
46
NA*
46
$206.99
$250.83
$216.18
$272.54
$336.21
$322.82
47
NA*
47
NA*
$215.68
$261.36
$225.26
$283.98
$350.33
$336.37
To easily
compare
all
of
the
48 interested
NA*in,
48
NA*
$225.61
$273.40
$235.64
$297.06
$366.47
plans
you are
$ $235.41 $ $285.28 $ $245.87 $ $309.9649 $$382.38
$$$351.87
$
NA*
49
NA*
$367.15
transfer your premiums
50the enclosed
NA*
50
NA*
$246.45
$298.65
$257.40
$324.50
$400.31
$384.37
to the
top of
* If you are age 65 or older, you can only app
* Also
to people who $257.35
have received certifi
cation from an
Exchange that
they
are
exempt
from
the
individual
mandate
bec
51
NA*
51 available NA*
$311.87
$268.78
$338.85
$418.02
$401.37
fold-out
chart.
**
Also
available
to people
who
have receive
coverage option or because they qualify for a hardship exemption. Visit your public Exchange
more
details.
coverage
or because$420.09
they qualify f
52 foroption
NA*
52
NA*
$269.36
$326.41
$281.32
$354.66
$437.52
** If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
53
NA*
53
NA*
$281.50
$341.13
$294.00
$370.65
$457.25
$439.03
16
54
NA*
54
NA*
$294.61
$357.01
$307.70
$387.91
$478.54
$459.47
15$307.72
55
NA*
55
NA*
$372.90
$321.39
$405.17
$499.83
$479.92
56
NA*
56
NA*
$321.93
$390.12
$336.23
$423.88
$522.92
$502.08
Calculating your total
monthly premium
Consumer Health Insurance Plans 2014
Northern Virginia
Northern Virginia
Bronze Level Plans
Age
BlueChoice BlueChoice BlueChoice BlueChoice
Young Adult HSA Bronze Plus Bronze HSA Bronze
$4,000
$5,500
$6,000
$6,350
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+**
$75.29
$118.57
$118.57
$118.57
$118.57
$119.04
$121.42
$124.26
$128.89
$132.68
$134.58
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
NA*
$
$87.62
$137.99
$137.99
$137.99
$137.99
$138.54
$141.30
$144.61
$150.00
$154.41
$156.62
$159.93
$163.24
$165.31
$167.52
$168.62
$169.73
$170.83
$171.94
$174.14
$176.35
$179.66
$182.84
$187.25
$192.77
$199.26
$206.99
$215.68
$225.61
$235.41
$246.45
$257.35
$269.36
$281.50
$294.61
$307.72
$321.93
$336.28
$351.60
$359.19
$374.50
$387.75
$396.45
$407.35
$413.97
$413.97
$
$106.18
$167.22
$167.22
$167.22
$167.22
$167.89
$171.23
$175.25
$181.77
$187.12
$189.79
$193.81
$197.82
$200.33
$203.01
$204.34
$205.68
$207.02
$208.36
$211.03
$213.71
$217.72
$221.57
$226.92
$233.61
$241.47
$250.83
$261.36
$273.40
$285.28
$298.65
$311.87
$326.41
$341.13
$357.01
$372.90
$390.12
$407.52
$426.08
$435.27
$453.84
$469.89
$480.42
$493.63
$501.66
$501.66
$
Silver Level Plans
BluePreferred
HSA Bronze
$3,500
$91.52
$144.12
$144.12
$144.12
$144.12
$144.70
$147.58
$151.04
$156.66
$161.27
$163.58
$167.04
$170.49
$172.66
$174.96
$176.11
$177.27
$178.42
$179.57
$181.88
$184.19
$187.64
$190.96
$195.57
$201.34
$208.11
$216.18
$225.26
$235.64
$245.87
$257.40
$268.78
$281.32
$294.00
$307.70
$321.39
$336.23
$351.22
$367.22
$375.14
$391.14
$404.98
$414.06
$425.44
$432.36
$432.36
$
$115.37
$181.69
$181.69
$181.69
$181.69
$182.42
$186.05
$190.41
$197.50
$203.31
$206.22
$210.58
$214.94
$217.66
$220.57
$222.03
$223.48
$224.93
$226.39
$229.29
$232.20
$236.56
$240.74
$246.55
$253.82
$262.36
$272.54
$283.98
$297.06
$309.96
$324.50
$338.85
$354.66
$370.65
$387.91
$405.17
$423.88
$442.78
$462.95
$472.94
$493.11
$510.55
$522.00
$536.35
$545.07
$545.07
$
BlueChoice BlueChoice
Silver
Plus Silver
$2,000
$2,500
$142.33
$224.14
$224.14
$224.14
$224.14
$225.04
$229.52
$234.90
$243.64
$250.81
$254.40
$259.78
$265.16
$268.52
$272.11
$273.90
$275.69
$277.49
$279.28
$282.86
$286.45
$291.83
$296.99
$304.16
$313.12
$323.66
$336.21
$350.33
$366.47
$382.38
$400.31
$418.02
$437.52
$457.25
$478.54
$499.83
$522.92
$546.23
$571.11
$583.44
$608.32
$629.83
$643.95
$661.66
$672.42
$672.42
$
BluePreferred
HSA Silver
$1,500
BlueChoice
HSA Silver
$1,300
$149.89
$236.05
$236.05
$236.05
$236.05
$236.99
$241.72
$247.38
$256.59
$264.14
$267.92
$273.58
$279.25
$282.79
$286.56
$288.45
$290.34
$292.23
$294.12
$297.90
$301.67
$307.34
$312.77
$320.32
$329.76
$340.86
$354.08
$368.95
$385.94
$402.70
$421.59
$440.23
$460.77
$481.54
$503.97
$526.39
$550.70
$575.25
$601.46
$614.44
$640.64
$663.30
$678.17
$696.82
$708.15
$708.15
$135.48
$213.36
$213.36
$213.36
$213.36
$214.21
$218.48
$223.60
$231.92
$238.75
$242.16
$247.28
$252.40
$255.61
$259.02
$260.73
$262.43
$264.14
$265.85
$269.26
$272.67
$277.79
$282.70
$289.53
$298.06
$308.09
$320.04
$333.48
$348.84
$363.99
$381.06
$397.92
$416.48
$435.25
$455.52
$475.79
$497.77
$519.96
$543.64
$555.38
$579.06
$599.54
$612.98
$629.84
$640.08
$640.08
$136.66
$215.21
$215.21
$215.21
$215.21
$216.07
$220.38
$225.54
$233.93
$240.82
$244.26
$249.43
$254.59
$257.82
$261.26
$262.99
$264.71
$266.43
$268.15
$271.60
$275.04
$280.20
$285.15
$292.04
$300.65
$310.76
$322.82
$336.37
$351.87
$367.15
$384.37
$401.37
$420.09
$439.03
$459.47
$479.92
$502.08
$524.47
$548.36
$560.19
$584.08
$604.74
$618.30
$635.30
$645.63
$645.63
$
$
$
*A lso available to people who have received certification from an Exchange that they are exempt from the individual mandate because they do not have an affordable
coverage option or because they qualify for a hardship exemption. Visit your public Exchange for more details.
** If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
16
Consumer Health Insurance Plans 2014
Northern Virginia
Northern Virginia
Gold Level Plans
Age
Platinum Level Plans
HealthyBlue
Gold
$1,500
BlueChoice
Gold
$1,000
BluePreferred
Gold
$500
BlueChoice
Gold
$0
$192.63
$303.35
$303.35
$303.35
$303.35
$304.56
$310.63
$317.91
$329.74
$339.45
$344.30
$351.58
$358.86
$363.41
$368.27
$370.69
$373.12
$375.55
$377.97
$382.83
$387.68
$394.96
$401.94
$411.65
$423.78
$438.04
$455.03
$474.14
$495.98
$517.52
$541.78
$565.75
$592.14
$618.83
$647.65
$676.47
$707.72
$739.26
$772.94
$789.62
$823.29
$852.41
$871.52
$895.49
$910.05
$910.05
$156.47
$246.41
$246.41
$246.41
$246.41
$247.40
$252.32
$258.24
$267.85
$275.73
$279.68
$285.59
$291.50
$295.20
$299.14
$301.11
$303.08
$305.06
$307.03
$310.97
$314.91
$320.83
$326.49
$334.38
$344.23
$355.82
$369.62
$385.14
$402.88
$420.38
$440.09
$459.55
$480.99
$502.68
$526.09
$549.49
$574.87
$600.50
$627.85
$641.41
$668.76
$692.41
$707.94
$727.40
$739.23
$739.23
$190.63
$300.21
$300.21
$300.21
$300.21
$301.41
$307.42
$314.62
$326.33
$335.93
$340.74
$347.94
$355.15
$359.65
$364.45
$366.86
$369.26
$371.66
$374.06
$378.87
$383.67
$390.87
$397.78
$407.38
$419.39
$433.50
$450.32
$469.23
$490.84
$512.16
$536.18
$559.89
$586.01
$612.43
$640.95
$669.47
$700.39
$731.61
$764.94
$781.45
$814.77
$843.59
$862.50
$886.22
$900.63
$900.63
$175.18
$275.87
$275.87
$275.87
$275.87
$276.97
$282.49
$289.11
$299.87
$308.70
$313.11
$319.73
$326.35
$330.49
$334.91
$337.11
$339.32
$341.53
$343.73
$348.15
$352.56
$359.18
$365.53
$374.36
$385.39
$398.36
$413.81
$431.18
$451.05
$470.63
$492.70
$514.50
$538.50
$562.77
$588.98
$615.19
$643.60
$672.30
$702.92
$718.09
$748.71
$775.19
$792.57
$814.37
$827.61
$827.61
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+*
$
$
$
BluePreferred HealthyBlue
Platinum
Platinum
$0
$0
$245.72
$386.96
$386.96
$386.96
$386.96
$388.51
$396.25
$405.53
$420.63
$433.01
$439.20
$448.49
$457.77
$463.58
$469.77
$472.87
$475.96
$479.06
$482.15
$488.34
$494.53
$503.82
$512.72
$525.10
$540.58
$558.77
$580.44
$604.82
$632.68
$660.15
$691.11
$721.68
$755.35
$789.40
$826.16
$862.92
$902.78
$943.02
$985.97
$1,007.26
$1,050.21
$1,087.36
$1,111.74
$1,142.31
$1,160.88
$1,160.88
$
$
* If you are age 65 or older, you can only apply if you are NOT eligible for Medicare.
