“Just Stay In”

1. “Just Stay In”

2. Less Coinsurance Less Out of Pocket Contracting Providers will write off anything they charge over out allowable amount. Contracting Providers will file the claim for the patient. Advantages of Using a Contracting Provider

3. Benefit Summary

4. Reasonable Allowance: The amount determined by Blue Cross and Blue Shield of Nebraska to be payable to noncontracting providers for a covered service. This amount will be one of the following amounts, not to exceed billed charges: a Maximum Benefit Amount, or an amount determined to be reasonable for similar service by similar providers in Nebraska or in another geographic area, or a percentage or other discounted amount based on the billed charge, or an amount otherwise determined to be reasonable by Blue Cross and Blue Shield of Nebraska. Reasonable Allowance

5. We are making this change for a couple of reasons. First and foremost, we want to continue to encourage our members to use Blue Cross and Blue Shield contracting providers. The strength of our provider networks remains a top advantage of Blue Cross and Blue Shield membership. And it’s never been easier to find a contracting provider wherever a member happens to be. Blue Cross and Blue Shield networks, both locally and nationally, are extremely robust. In Nebraska, 100% of nongovernmental acute care hospitals contract with Blue Cross and Blue Shield, along with 93% of physicians. Nationwide, Blue Cross and Blue Shield networks encompass 88% of doctors and 99% of hospitals. We are also making this change to continue to keep in line with industry provider reimbursement standards. Why are you lowering the amount you reimburse noncontracting providers?

6. Very few. Less than 3% of the claims we receive are for services from noncontracting providers. The vast majority of our members use contracting providers, and therefore get the maximum benefit from their Blue Cross and Blue Shield coverage. This change will not affect them. How many of your members will this change affect?

7. When a member uses a noncontracting provider, there is often increased deductible and coinsurance responsibility. In addition, noncontracting providers are able to bill and collect from our members any balance over our Reasonable benefit allowance—meaning that members will have to pay more out-of-pocket. Blue Cross and Blue Shield contracting providers, however, have agreed to hold our members “harmless,” meaning they can’t balance bill them for any charges over our Reasonable benefit allowance (not including deductible, coinsurance and copay amounts, and any charges for noncovered services, which are the member’s responsibility). What will be the impact of the change on someone who uses a noncontracting provider?

8. Our provider reimbursement practices are in keeping with industry standards. The new noncontracting reimbursement rates are comparable to what Blue Cross and Blue Shield of Nebraska would pay to a contracting PPO provider in the state of Nebraska. However, it’s to our members’ advantage to use contracting providers—they will most likely pay less in deductible and coinsurance and they can’t be balance billed for amounts over our benefit allowance (except for deductible, coinsurance and copay amounts, and any charges for noncovered services). Because of this, using a noncontracting provider could significantly increase an individual’s out of pocket. Contracting providers are also reimbursed directly, so the member doesn’t have to worry about that, either. What is your reimbursement to noncontracting providers?

9. Our benefit allowance to providers is based on the allowable charge for a covered service. Generally, the allowable charge for services by PPO and Participating hospitals, doctors and other health care professionals will be the contracted amount. The allowable charge for services by noncontracting hospitals, doctors and other health care professionals will generally be the lesser of the billed charge or the Reasonable Allowance for the service. How do you reimburse providers?

10. It’s easy. Our members have a few different ways of locating contracting providers. To locate providers in Nebraska, they can go to our website, www.bcbsne.com, and do an online search. They can also call our Customer Service Center, and a representative can mail a personalized paper directory. To locate contracting providers outside Nebraska, members can go to the Hospital and Doctor Finder section of the Blue Cross and Blue Shield Association’s website, www.bcbs.com (a link is provided on our website). They can also call the toll-free Provider Locator number, 1-800-810-BLUE. How can a member find out the contracting Blue Cross and Blue Shield providers in his/her area?