The following information will explain the health care benefits available to you or your covered dependents and your financial responsibilities under the SuperCare1 plan.
Benefit Periods to Determine Deductibles
All benefit periods, except where noted, are based on a calendar year, beginning on January 1 of each year and ending on December 31 of that year. Deductible benefit periods are not calculated on the CMU plan year.
During each benefit period you are required to meet an individual deductible or a family deductible before payment will begin for covered services subject to the deductible. Only services covered under this plan may be applied toward the deductible.
- Carry-Over Provision – Eligible expenses incurred and applied toward your deductible during the last three months of any calendar year, will be applied toward the following year’s deductible.
- Common Accident Provision – If a common accident causes injury to two or more covered individuals in your family, a single deductible will be applied, in both the calendar year the accident occurs and the next following calendar year, to the combined covered charges incurred as a result of the common accident.
- Common Communicable Disease Provisions – If two or more covered individuals in your family contract the same communicable disease while residing in the same household and within three months of the date the first person contracted the disease, a single deductible will be applied, in both the calendar year in which the disease was contracted and the next following calendar year, to the combined covered charges incurred as a result of the common disease.
After you have met your deductible where required, the plan will pay 90% (except where noted) of the reasonable amount, for all covered services. The remaining 10% is your co-payment.
Family Stop-Loss – This plan has a special feature which limits your out-of-pocket co-payment expenses for each benefit period. Once you have paid $1,000 in co-payment expenses, the plan will pay 100% of the reasonable amount for covered services for the rest of the calendar year. The amount of co-payment liability does not include the cash deductible, charges which exceed specified benefit maximum amounts, charges which exceed a reasonable amount, prescription co-payments, or any charges which are not covered under this plan.
A “physician” is a doctor of medicine (MD) or osteopathy (DO) legally qualified and licensed to practice medicine and perform surgery at the time and place services are performed. An optometrist, dentist, podiatrist, or a doctor of chiropractic who is legally qualified and licensed to practice at the time and place services are performed is deemed to be a physician to the extent that the doctor renders services which he/she is legally qualified to perform.
A “physician” is also a person who is licensed under ACT 368 Public Acts of Michigan 1978, as a fully licensed psychologist at the time services are performed. In a state where there are no certification or licensure requirements, a psychologist is one who is recognized as such by the appropriate professional society at the time and place services are performed.
Approved Amounts and Reasonable Amounts
Blue Cross and Blue Shield covered charges, fees, and expenses will not include any amount in excess of what is determined as BCBSM’s approved amount. BCBSM covered charges, fees, and expenses will not include any amount in excess of what BCBSM determines to be reasonable.
Benefits under this plan are available for services which are determined by MESSA/BCBSM/BCS to be medically necessary. This includes services, supplies, or care provided by a hospital, doctor, or other heath care provider to diagnose or treat the patient’s medical condition, illness, or injury. Services must be consistent with accepted standards for good medical practice and must not be primarily for the convenience of the member, physician, or family.
Pre-Admission Review (PAR)
This is a provision of the plan which authorizes medically necessary admissions to the hospital. You or your doctor must request prior approval from MESSA for admissions to a hospital or other medical facility. If PAR guidelines are not followed you may have additional financial responsibilities in excess of the deductible and co-payment requirements.
Second Surgical Opinion
This is a provision of the plan which pays up to 100% of the reasonable amount towards the cost of a second surgical opinion when required by MESSA.
Medical Case Management (MCM)
This provision of the plan is designed to assist you if you are diagnosed with a catastrophic illness or injury. The program is tailored to meet your individual needs, based on your unique medical condition. Prior approval must be obtained from MESSA before benefits can begin. Eligibility for a termination of MCM benefits is made on a case-by-case basis in accordance with BCBSM/BCS’s criteria.