17
$224.20
$353.07
$353.07
$353.07
$353.07
$354.48
$361.54
$370.02
$383.79
$395.09
$400.73
$409.21
$417.68
$422.98
$428.63
$431.45
$434.28
$437.10
$439.93
$445.57
$451.22
$459.70
$467.82
$479.12
$493.24
$509.83
$529.61
$551.85
$577.27
$602.34
$630.58
$658.48
$689.19
$720.26
$753.80
$787.35
$823.71
$860.43
$899.62
$919.04
$958.23
$992.13
$1,014.37
$1,042.26
$1,059.21
$1,059.21
$
A plan just for yourself?
For each plan you’re
interested in.
1. Go down the plan column
to the row that matches
your age when coverage
will begin.
2. Circle that premium – you
can add it to the top of the
folding chart to use later
3. Repeat for all of the plans
you’re interested in
Family plan? Use the same
rate table.
1. Find the age rows in the
plan column and circle the
rates for:
You
Your spouse
Your 3 oldest kids under
21 (all are covered, but
only 3 count toward
overall rate)
All kids 21-25
2. Add up everyone’s rate
3. Transfer that total premium
to the top of fold-out chart
4. Repeat for each plan you
want to consider
To easily compare all of the
plans you are interested in,
transfer your premiums
to the top of the enclosed
fold-out chart.
Dental and vision
Vision (included)
Every CareFirst health plan includes basic eye-care benefits for everyone
covered by your plan. These important benefits are offered to you through our
network administrator, Davis Vision. An independent company, Davis Vision
does not provide CareFirst products or services, but is the administrator for the
products, services and discounts described below.
Included in your CareFirst qualified health plan (age 19 and over):
■■ One no-charge in-network routine exam per calendar year, or
out-of-network exams are reimbursed up to $40 per calendar year
■■ If needed, get discounts of approximately 30% on:
eyeglass lenses, frames and contacts
laser vision correction
scratch resistant lens coating & progressive lenses
■■ No claims to file when you see a Davis Vision provider
For family members up to age 19, our Pediatric vision benefits include:
■■ One no-charge in-network eye exam per calendar year, or
Up to $40 reimbursement for out-of-network exam per calendar year
■■ No copay in Davis Vision collection (in network) for:
frames and basic spectacle lenses or contact lenses
■■ Reimbursement for single vision lenses, up to $40, and frames up to
$70, from an out-of-network provider
For a routine eye exam, just call and make an appointment with one of our many
providers. Remember, both the pediatric and adult vision benefits listed above
are available to you for no additional charge to your monthly premium.
To locate a vision care provider, contact Davis Vision at (800) 783-5602 or
visit www.carefirst.com/doctor.
19
Consumer Health Insurance Plans 2014
Northern Virginia
A family approach to dental care
When you buy a CareFirst health plan, you have options to take care
of your whole body, including your teeth. We have dental coverage for
everyone in your family…starting with the kids, whose dental benefits
are a no-charge part of all our plans.
Want more information?
If you want more information on any one of
our four optional Dental plans, including an
application, just mail in the postage-paid
card on the next page.
CareFirst offers the four Dental Plans highlighted to the right for family
members 19 and older. With affordable premiums, a large network and
a range of deductibles and cost-sharing, CareFirst has a dental plan
that’s right for your family.
If you’d rather talk to a Product Consultant,
please call (800) 544-8703.
Pediatric dental (included)
In-Network
Out-of-Network
Member Pays
Individual Cost Per Day
Included in your medical plan premium-no additional monthly charge
$50 Individual per calendar year
(Applies to Classes II, III & IV)
Deductible
$25 Individual per calendar year
(Applies to Classes II, III & IV)
Network
Over 3,600 providers in MD, DC, and Northern VA. 63,000 dentists nationally.
Preventive & Diagnostic Services (Class I)
Basic Services (Class II) Fillings, simple
extractions, non-surgical periodontics
Major Services – Surgical (Class III) Surgical
periodontics, endodontics, oral surgery
Major Services – Restorative (Class IV)
Inlays, onlays, dentures, crowns
Orthodontic Services (Class V)
when medically necessary
No charge
20% of Allowed Amount* (no deductible)
20% of Allowed Amount* after deductible
40% of Allowed Amount* after deductible
50% of Allowed Amount* after deductible
65% of Allowed Amount* after deductible
50% of Allowed Amount* no deductible
65% of Allowed Amount* no deductible
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights not given
through the benefit plan.
*CareFirst payments are based upon the CareFirst Allowed Amount. Participating dentists accept 100% of the CareFirst Allowed Amounts as payment in full
for covered services. Non-participating dentists may bill the member for any amount over the Allowed Amount. Providers are not required to accept CareFirst’s
Allowed Amounts on non-covered services. This means you may have to pay your dentist’s entire billed amount for these non-covered services. At your dentist’s
discretion, they may choose to accept the CareFirst Allowed Amount, but are not required to do so. Please talk with your dentist about your cost for any
dental services.
20
Consumer Health Insurance Plans 2014
Northern Virginia
Optional dental plans
All CareFirst medical plans provide you with Pediatric Dental benefits. To get dental coverage for adult members aged 19
and older on your policy, you can choose from four dental plans: Dental HMO, Preferred Dental, BlueDental Preferred and
Preferred Dental Plus.
Dental HMO
In-Network Only
Preferred
Dental
In-Network
BlueDental
Preferred
Preferred Dental Plus
In-Network
In-Network
Out-of-Network Coverage available
Member Pays
Individual Cost Per Day
Less than $.35
Less than $.50
Less than $1.00
Less than $1.30
None
None
$25 Individual/$75
Family (Applies to
Classes II, III & IV) per
calendar year
$25 Individual/$75
Family (Applies to
Classes II, III & IV) per
contract year
Deductible
Network
Preventive & Diagnostic
Services (Class I)
Basic Services (Class
II) Fillings, simple
extractions, non-surgical
periodontics
Major Services –
Surgical (Class III)
Surgical periodontics,
endodontics,
oral surgery
Over 580 providers in
Over 3,600 providers in
MD, DC, and Northern VA MD, DC, and Northern VA
$20 copay per office visit
No charge
$20-$70 copay per
office visit
No charge
20% of Allowed Amount*
after deductible
No charge
20% of Allowed Amount*
after deductible
20% of Allowed Amount*
after deductible &
12 month Benefit
Waiting Period
Not covered
Copays per service
Major Services –
Restorative (Class
IV) Inlays, onlays,
dentures, crowns
Orthodontic Services
(Class V)
Over 3,600 providers in MD, DC, and Northern VA
63,000 dentists nationally
50% of Allowed Amount*
after deductible
50% of Allowed Amount*
after deductible &
12 month Benefit
Waiting Period
50% of Allowed Amount* 50% of Allowed Amount*
after 12 month Benefit
(no deductible) when
Waiting Period
medically necessary
Child: $2,500 per
member / Adult: $2,700
per member
Please note: Annual benefit maximums apply to some plans. The benefit summary above is
incomplete and does not provide full benefit details.
Not all services and procedures are covered by your benefits contract. This plan summary is for
comparison purposes only and does not create rights not given through the benefit plan.
*CareFirst payments are based upon the CareFirst Allowed Amount. Participating dentists
accept 100% of the CareFirst Allowed Amounts as payment in full for covered services. Nonparticipating dentists may bill the member for any amount over the Allowed Amount. Providers
are not required to accept CareFirst’s Allowed Amounts on non-covered services. This means
you may have to pay your dentist’s entire billed amount for these non-covered services. At
your dentist’s discretion, they may choose to accept the CareFirst Allowed Amount, but are not
required to do so. Please talk with your dentist about your cost for any dental services.
21
For BlueDental Preferred
and Preferred Dental Plus, you can apply online!
Go to:
www.CareFirst.com/individual
Mail This Card For Free Information
YES, please rush me more information about the
plan(s) that I’ve checked below. I understand this
information is free and I am under no obligation.
Dental Plan Options
BlueDental Preferred
Dental HMO
Preferred Dental
Preferred Dental Plus
U65DEN2014
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
The CareFirst BlueCross BlueShield
family of health care plans
The rewards of enrolling in
HealthyBlue plans
We’re proud our health insurance plans are there when our policyholders need them. But we’re just
as proud to create exclusive programs like HealthyBlue that promote, inform, encourage and actually
reward you for taking an active role in living a healthy lifestyle.
More and more people are choosing our HealthyBlue plans because they
actually get a financial reward for committing to living a healthier lifestyle. If
you choose our HealthyBlue Gold $1,500 or our HealthyBlue Platinum $0 plan,
you can earn a gift card that you can use to pay your premium, deductible, gym
memberships, athletic equipment and other fitness-related items.
Each year with a HealthyBlue plan, you can earn a Healthy Reward gift card
worth $200 per adult, or up to $500* per family. To qualify, HealthyBlue
plan members:
■■ Choose a CareFirst BlueChoice PCP
■■ Take an online Health Assessment
■■ Complete a Health and Wellness Evaluation
with their PCP
As you can see, Healthy Rewards is a simple process. But
the benefits are far greater than a gift card. Because the
gift of better health can last a lifetime.
Learn more about Healthy Rewards at
www.CareFirst.com/healthyblue for a full list of
eligible items.
HealthyBlue plan holders can use
the Healthy Reward they earn on
everything from:
Hearing aids
Blood tests
Eldercare
Dental xrays
BP monitors to
to
to
to
to
hunting gear
boys’ or girls’ camps
exercise equipment
diet workshops
bicycle parts
See the full list at
www.CareFirst.com/healthyblue
*Children age 2–17 can receive $25 by completing Steps 1–3. Children under age 2 are not eligible for a Healthy Reward.
25
Taking your health to
the next level
CareFirst believes everyone has a vibrant, healthy person inside them. And whether you’ve been healthy
all your life, or simply aspire to be, our renowned Health & Wellness program offers the information,
inspiration and communication you need to look great, feel great and to be great! CareFirst offers a
community like no other for you to reach your health and wellness goals. Here are some of the ways
we do it.
Healthy deals
Trust the largest health insurer in the region to negotiate
money-saving rates for you. Save at fitness centers and
spas, on acupuncture, massages, chiropractic, nutritional
counseling, laser vision correction and more.
See our updated list online at www.CareFirst.com/options.
24/7 access to a registered nurse
You can’t always plan when you’ll need a trusted answer
to a health care questions. With Nurse Line—First HelpTM,
you can plan on having a nurse answer your call to help
guide you to the best care for the situation. You deserve
to have a reliable answer to your questions. When you call
800-535-9700, that’s exactly what you’ll get.
The info you need, at your fingertips
CareFirst gives you a world of valuable information
online at www.CareFirst.com/mycarefirst. More than 300
interactive health tools are waiting for you, as well as
400+ podcasts, searchable recipes, video, tutorials and an
encyclopedia with info on more than 3,000 conditions.
Stay in the know
Vitality Magazine has tools to help you achieve a healthier
lifestyle. Three times a year you’ll get info on health and
wellness topics, updates to your health plan, articles about
nutrition, preventive health, physical fitness and more…all
free of charge!
Keep track of your health with
our Pedometer App
If you’ve got an iPhone, iPod Touch
or Droid, you’ve got a powerful way
to control your weight, reduce stress,
strengthen your heart and lungs and
improve bone density. The free Ready,
Step, Go! App counts your steps,
distance traveled and calories burned.
Search for it on your favorite app store.
Wellness in your Inbox
Want even more frequent news you can use to be
the healthiest you ever? Every month, we’ll send you
more articles and recipes, personalized to the areas
of interest you choose when you sign up online at
www.CareFirst.com/healthnews.
27
Consumer Health Insurance Plans 2014
Northern Virginia
Health Coaching by phone
Some of us achieve our goals faster with the help and
encouragement of another person. Our Telephone Health
Coaching program will give you confidence as you learn
new and positive lifestyle behaviors. You can get your
coaching through a secure, private Web-based message
board and by phone to develop a personalized plan
with milestones along the way to achieving your goals.
Everyone needs a coach now and then. Yours is waiting
for you.
Away from home care
You and your family have access to routine and urgent care
when you’re away from home for more than 90 consecutive
days in these participating states: Arizona, Arkansas,
California, Colorado, Connecticut, Delaware, District
of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana,
Kentucky, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, Missouri, Nevada, New Hampshire,
New Jersey, New Mexico, New York, North Carolina, Ohio,
Oklahoma, Pennsylvania, Texas, Virginia, and Wisconsin.
Account info to go!
The free My Account mobile app puts the account
information you need just a tap or swipe away. It lets you
take a more active role in managing your care, accessing
your claims info and having an easy backup view of your
ID card. It’s also a quick way to find a doctor or urgent
care provider when you need one fast. Optimized for
smartphones and tablets, you’ll find the My Account app in
your favorite app store: just do a search for “CareFirst” and
you’ll be set!
Staying connected
We’ve been committed to being an active part of your
community for more than 75 years, and that includes the
online communities you spend time in. Join our 10,000+
Facebook followers and contribute to our vibrant Twitter
community to get the latest information on health care
reform, healthy recipes, wellness tips, fitness challenges
and great prizes—directly to your news feed. Or check us
out on YouTube to learn about the basics of health care
reform and how it will impact you.
28
Enroll today
Three ways to enroll in your
new CareFirst plan
At this point, you should have decided on the CareFirst plan that’s best for your needs.
You’re almost done!
When your coverage will start
There are three ways you can enroll for your new plan, if
you live in the cities of Alexandria and Fairfax, the town
of Vienna, Arlington County and the areas of Fairfax and
Prince William Counties in Virginia lying east of Route 123.
The effective date is the date your coverage begins.
■■ Enroll online at:
www.CareFirst.com/individual
It’s fast and you’ll get an instant confirmation.
■■ Use this paper application and mail it to us
in the pre-paid envelope. We’ll mail you a
confirmation.
Enroll:
For effective date of:
Oct. 1 – Dec. 20
Jan. 1, 2014
Dec. 21 – Jan. 20
Feb. 1, 2014
Jan. 21 – Feb. 20
Mar. 1, 2014
Feb. 21 – Mar. 20
Apr. 1, 2014
Mar. 21 – Mar. 31
May 1, 2014
Note: If you are enrolling through Virginia’s Health
Insurance Marketplace, please be sure to check your
effective date directly with the Marketplace. The dates
listed above apply to enrollments through CareFirst.
com only.
■■ Enroll through your broker.
When you’re ready to review a listing of providers, visit
www.CareFirst.com/findadoc. If you’d prefer a printed
directory, give us a call and we’ll send you one.
Paying for your plan
If you’re still undecided about which CareFirst plan is
best for you, give one of our Product Consultants a call
at (410) 356-8000 or toll free at (800) 544-8703, 7 days a
week, 8:00 am – 8:00 pm.
Payment is due before your effective date in order for your
coverage to begin.
If you enroll through:
Send your first premium:
Need language assistance?
The CareFirst site
before your effective date
You can use the same number for our no-charge
bi-lingual services.
This paper form
ithin 30 days
w
(we’ll mail you a bill)
Virginia’s Health
Insurance Marketplace
within 30 days of enrollment
Ready to buy your CareFirst plan
with financial assistance?
Convenient e-Billing
When you set up automated recurring monthly premium
payments, your first payment will be sent to CareFirst
automatically. You can also set it up in Section 7 of this
application or online at www.CareFirst.com/myaccount
where you’ll be able to view and pay bills and monitor
payments 24/7.
To apply for a plan with Subsidies you
must contact Virginia’s Health Insurance
Marketplace.
29
Individual Application
Virginia Residents
Group Hospitalization and Medical Services, Inc.
CareFirst BlueChoice, Inc.
840 First Street, NE, Washington, DC 20065
INSTRUCTIONS
1. Please fill out all applicable spaces on this application.
Print or type all information.
2. Sign and return this application in the postage-paid
return envelope if provided, or mail to:
Mailroom Administrator
P.O. Box 14651, Lexington, KY 40512
Give careful attention to all questions in this application.
Accurate, complete information is necessary before
your application can be processed. If incomplete, the
application will be returned and your coverage will be
delayed.
Are you applying for new coverage or are you making changes
to a current policy? Check one box.
New coverage
Making changes
1. PRIMARY APPLICANT INFORMATION (The primary applicant will be the Head of Household)
Last Name
First Name
Initial
Social Security #
Residence Address: (Number and Street, Apt #)
City and State
Zip Code (9-digit, if known)
Billing Address, if different: (Number and Street, Apt #)
City and State
Zip Code (9-digit, if known)
Date of Birth
/
/
Home Phone
(
Sex
Male
Marital Status
Single
Female
Work/Cell Phone
)
(
Married
Domestic Partner
Tobacco Usage*
Yes
No
)
*Tobacco usage means any use of tobacco, including but not limited to cigarettes, for other than religious or ceremonial use, on average four or more times
per week within the past 6 months.
2. ENROLLING FAMILY MEMBER(S) (Complete only if you are enrolling a Spouse, Partner or Dependent(s) to your plan)
Last Name
First Name
M.I.
Relationship
Social Security #
Date of Birth
Sex
Tobacco
Usage
Spouse
M
F
Yes
No
Domestic
Partner
M
F
Yes
No
Dependent 1
M
F
Yes
No
Dependent 2
M
F
Yes
No
Dependent 3
M
F
Yes
No
Dependent 4
M
F
Yes
No
Dependent 5
M
F
Yes
No
Dependent 6
M
F
Yes
No
Dependent 7
M
F
Yes
No
Dependent 8
M
F
Yes
No
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
MVAAP (4/13)
1
CDS1096-1P (6/13)
3. PLAN SELECTION (Check one)
Plan Name
Deductible
Health Maintenance Organization (HMO) Plans Underwritten by
CareFirst BlueChoice, Inc.
In-Network
Out-of-Network
Individual: $6,350
Family: $12,700
N/A
BlueChoice HSA Bronze $6,000*
Individual: $6,000
Family: $12,000
N/A
BlueChoice HSA Bronze $4,000*
Individual: $4,000
Family: $8,000
N/A
BlueChoice Silver $2,000*
Individual: $2,000
Family: $4,000
N/A
BlueChoice HSA Silver $1,300*
Individual: $1,300
Family: $2,600
N/A
BlueChoice Gold $1,000*
Individual: $1,000
Family: $2,000
N/A
Individual: $0
Family: $0
N/A
BlueChoice Young Adult $6,350*
BlueChoice Young Adult is only available for individuals under age 30. Some exceptions may apply.
BlueChoice Gold $0*
Point of Service (POS) Plans Underwritten by CareFirst BlueChoice, Inc. for in-network benefits
and by Group Hospitalization and Medical Services Inc. for out-of-network benefits.
BlueChoice Plus Bronze $5,500*
Individual: $5,500
Family: $11,000
Individual: $6,350
Family: $12,700
BlueChoice Plus Silver $2,500*
Individual: $2,500
Family: $5,000
Individual: $5,000
Family: $10,000
HealthyBlue Gold $1,500*
Individual: $1,500
Family: $3,000
Individual: $2,500
Family: $5,000
HealthyBlue Platinum $0*
Individual: $0
Family: $0
Individual: $1,000
Family: $2,000
Preferred Provider Organization (PPO) Plans Underwritten by Group Hospitalization and Medical Services, Inc.
BluePreferred HSA Bronze $3,500
Individual: $3,500
Family: $7,000
Individual: $7,000
Family: $14,000
BluePreferred HSA Silver $1,500
Individual: $1,500
Family: $3,000
Individual: $3,000
Family: $6,000
Individual: $500
Family: $1,000
Individual: $1,000
Family: $2,000
Individual: $0
Family: $0
Individual: $1,000
Family: $2,000
BluePreferred Gold $500
BluePreferred Platinum $0
Important Deductible Information:
For HSA Plans (HSA listed in plan name): Single party applications: the Individual Deductible must be met before full benefits
will begin. Multi-party applications: the Family Deductible must be met before full benefits will be available to any member on the
policy. Once the Family deductible has been met, full benefits will become available to everyone covered.
For non-HSA Plans (HSA is not listed in plan name): Single party applications: the Individual Deductible must be met before
full benefits will begin. Multi-party applications: if one member on the policy meets the Individual Deductible, full benefits will
begin for that member. That member will not be able to contribute more than the Individual Deductible amount towards the Family
Deductible. Once the Family Deductible has been met, full benefits will be available to all members on the policy.
Please Note: Coverage will begin immediately for preventive benefits as they are not subject to a deductible. Other benefits, as
specified in the member contract, also may be covered without having to meet a deductible first. In-network and out-of-network
(if applicable) deductible expenses will not be applied to each other.
MVAAP (4/13)
2
CDS1096-1P (6/13)
4. PRIMARY CARE PHYSICIAN INFORMATION
*If you selected a BlueChoice or HealthyBlue plan in Section 3, please select a Primary Care Physician from the CareFirst
BlueChoice Directory available at www.carefirst.com/doctor. Indicate the PCP ID number for all enrolling applicants below:
Applicant Name
PCP ID
Spouse/Domestic Partner
PCP ID
Eligible Dependent Name(s)
PCP ID
5. OTHER INSURANCE INFORMATION
IF YOU HAVE OTHER INSURANCE, FAILURE TO COMPLETE THIS SECTION WILL CAUSE SIGNIFICANT DELAYS IN PROCESSING
ANY CLAIMS SUBMITTED.
Yes
No
1. Is anyone listed on this application eligible for Medicare?
If yes, please provide the following:
Name of family member(s)
Medicare No
Effective Date
2. Is anyone listed on this application covered by other health insurance,
including other Blue Cross and Blue Shield coverage?
If yes, please provide the following:
Name of family member(s)
Insurance Company
Policy Number and Type
Yes
No
Yes
No
Yes
No
Effective Date
If you are accepted, will your new CareFirst coverage replace your existing policy?
3. Has anyone listed on this application been without health insurance for the past 12-months or longer?
If yes, please list name(s):
MVAAP (4/13)
3
CDS1096-1P (6/13)
6. NON-OPEN ENROLLMENT APPLICATION ELIGIBILITY
Do you qualify for a Limited Open Enrollment period based on one of the five triggering events listed below?
If YES, please select the triggering event to determine your eligibility. You will be required to provide documentation
as proof of your triggering event. If NO, please skip to Section 7.
1. Are you adding a qualified dependent, recognized through marriage, birth, adoption or court-appointed within the
last 60 days, to your plan?
Yes
No
Yes
No
You lost minimum essential coverage (not including failure to pay premiums or rescissions)?
Yes
No
You experienced an error in enrollment by the Health Insurance Marketplace in Virginia or by the Department of
Health and Human Services?
Yes
No
The plan substantially violated a material provision of its contract?
Yes
No
3. Within the last 60 days, have you or your dependents become newly ineligible for subsidies?
Yes
No
4. Within the last 60 days, have you gained access to new Qualified Health Plans as a result of a permanent move?
Yes
No
5. Within the last 30 days, were you terminated from a non-calendar year individual health insurance policy?
Yes
No
2. Within the last 60 days, were you enrolled in a qualified health plan in which:
7. RECURRING AUTOMATED PREMIUM PAYMENT
CareFirst wants to help you save time! Our standard method of payment for members is recurring automated payment by bank
withdrawal. To take advantage of this time-saving payment option, please fill out the information below.
If you do not wish to set up an automated payment account and intend to pay by submitting paper checks or by credit card then
please check this box.
Information Required for Recurring Automated Payment:
Checking Account
Savings Account
Bank Name:
Routing Number:
Account Number:
Name that appears on the Account:
0123
NAME
ADDRESS
CITY, STATE ZIP
01-23456789
BANK NAME
ADDRESS
CITY, STATE ZIP
FOR
Bank Routing
Number
Sa
m
PAY TO THE
ORDER OF
pl
e
DATE
$
DOLLARS
Bank Account
Number
Check
Number
I hereby authorize CareFirst to charge my account for the payment of premiums due for an unpaid invoice. If any check draft is
dishonored for any reason, or drawn after the depositor’s authorization has been withdrawn, CareFirst agrees that the financial
institution will not be held liable. I understand that non-payment of premiums due to dishonored auto-draft payment attempts
may result in termination of coverage. I also understand that if the Primary Applicant elects to pay premium through an electronic
payment, CareFirst may not debit or charge the amount of the premium due prior to the premium due date, except as authorized
by the Primary Applicant. My recurring payments will be processed on the 6th of each month (including holidays). Members
registered for recurring automated premium payment will not receive a paper bill in the mail. However, you may view and print
your invoice during the recurring automated payment period from the invoice history online at www.carefirst.com/myaccount.
Signature of Account Holder
X
MVAAP (4/13)
Date:
4
CDS1096-1P (6/13)
8. ELECTRONIC COMMUNICATION CONSENT
CareFirst wants to help you manage your health care information and protect the environment by offering you the option of
electronic communication.
Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or
text messaging by providing your email address and/or cell phone number and consent below.
Electronic notices regarding your CareFirst health care coverage include, but are not limited to:
• Explanation of Benefits Alerts
• Reminders
• Notice of HIPAA Privacy Practices
• Certification of Creditable Coverage
You may also receive information on programs related to your existing products and services along with new products and
services that may be of interest to you.
Please note, you may change your email and consent information anytime by logging into www.carefirst.com/myaccount or by
calling the customer service phone number on your ID card. You can also request a paper copy of electronic notices at any time
by calling the customer service phone number on your ID card.
I understand that to access the information provided electronically through email, I must have the following:
• Internet access;
• An email account that allows me to send and receive emails; and
• Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher), and Adobe Acrobat Reader 4 (or higher).
I understand that to receive notices through text messaging,
• A text messaging plan with my cell phone provider is required; and
• Standard text messaging rates will apply.
By checking below, I hereby agree to electronic delivery of notices, instead of paper delivery by:
Email only
Cell phone text messaging only
Primary Applicant Name
Email and cell phone text messaging
Email Address
Cell Phone Number
Alternate Email Address
Alternate Cell Phone Number
Spouse / Domestic Partner Name
Email Address
Cell Phone Number
Eligible Dependent Name(s)
Email Address
Cell Phone Number
CareFirst will not sell your email or phone number to any third party and we do not share it with third parties except for
CareFirst business associates that perform functions on our behalf or to comply with the law.
MVAAP (4/13)
5
CDS1096-1P (6/13)
9. CONDITIONS OF ENROLLMENT — Please Read This Section Carefully
IT IS UNDERSTOOD AND AGREED THAT:
A copy of this application is available to the Primary Applicant
(or to a person authorized to act on his/her behalf) upon
request, from CareFirst.
I understand that I have the right to cancel this authorization
at any time, in writing, except to the extent that CareFirst has
already taken action in reliance on this authorization. I also
understand that CareFirst Notice of Privacy Practices includes
information pertaining to authorizations and to requirements of
revocation. A copy of the Notice may be obtained by contacting
the CareFirst Privacy Office. CareFirst is required to tell you by
law that information disclosed pursuant to this authorization
may be subject to re-disclosure and that under some limited
circumstances will no longer be protected by federal privacy
regulations.
If CareFirst determines that additional information is needed, I
will receive an authorization to release that information. Failure
to execute an authorization may result in the denial of my
application for coverage. Additionally I understand that failure
to complete any section of this application, including signing
below, may delay the processing of my application.
To the best of my knowledge and belief, all statements made
on this application are complete, true and correctly recorded.
They are representations that are made to induce the issuance
of, and form part of the consideration for a CareFirst policy.
CareFirst will provide 30-days advance written notice of any
rescission of coverage and refund any premiums to the Primary
Applicant. The Member is responsible for repayment of any
claim payment made by CareFirst on the Member’s behalf.
If you have any questions concerning the benefits and
services that are provided by or excluded under this
Agreement, please contact a membership services
representative before signing this application.
WARNING: ANY PERSON WHO, WITH THE INTENT TO
DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD
AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES
A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT
MAY HAVE VIOLATED VIRGINIA STATE LAW.
The undersigned applicant and agent certify that the applicant has read, or had read to him/her, the completed application and
that the applicant realizes that any false statement or misrepresentation in the application may result in the loss of coverage under
the policy.
Date
Signature of Primary Applicant: X
Date
Signature of Applicant 2: X
(Spouse or Domestic Partner)
NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the
parent or legal guardian, must be signed by the parent or legal guardian.
Date
Parent or Legal Guardian’s Signature: X
Date
Signature of Agent: X
FOR OFFICE USE ONLY:
Re-sign and re-date below only if box is checked.
Date
Signature of Primary Applicant: X
Date
Signature of Applicant 2: X
(Spouse or Domestic Partner)
Date
Parent or Legal Guardian’s Signature: X
FOR BROKER USE ONLY:
Name:
NPN#
SSN/Tax ID #
CareFirst-Assigned ID #
Contracted Broker:
Sub-Agent/Sub-Agency:
Writing Agent:
MVAAP (4/13)
6
CDS1096-1P (6/13)
Artwork for Envelope, Business, #10 (4.125" x 9.5")
Layout: # 10 LETTER.LYT IMB.LYT
July 16, 2012
Produced by DAZzle Designer, Version 9.0.05
(c) 1993-2009, Endicia, www.Endicia.com
U.S. Postal Service, Serial #NO
CAREFIRST BLUECROSS BLUESHIELD
CAREFIRST
BLUECROSS BLUESHIELD
PO BOX 14651
PO BOX
14651
LEXINGTON KY 40512-9876
LEXINGTON KY 40512-9876
POSTAGE
WILL
BE
PAID
BY
ADDRESSEE
POSTAGE
WILL
BE
PAID
BY
ADDRESSEE
CAREFIRST BLUECROSS BLUESHIELD
PO BOX 14651
BUSINESS
REPLY
MAILDC
BUSINESS
MAIL
KY REPLY
40512-9876
FIRLEXINGTON
ST-CLASSMAIL
MAILPERMIT
PERMIT
NO11562
11562WASHINGTON
WASHINGTONDC
FIRST-CLASS
NO.
POSTAGE WILL BE PAID BY ADDRESSEE
FIRST-CLASS MAIL PERMIT NO. 11562 WASHINGTON DC
BUSINESS REPLY MAIL
IMPORTANT: DO NOT ENLARGE, REDUCE OR MOVE the FIM and POSTNET barcodes. They are only valid as printed!
Special care must be taken to ensure FIM and POSTNET barcode are actual size AND placed properly on the mail piece
to meet both USPS regulations and automation compatibility standards.
IMPORTANT: DO NOT ENLARGE, REDUCE OR MOVE the FIM and POSTNET barcodes. They are only valid as printed!
Special care must be taken to ensure FIM and POSTNET barcode are actual size AND placed properly on the mail piece
to meet both USPS regulations and automation compatibility standards.
Fold and Detach Along Perforation
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
NO POSTAGE
POSTAGE
NO
NECESSARY
NECESSARY
IF MAILED
MAILED
IF
IN THE
IN
UNITED STATES
UNITED
Additional information
Our commitment
to you
CareFirst’s privacy practices
In addition, we limit access to your personal, financial
and medical information to those CareFirst employees,
brokers, benefit plan administrators, consultants, business
partners, providers and agents who need to know this
information to conduct CareFirst business or to provide
products or services to you.
The following statement applies to CareFirst of Maryland,
Inc. and Group Hospitalization and Medical Services, Inc.
doing business as CareFirst BlueCross BlueShield, and
their affiliates (collectively, CareFirst).
When you apply for any type of insurance, you disclose
information about yourself and/or members of your family.
The collection, use and disclosure of this information are
regulated by law. Safeguarding your personal information
is something that we take very seriously at CareFirst.
CareFirst is providing this notice to inform you of what we
do with the information you provide to us.
Disclosure of Your Information
In order to protect your privacy, affiliated and nonaffiliated
third parties of CareFirst are subject to strict confidentiality
laws. Affiliated entities are companies that are a part of the
CareFirst corporate family and include health maintenance
organizations, third party administrators, health insurers,
long‑term care insurers and insurance agencies. In certain
situations related to our insurance transactions involving
you, we disclose your personal, financial and medical
information to a nonaffiliated third party that assists us in
providing services to you. When we disclose information to
these critical business partners, we require these business
partners to agree to safeguard your personal, financial and
medical information and to use the information only for the
intended purpose, and to abide by the applicable law. The
information CareFirst provides to these business partners
can only be used to provide services we have asked them
to perform for us or for you and/or your benefit plan.
Categories of Personal Information We May
Collect
We may collect personal, financial and medical information
about you from various sources, including:
■■ Information you provide on applications or
other forms, such as your name, address, social
security number, salary, age and gender.
■■ Information pertaining to your relationship
with CareFirst, its affiliates or others, such as
your policy coverage, premiums and claims
payment history.
■■ Information (as described in preceding
paragraphs) that we obtain from any of
our affiliates.
■■ Information we receive about you from other
sources, such as your employer, your provider
and other third parties.
Changes in Our Privacy Policy
CareFirst periodically reviews its policies and reserves the
right to change them. If we change the substance of our
privacy policy, we will continue our commitment to keep
your personal, financial and medical information secure – it
is our highest priority. Even if you are no longer a CareFirst
customer, our privacy policy will continue to apply to your
records. You can always review our current privacy policy
online at www.CareFirst.com.
How Your Information Is Used
We use the information we collect about you in connection
with underwriting or administration of an insurance policy
or claim or for other purposes allowed by law. At no
time do we disclose your personal, financial and medical
information to anyone outside of CareFirst unless we have
proper authorization from you or we are permitted or
required to do so by law. We maintain physical, electronic
and procedural safeguards in accordance with federal and
state standards that protect your information.
39
Consumer Health Insurance Plans 2014
Northern Virginia
Rights and responsibilities
Notice of Privacy Practices
CareFirst BlueCross BlueShield (CareFirst) is committed to
keeping the confidential information of members private.
Under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), we are required to send our Notice
of Privacy Practices to members. This notice outlines the
uses and disclosures of protected health information,
the individual’s rights and CareFirst’s responsibility for
protecting the member’s health information.
To obtain an additional copy of our Notice of Privacy
Practices, go to www.CareFirst.com and click on “Legal
Mandates” at the bottom of the page, click on “Patient
Rights & Responsibilities” then click on “Members
Privacy Policy.”
If you send your comments to us in writing, please include
your identification number and provide us with as much
detail as possible regarding the event or incident. Please
include your daytime telephone number so that we may
contact you directly if we need additional information. Our
Quality of Care Department will investigate your concerns,
share those issues with the provider involved and request
a response. We will then provide you with a summary of
our findings. CareFirst member complaints are retained
in our provider files and are reviewed when providers are
considered for continuing participation
with CareFirst.
If you wish, you may also contact the appropriate
jurisdiction’s regulatory department regarding
your concern:
Virginia Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
Toll-free within Virginia: 1-800-552-7945
804-371-9691
Member Satisfaction
CareFirst wants to hear your concerns and/or complaints
so that they may be resolved. We have procedures that
address medical and non-medical issues. If a situation
should occur for which there is any question or difficulty,
here’s what you can do:
Complaint Intake
Office of Licensure and Certification
Virginia Department of Health
9960 Mayland Drive, Suite 401
Henrico, VA 23233-1463
Toll free: 1-800-955-1819
Richmond metropolitan area: 804-367-2106
Fax: 804-527-4503
E-mail: [email protected]
■■ If your comment or concern is regarding the quality
of service received from a CareFirst representative or
related to administrative problems (e.g., enrollment,
claims, bills, etc.) you should contact Member
Services. If you send your comments to us in writing,
please include your member ID number and provide us
with as much detail as possible regarding any events.
Please include your daytime telephone number so
that we may contact you directly if we need additional
information.
■■ If your concern or complaint is about the quality of
care or quality of service received from a specific
provider, contact Member Services. A representative
will record your concerns and may request a written
summary of the issues. To write to us directly with a
quality of care or service concern, you can:
For assistance in resolving a billing or payment dispute
with the health plan or a health care provider, contact
the Health Education and Advocacy Unit of the Consumer
Protection Division of the Office of the Attorney General at:
Office of the Managed Care Ombudsman
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
Toll-free: 1-877-310-6560
804-371-9032
Email: [email protected]
Send an email to:
[email protected]
Fax a written complaint to: (301) 470-5866
rite to:
W
CareFirst BlueCross BlueShield
Quality of Care Department,
P.O. Box 17636, Baltimore, MD 21297
Hearing Impaired
To contact a Member Services representative, please
choose the appropriate hearing impaired assistance
40
Consumer Health Insurance Plans 2014
Northern Virginia
Your Rights
number below, based on the region in which your
coverage originates.
You have the following rights regarding your own Protected
Health Information. You have the right to:
Maryland Relay Program: (800) 735-2258
National Capital Area TTY: (202) 479-3546.
Please have your Member Services number ready.
■■ Request that we restrict the PHI we use or
disclose about you for payment or health
care operations.
Language Assistance
Interpreter services are available through Member Services.
When calling Member Services, inform the representative
that you need language assistance.
Note: CareFirst appreciates the opportunity to improve
the level of quality of care and services available for you.
As a member, you will not be subject to disenrollment
or otherwise penalized as a result of filing a complaint
or appeal.
■■ Request that we communicate with you regarding
your information in an alternative manner or
at an alternative location if you believe that
a disclosure of all or part of your PHI may
endanger you.
■■ Inspect and copy your PHI that is contained
in a designated record set including your
medical record.
■■ Request that we amend your information if you
Confidentiality of Subscriber/ Member
Information
believe that your PHI is incorrect or incomplete.
■■ An accounting of certain disclosures of your PHI
All health plans and providers must provide information
to members and patients regarding how their information
is protected. You will receive a Notice of Privacy Practices
from CareFirst or your health plan, and from your providers
as well, when you visit their office.
that are for some reasons other than treatment,
payment, or health care operations.
■■ Give us written authorization to use your
CareFirst has policies and procedures in place to protect
the confidentiality of member information. Your confidential
information includes Protected Health Information (PHI),
whether oral, written or electronic, and other nonpublic
financial information. Because we are responsible for your
insurance coverage, making sure your claims are paid, and
that you can obtain any important services related to your
health care, we are permitted to use and disclose (give
out) your information for these purposes. Sometimes we
are even required by law to disclose your information in
certain situations. You also have certain rights to your own
protected health information on your behalf.
protected health information or to disclose it to
anyone for any purpose not listed in this notice.
Inquiries and Complaints
If you have a privacy-related inquiry, please contact the
CareFirst Privacy Office at (800) 853‑9236 or send an email
to: [email protected].
Members’ Rights and Responsibilities Statement
Members have the right to:
■■ Be treated with respect and recognition of their
dignity and right to privacy.
■■ Receive information about the health plan, its
Our Responsibilities
services, its practitioners and providers, and
members’ rights and responsibilities.
We are required by law to maintain the privacy of your
PHI, and to have appropriate procedures in place to do so.
In accordance with the federal and state Privacy laws, we
have the right to use and disclose your PHI for treatment,
payment activities and health care operations as explained
in the Notice of Privacy Practices. We may disclose your
protected health information to the plan sponsor/employer
to perform plan administration function. The Notice is sent
to all policy holders upon enrollment.
■■ Participate with practitioners in decision-making
regarding their health care.
■■ Participate in a candid discussion of appropriate
or medically necessary treatment options
for their conditions, regardless of cost or
benefit coverage.
■■ Make recommendations regarding the
organization’s members’ rights and
responsibilities.
41
Consumer Health Insurance Plans 2014
Northern Virginia
■■ Voice complaints or appeals about the health
plan or the care provided.
Members have a responsibility to:
■■ Provide, to the extent possible, information
that the health plan and its practitioners and
providers need in order to care for them.
■■ Understand their health problems and participate
in developing mutually agreed upon treatment
goals to the degree possible.
■■ Follow the plans and instructions for care that
they have agreed on with their practitioners.
■■ Pay copayments or coinsurance at the time
of service.
■■ Be on time for appointments and to notify
practitioners/providers when an appointment
must be canceled.
Eligible Individuals’ Rights Statement Wellness
and Health Promotion Services
Eligible individuals have a right to:
■■ Receive information about the organization,
including wellness and health promotion
services provided on behalf of the employer
or plan sponsors; organization staff and staff
qualifications; and any contractual relationships.
■■ Decline participation or disenroll from wellness
and health promotion services offered by the
organization.
■■ Be treated courteously and respectfully by the
organization’s staff.
■■ Communicate complaints to the organization and
receive instructions on how to use the complaint
process that includes the organization’s
standards of timeliness for responding to and
resolving complaints and quality issues.
Compensation and
premium disclosure statement
Our compensation to providers who offer health care
services and behavioral health care services to our insured
members or enrollees may be based on a variety of
payment mechanisms such as fee-for-service payments,
salary, or capitation. Bonuses may be used with these
various types of payment methods.
If you desire additional information about our methods of
paying providers, or if you want to know which method(s)
apply to your physician, please call our Member Services
Department at the number listed on your identification
card, or write to:
CareFirst BlueChoice, Inc.
840 First Street, NE
Washington, DC 20065
Attention: Member Services
A. Methods of Paying Physicians
The following definitions explain how insurance carriers
may pay physicians (or other providers) for your health
care services.
The examples show how Dr. Jones, an obstetrician/
gynecologist, would be compensated under each method
of payment.
Salary: A physician (or other provider) is an employee of
the HMO and is paid compensation (monetary wages) for
providing specific health care services.
Since Dr. Jones is an employee of an HMO, she receives her
usual bi-weekly salary regardless of how many patients
she sees or the number of services she provides. During
the months of providing pre-natal care to Mrs. Smith, who
is a member of the HMO, Dr. Jones’ salary is unchanged.
Although Mrs. Smith’s baby is delivered by Cesarean
section, a more complicated procedure than a vaginal
delivery, the method of delivery will not have an effect upon
Dr. Jones’ salary.
Capitation: A physician (or group of physicians) is paid
a fixed amount of money per month by an HMO for each
patient who chooses the physician(s) to be his or her
doctor. Payment is fixed without regard to the volume of
services that an individual patient requires.
Under this type of contractual arrangement, Dr. Jones
participates in an HMO network. She is not employed by
the HMO. Her contract with the HMO stipulates that she is
42
Consumer Health Insurance Plans 2014
Northern Virginia
paid a certain amount each month for patients who select
her as their doctor. Since Mrs. Smith is a member of the
HMO, Dr. Jones monthly payment does not change as a
result of her providing ongoing care to Mrs. Smith. The
capitation amount paid to Dr. Jones is the same whether or
not Mrs. Smith requires obstetric services.
Case Rate: The HMO or insurer and the physician (or other
provider) agree in advance that payment will cover a
combination of services provided by both the physician (or
other provider) and the hospital for an episode of care.
Fee-for-Service: A physician (or other provider) charges a
fee for each patient visit, medical procedure, or medical
service provided. An HMO pays the entire fee for physicians
it has under contract and an insurer pays all or part of that
fee, depending on the type of coverage. The patient is
expected to pay the remainder.
This type of arrangement stipulates how much an insurer
or HMO will pay for a patient’s obstetric services. All
office visits for prenatal and postnatal care, as well as the
delivery, and hospital-related charges are covered by one
fee. Dr. Jones, the hospital, and other providers (such as an
anesthesiologist) will divide payment from the insurer or
HMO for the care provided to Mrs. Smith.
B. Percentage of Provider
Payment Methods
Dr. Jones’ contract with the insurer or HMO states that
Dr. Jones will be paid a fee for each patient visit and each
service she provides. The amount of payment Dr. Jones
receives will depend upon the number, types, and
complexity of services, and the time she spends providing
services to Mrs. Smith. Because Cesarean deliveries are
more complicated than vaginal deliveries, Dr. Jones is paid
more to deliver Mrs. Smith’s baby than she would be paid
for a vaginal delivery. Mrs. Smith may be responsible for
paying some portion of Dr. Jones’ bill.
CareFirst BlueChoice, Inc. is a network model HMO and
contracts directly with the primary care and specialty care
providers. According to this type of arrangement, CareFirst
BlueChoice, Inc. reimburses providers primarily on a
discounted fee-for-service payment method. The provider
payment method percentages for CareFirst BlueChoice, Inc.
are approximately 99% discounted fee-for-service with less
than 1% capitated.
Discounted Fee-for-Service: Payment is less than the
rate usually received by the physician (or other provider)
for each patient visit, medical procedure, or service. This
arrangement is the result of an agreement between the
payer, who gets lower costs and the physician (or other
provider), who usually gets an increased volume of patients.
C. Distribution of Premium Dollars
The bar graph below illustrates the proportion of every
$100 in premium used by CareFirst BlueChoice, Inc. to pay
physicians (or other providers) for medical care expenses,
and the proportion used to pay for plan administration.
Like fee-for-service, this type of contractual arrangement
involves the insurer or HMO paying Dr. Jones for each
patient visit and each delivery; but under this arrangement,
the rate, agreed upon in advance, is less than Dr. Jones’
usual fee. Dr. Jones expects that in exchange for agreeing
to accept a reduced rate, she will serve a certain number of
patients. For each procedure that she performs, Dr. Jones
will be paid a discounted rate by the insurer or HMO.
These numbers represent an average for all HMO accounts
based on our annual statement. The ratio of direct medical
care expenses to plan administration will vary by account.
100%
90%
80%
90%
70%
60%
Bonus: A physician (or other provider) is paid an additional
amount over what he or she is paid under salary, capitation,
fee-for-service, or other type of payment arrangement.
Bonuses may be based on many factors, including member
satisfaction, quality of care, control of costs and use
of services.
50%
40%
30%
20%
10%
An HMO rewards its physician staff or contracted physicians
who have demonstrated higher than average quality and
productivity. Because Dr. Jones has delivered so many
babies and she has been rated highly by her patients and
fellow physicians, Dr. Jones will receive a monetary award in
addition to her usual payment.
43
10%
0%
Medical
Plan Administration
Consumer Health Insurance Plans 2014
Northern Virginia
Exclusions and limitations
extractions, treatment of cavities, care of the gums or
bones supporting the teeth, treatment of periodontal
abscess and periodontal disease, removal of teeth,
orthodontics, replacement of teeth, or any other dental
services or supplies. Benefits for accidental bodily injury
are described in Section 1.22.A. Benefits for oral surgery
are described in Section 1.23. Benefits for treatment of
cleft lip, cleft palate or both or ectodermal dysplasia are
described in Section 1.5.E and Section 1.24. Benefits
for pediatric dental services are described in Section
2. All other procedures involving the teeth or areas and
structures surrounding and/or supporting the teeth,
including surgically altering the mandible or maxillae
(orthognathic surgery) for Cosmetic purposes or for
correction of malocclusion unrelated to a documented
functional impairment are excluded.
References to specific Sections are to pages in the member
contract and not to pages in this brochure.
16.1 General Exclusions Coverage is not provided for:
A.Any services, tests, procedures, or supplies which
CareFirst determines are not necessary for the prevention,
diagnosis, or treatment of the Member’s illness, injury,
or condition. Although a service or supply may be
listed as covered, benefits will be provided only if it is
Medically Necessary and appropriate in the Member’s
particular case.
B.Any treatment, procedure, facility, equipment, drug, drug
usage, device, or supply which, in CareFirst’s judgment,
is Experimental/Investigational, or not in accordance with
accepted medical or psychiatric practices and standards in
effect at the time of treatment, except for covered benefits
for clinical trials.
C. The cost of services that:
1.Are furnished without charge; or
2.Are normally furnished without charge to persons
without health insurance coverage; or
3.Would have been furnished without charge if a Member
were not covered under the Agreement or under any
health insurance.
This exclusion does not apply to:
a) Medicaid;
b)Care received in a Veteran’s hospital unless the
care is rendered for a condition that is a result of a
Member’s military service.
D.Any service, supply, drug or procedure that is not
specifically listed in the Member’s Agreement as a covered
benefit or that do not meet all other conditions and criteria
for coverage as determined by CareFirst, except as required
to be covered under state or federal laws and regulations.
Provision of services by a health care provider does not,
by itself, entitle a Member to benefits if the services are
not covered or do not otherwise meet the conditions and
criteria for coverage.
E.Routine, palliative, or Cosmetic foot care (except for
conditions determined by CareFirst to be Medically
Necessary such as care rendered for diabetes or vascular
disease), including flat foot conditions, supportive devices
for the foot, treatment of subluxations of the foot, care of
corns, bunions (except capsular or bone surgery), calluses,
toe nails, fallen arches, weak feet, chronic foot strain, and
symptomatic complaints of the feet.
F.Any type of dental care (except treatment of accidental
bodily injuries, oral surgery, cleft lip or cleft palate
or both, or ectodermal dysplasia and pediatric dental
services listed in the sections noted below), including
G.Cosmetic surgery (except benefits for reconstructive breast
surgery or reconstructive surgery) or other services primarily
intended to correct, change, or improve appearances.
Cosmetic means a service or supply which is provided with
the primary intent of improving appearances and not for the
purpose of restoring bodily function or correcting deformity
resulting from disease, trauma, or previous therapeutic
intervention as determined by CareFirst. This exclusion
includes treatment of varicose veins or telangiectatic dermal
veins (spider veins) for cosmetic purposes.
H.Treatment rendered by a health care provider who is the
Member’s Spouse, parent, child, grandparent, grandchild,
sister, brother, great grandparent, great grandchild, aunt,
uncle, niece, or nephew, or resides in the Member’s home.
I.All non-Prescription Drugs, medications, biologicals, and
Over-the-Counter disposable supplies, routinely obtained
without a prescription and self-administered by the Member,
except as listed as a Covered Service above, including but
not limited to: cosmetics or health and beauty aids, support
devices, non-medical items, foot care items, first aid and
miscellaneous medical supplies (whether disposable or
durable), personal hygiene supplies, incontinence supplies,
and Over-the-Counter medications and solutions, except
for Over-the-Counter medication or supplies dispensed
under a written prescription by a health care provider that
is identified in the current recommendations of the United
States Preventive Services Task Force that have in effect a
rating of “A” or “B”.
J.Any procedure or treatment designed to alter an
individual’s physical characteristics to those of the
opposite sex.
K.All assisted reproductive technologies including artificial
insemination and intrauterine insemination, in vitro
fertilization, gamete intra-fallopian tube transfer, zygote
intra-fallopian transfer cryogenic preservation or storage
of eggs and embryo and related evaluative procedures,
drugs, diagnostic services and medical preparations
related to the same.
44
Consumer Health Insurance Plans 2014
Northern Virginia
L.Services to reverse voluntary, surgically induced infertility,
such as a reversal of a sterilization.
U.Medical or surgical treatment of myopia or hyperopia,
including radial keratotomy and other forms of refractive
keratoplasty or any complications thereof.
M.Treatment of sexual dysfunctions or inadequacies
including, but not limited to, surgical implants for
impotence, medical therapy, and psychiatric treatment.
V.Services that are beyond the scope of the license of the
provider performing the service.
N.E xpenses related to a surrogate pregnancy when the
surrogate is not a Member.
O.Paternity testing.
W.Services that are solely based on court order or as
a condition of parole or probation, unless approved
by CareFirst.
P.Treatment of sexual dysfunctions or inadequacies
including, but not limited to, surgical implants for
impotence, medical therapy, and psychiatric treatment.
X.Health education classes and self-help programs, other
than programs for the treatment of diabetes or provided as
part of a covered preventive services visit.
Q.Fees and charges relating to fitness programs, weight loss,
or weight control programs, physical or other programs
involving such aspects as exercise, physical conditioning,
use of passive or patient-activated exercise equipment or
facilities and self-care or self-help training or education,
except for self-management training and educational
services received as outpatient diabetes care or as part
of a covered preventive services visit. This exclusion
includes charges for health club memberships, health spa
services, exercise classes, and personal trainer services.
Cardiac rehabilitation programs are covered as described
in Section 1.
Y.Acupuncture services.
Z.Any service related to recreational activities. This
includes, but is not limited to, sports, games, equestrian,
and athletic training. These services are not covered
unless authorized or approved by CareFirst even though
they may have therapeutic value or be provided by a
health care provider.
AA.Services or supplies for injuries or diseases related to a
covered person’s job to the extent the covered person is
required to be covered by a workers compensation law.
BB.Non-medical services. including, but is not limited to:
R.Medical or surgical treatment for obesity, weight reduction,
dietary control, commercial weight loss programs, or
medical nutritional therapy for treatment of obesity. This
exclusion does not apply to:
1.Surgical procedures for the treatment of
Morbid Obesity;
2.Well child care visits for obesity evaluation
and management;
3.Evidence-based items or services for preventive care
and screening for obesity that have in effect a rating of
“A” or “B” in the current recommendations of the United
States Preventive Services Task Force (USPSTF);
4.For infants, children, and adolescents, evidenceinformed preventive care and screening for obesity
provided for in the comprehensive guidelines
supported by the Health Resources and Services
Administration; and
1.Telephone consultations, failure to keep a scheduled
visit, completion of forms (except for forms that may
be required by CareFirst), copying charges or other
administrative services provided by the health care
provider or the health care provider’s staff. This
exclusion does not apply to telemedicine as described
in Section 1.30.
2.Administrative fees charged by a physician or medical
practice to a Member to retain the physician’s or
medical practices services, e.g., “concierge fees” or
boutique medical practice membership fees. Benefits
under the Agreement are available for Covered Services
rendered to the Member by a health care provider.
CC. Group Speech Therapy.
DD.Non-medical ancillary services such as vocational
rehabilitation, employment counseling, or
educational therapy.
EE.Services, drugs, or supplies the Member receives without
charge while in active military service.
5. Office visits for the treatment of childhood obesity.
S. Nutritional counseling and related services, except when
provided as part of diabetes education, hospice care, or
when received as part of a preventive services screening.
FF.Custodial Care.
T.Nutritional and/or dietary supplements, except as provided
in Section 10 or as required by law. This exclusion
includes, but is not limited to, those nutritional formulas
and dietary supplements that can be purchased Over
the Counter, which by law do not require either a written
prescription or dispensing by a licensed pharmacist.
HH.Durable Medical Equipment or Medical Supplies associated
or used in conjunction with non-covered items or services.
45
GG.Services or supplies received before the Effective Date of
the Member’s coverage under the Agreement.
II.Services required solely for employment, insurance,
foreign travel, school, camp admissions or participation
in sports activities.
JJ.Work Hardening Programs. Work Hardening Program
means a highly specialized rehabilitation program
designed to simulate workplace activities and
Consumer Health Insurance Plans 2014
Northern Virginia
surroundings in a monitored environment with the goal of
conditioning the participant for a return to work.
KK.Chiropractic services or spinal manipulation treatment
other than spinal manipulation treatment for
musculoskeletal conditions of the spine.
7.Interim prosthetic devices, fixed or removable and not
part of a permanent or restorative prosthetic service.
LL.Any illness or injury caused by war (a conflict between
nation states), declared or undeclared, including
armed aggression.
8.Additional fees charged for visits by a Dentist to the
Member’s home, to a hospital, to a nursing home, or for
office visits after the Dentist’s standard office hours.
CareFirst shall provide the benefits for the dental service
as if the visit was rendered in the Dentist’s office during
normal office hours.
MM.Biofeedback therapy, neurofeedback, and related testing.
9.Transseptal fiberotomy.
NN.Applied behavioral analysis.
10.Orthognathic Surgery.
OO.Birthing centers.
11.The repair or replacement of any orthodontic appliance,
unless specifically listed as a Covered Dental Service.
16.2 Pediatric Dental Services
A.Limitations
1.Covered Dental Services must be performed by or
under the supervision of a Dentist with an active and
unrestricted license, within the scope of practice for
which licensure or certification has been obtained.
2.Benefits will be limited to standard procedures and
will not be provided for personalized restorations or
specialized techniques in the construction of dentures
including precision attachments, custom denture teeth
and implant supported fixed or removable prostheses.
3.If a Member switches from one Dentist to another
during a course of treatment, or if more than one
Dentist renders services for one dental procedure,
CareFirst shall pay as if only one Dentist rendered
the service.
4.CareFirst will reimburse only after all dental procedures
for the condition being treated have been completed
(this provision does not apply to orthodontic services).
5.In the event there are alternative dental procedures
that meet generally accepted standards of professional
dental care for a Member’s condition, benefits will be
based upon the lowest cost alternative procedure.
B. Exclusions
Benefits will not be provided for:
1.Replacement of a denture or crown as a result of loss
or theft.
2.Replacement of an existing denture or crown that is
determined by CareFirst to be satisfactory or repairable.
3.Replacement of dentures, metal and/or porcelain crowns,
inlays, onlays and crown build-ups within 60 months from
the date of placement or replacement for which benefits
were paid in whole or in part under the terms of the
Agreement and are judged by CareFirst to be adequate
and functional.
4. Gold foil fillings.
5. Periodontal appliances.
6.Bacteriologic studies, histopathologic exams, accession of
tissue, caries susceptibility tests, diagnostic radiographs,
and other pathology procedures, unless specifically listed
as a Covered Dental Service.
12.Any orthodontic services after the last day of the month
in which Covered Dental Services ended except as
specifically described in Section 2.
13.Separate billings for dental care services or supplies
furnished by an employee of a Dentist which are normally
included in the Dentist’s charges and billed for by them.
14.Transitional orthodontic appliance, including a lower
lingual holding arch placed where there is not premature
loss of the primary molar.
15.Limited or complete occlusal adjustments in connection
with periodontal surgical treatment when received in
conjunction with restorative service on the same date
of service.
16.Orthodontic or any other services for Cosmetic purposes.
17.Oral orthotic appliances, unless specifically listed as a
Covered Dental Service.
18.Bridges and recementation of bridges.
16.3 Pediatric Vision Services
Benefits will not be provided for the following:
A.Any pediatric vision service stated in Section 3 for
Members over age 19. If Member is under age 19 at the
start of the Benefit Period but turns 19 during the Benefit
Period, then the Member will receive covered pediatric
vision services through the rest of that Calendar Year.
B.Diagnostic services, except as listed in Section 3.
C.Services or supplies not specifically approved by the
Vision Care Designee where required in this Description of
Covered Services.
D.Orthoptics, vision training, and low vision aids.
E.Non-prescription (Plano) lenses and/or glasses, sunglasses
or contact lenses.
F.Except as otherwise provided, Vision Care services that
are strictly Cosmetic in nature including, but not limited
to, charges for personalization or characterization of
prosthetic appliances;
G.Services and materials not meeting accepted standards of
optometric practice.
H.Services and materials resulting from the Member’s failure
to comply with professionally prescribed treatment.
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Consumer Health Insurance Plans 2014
Northern Virginia
I.Office infection control charges.
16.7 H
ospice Care Services
J.State or territorial taxes on vision services performed.
Benefits will not be provided for the following:
K.Special lens designs or coatings other than those
described herein.
A.Services, visits, medical equipment, or supplies not
authorized by CareFirst.
L.Replacement of lost and/or stolen eyewear.
B.F inancial and legal counseling.
M.Two pairs of eyeglasses in lieu of bifocals.
C.Any services for which a Qualified Hospice Care Program
does not customarily charge the patient or his or
her family.
N.Insurance of contact lenses.
16.4 Organ and Tissue Transplants
D.Reimbursement for volunteer services.
Benefits will not be provided for the following:
E.Chemotherapy or radiation therapy, unless used for
symptom control.
A.Non-human organs and their implantation. This exclusion
will not be used to deny Medically Necessary nonExperimental/Investigational skin grafts that are covered.
F.Meals on Wheels or other similar food service
arrangements.
B.Any hospital or professional charges related to any
accidental injury or medical condition of the donor of the
transplant material.
G.Rental or purchase of renal dialysis equipment and
supplies. Benefits for dialysis equipment and supplies are
available in Section 10, Medical Devices and Supplies.
C.Any charges related to transportation, lodging, and meals
unless authorized or approved by CareFirst.
16.8 M
ental Health and Substance Use Disorder Services
Coverage is not provided for:
D.Services for a Member who is an organ donor when the
recipient is not a Member.
A.Services solely on court order or as a condition of parole or
probation unless approved or authorized by the CareFirst
Medical Director.
E.Donor search services, including compatibility testing of
potential donors who are not immediate, blood related
family members.
F.Any service, supply, or device related to a transplant that is
not listed as a benefit.
16.5 I npatient Hospital Services
B.Cognitive rehabilitation therapy or coma
stimulation therapy.
C. Treatment of social maladjustment without symptoms of a
psychiatric disorder.
Coverage is not provided (or benefits are reduced, if
applicable) for the following:
D.Custodial Care.
A.Private room, unless Medically Necessary and/or
authorized or approved by CareFirst. If a private room
is not authorized or approved, the difference between
the charge for the private room and the charge for a
semiprivate room will not be covered.
F.Inpatient admissions for environmental changes.
E.Remedial or special education services.
16.9 Medical Devices and Supplies
Benefits will not be provided for purchase, rental, or repair of
the following:
B.Non-medical items and Convenience Items, such
as television and phone rentals, guest trays, and
laundry charges.
C.Except for covered Emergency Services and maternity care,
a health care facility admission or any portion of a health
care facility admission (other than Medically Necessary
Ancillary Services) that had not been approved by
CareFirst, whether or not services are Medically Necessary
and/or meet all other conditions for coverage.
D.Private duty nursing.
E.Care provided by interns, residents, or other hospital
employees that are billed separately from the hospital.
A. C
onvenience Items: Equipment that basically serves
comfort or convenience functions or is primarily for the
convenience of a person caring for a Member (e.g., an
exercycle or other physical fitness equipment, elevators,
hoyer lifts, and shower/bath bench).
B.Furniture items, movable objects or accessories that serve
as a place upon which to rest (people or things) or in which
things are placed or stored (e.g., chair or dresser).
C.Exercise equipment: Any device or object that serves as
a means for energetic physical action or exertion in order
to train, strengthen, or condition all or part of the human
body, (e.g., exercycle or other physical fitness equipment).
D. Institutional equipment
16.6 H
ome Health Care Services
A.Custodial Care, domestic, or housekeeping services.
Any device or appliance that is appropriate for use in a
medical facility and not appropriate for use in the home (e.g.,
parallel bars).
E. E
nvironmental control equipment: Equipment that can be
Coverage is not provided for:
B.Meals on Wheels or other similar food service
arrangements.
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Consumer Health Insurance Plans 2014
Northern Virginia
used for non-medical purposes, such as air conditioners,
humidifiers, or electric air cleaners. These items are
not covered even though they may be prescribed, in the
individual’s case, for a medical reason.
F.Eyeglasses or contact lenses, dental prostheses,
appliances, or hearing aids (including the examinations to
prescribe or fit hearing aids), except as otherwise provided
herein for cleft lip or cleft palate or both, or ectodermal
dysplasia or as stated in Section 1.21, Section 1.22.A.1,
Section 2, and Section 3.
G.Corrective shoes (unless required to be attached to a leg
brace), shoe lifts, or special shoe accessories or inserts.
H.Tinnitus maskers.
Experimental/
investigational services
The definition of Experimental Medical Care also
referenced as Experimental and Investigational Services is
as follows:
The term “experimental/ investigational” describes
services or supplies that are in the developmental stage
and are in the process of human or animal testing.
Services or supplies that do not meet all (5) of the
criteria listed below are deemed to be experimental and
investigational:
1. The technology* must have final approval
from the appropriate government regulatory
bodies; and
2. The scientific evidence must permit conclusions
concerning the effect of the technology on
health outcomes; and
3. The technology must improve the net health
outcome; and
4. The technology must be as beneficial as any
established alternatives; and
5. T he improvement must be attainable outside the
investigational setting.
*Technology includes drugs, devices, processes, systems or techniques.
48
Consumer Health Insurance Plans 2014
Northern Virginia
POLICY NUMBERS:
CAT: VA/CFBC/DB/HMO (1/14); VA/CFBC/EXC/HMO/CAT SOB
(1/14)
BluePreferred HSA Bronze $3,500: VA/CF/DB/BP (1/14); VA/
CF/EXC/BP/BRZ SOB (1/14)
BlueChoice HSA Bronze $4,000: VA/CFBC/DB/HMO (1/14);
VA/CFBC/EXC/HMO HSA/4000 BRZ SOB (1/14)
BlueChoice Plus Bronze $5,500: In-Network: VA/CFBC/DB/
BCOO/INN (1/14); VA/CFBC/EXC/BC+ IN/BRZ SOB (1/14). Outof-Network: VA/CF/DB/BCOO/OON (1/14); VA/CF/EXC/BC+
OON/BRZ SOB (1/14)
BlueChoice HSA Bronze $6,000: VA/CFBC/DB/HMO (1/14);
VA/CFBC/EXC/HMO HSA/6000 BRZ SOB (1/14)
BlueChoice HSA Silver $1,300: VA/CFBC/DB/HMO (1/14); VA/
CFBC/EXC/HMO HSA/SIL SOB (1/14)
BluePreferred HSA Silver $1,500: VA/CF/DB/BP/MSP (1/14);
VA/CF/EXC/BP/SIL SOB (1/14)
BlueChoice Silver $2,000: VA/CFBC/DB/HMO (1/14); VA/
CFBC/EXC/HMO/SIL SOB (1/14)
BlueChoice Plus Silver $2,000: In-Network: VA/CFBC/DB/
BCOO/INN (1/14); VA/CFBC/EXC/BC+ IN/SIL SOB (1/14). Outof-Network: VA/CF/DB/BCOO/OON (1/14); VA/CF/EXC/BC+
OON/SIL SOB (1/14)
CDS1107-1P (12/13)
BlueChoice Gold $0: VA/CFBC/DB/HMO (1/14); VA/CFBC/EXC/
HMO/GOLD 0 SOB (1/14)
BluePreferred Gold $500: VA/CF/DB/BP MSP (1/14; VA/CF/
EXC/BP/GOLD SOB (1/14)
BlueChoice Gold $1,000: VA/CFBC/DB/HMO (1/14); VA/CFBC/
EXC/HMO/GOLD 1000 SOB (1/14)
HealthyBlue Gold $1,500: In-Network: VA/CFBC/DB/HB/
INN (1/14); VA/CFBC/EXC/HB IN/GOLD SOB (1/14). Out-ofNetwork: VA/CF/DB/HB/OON (1/14); VA/CF/EXC/HB OON/
GOLD SOB (1/14)
HealthyBlue Platinum $0: In-Network: VA/CFBC/DB/HB/
INN (1/14); VA/CFBC/EXC/HB IN/PLAT SOB (1/14). Out-ofNetwork: VA/CF/DB/HB/OON (1/14); VA/CF/EXC/HB OON/
PLAT SOB (1/14)
BluePreferred Platinum $0: VA/CF/DB/BP (1/14); VA/CF/EXC/
BP/PLAT SOB (1/14)
AND ANY AMENDMENTS.
CareFirst BlueCross BlueShield
CareFirst BlueChoice, Inc.
10455 Mill Run Circle
Owings Mills, MD 21117-5559
www.carefirst.com
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
CDS1103-1P (9/13)