Blue Cross Idaho Medicaid Plus Summary Of Benefits

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Blue CrossIdaho Medicaid Plus2020Summary of BenefitsServing select counties in IdahoForm No. 19-005 (09-19)

For more information:MEMBERS1-800-289-7921TTY 1-800-377-1363ADDRESSPO Box 8266, Boise, ID 83707HOURS OF OPERATIONMonday through Fridayfrom 8 a.m. to 6 p.m. MSTFOR MORE INFORMATIONVisit us online at bcidaho.com/bcidahomedicaidplusEmail us at macs@bcidaho.comBlue Cross Idaho Medicaid Plus is an HMO health plan with an Idaho Medicaid contract. Enrollment in BlueCross Idaho Medicaid Plus depends on contract renewal and your eligibility as a dual eligible beneficiary. 2019 Blue Cross of Idaho Care Plus, Inc. (“Blue Cross of Idaho Care Plus”) is an Independent Licensee ofthe Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho Health Service, Inc.Esta información está disponible sin costo alguno en otros idiomas. Para información adicional, por favormarque a nuestro número de servicio al cliente 1-800-289-7921 de 8 a.m. a 6 p.m. MST Lunes – Viernes.Usuarios de TTY llamar al 1-800-377-1363.This document may be available in alternate formats such as audio and large print. Please call CustomerServiceif you need this in another format.2 SUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUS

This is a summary of drugand health services coveredby Blue Cross IdahoMedicaid Plus, from January 1to December 31, 2020.The benefit information provided is a summary ofwhat we cover and what you pay. It does not listevery service that we cover or list every limitation orexclusion. To get a complete list of services we cover,please request the “Evidence of Coverage.”BLUE CROSS IDAHO MEDICAID PLUS SUMMARY OF BENEFITS3

Who can join?To be an Idaho Medicaid Plus member, individuals must beeligible for and enrolled in both Medicare (Parts A, B andD) and Enhanced Medicaid. They must be over the age of21 and reside in the service area of select Idaho counties.Enrollment in Blue Cross Idaho Medicaid Plus depends onyour eligibility as a dual eligible beneficiary.Which providers can I use?Blue Cross Idaho Medicaid Plus (BCIMP) has a networkof providers that have an agreement with us to acceptour payment and any plan cost-sharing as payment infull. We have arranged for these providers to delivercovered services to members in our plan. The mostrecent list of providers is available on our website atbcidaho.com/FindAProvider.If you use providers that are not in our network, the planmay not pay for these services.What do we cover?As an Idaho Medicaid health plan, Blue Cross IdahoMedicaid Plus must cover all services covered by IdahoMedicaid.What is the monthlyplan premium?You pay nothing because of your Medicaid eligibility.What prescriptions does thisplan cover?This plan does not cover your Medicare Part D drugs.Some prescription drugs are covered for you under yourMedicaid benefits. The plan has a list of covered drugs.We call it the “Medicaid Drug List” for short. It tells whichprescription drugs are covered under the benefits includedin Blue Cross Idaho Medicaid Plus.The Medicaid Drug List helps you find which drugs arecovered by Medicaid. To get the most complete and currentinformation about which drugs are covered, you can visit theplan’s website at bcidaho.com/bcidahomedicaidplus or callCustomer Service at 1-800-289-7921.4SUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUS

How do I use the Summary of Benefits?Review the Medicaid benefits that start on page 6.To know more about the coverage and costs associated with thisplan, review your Evidence of Coverage or call Customer Service at1-800-289-7921.BLUE CROSS IDAHO MEDICAID PLUSPremium and BenefitsMonthly Plan PremiumMedical DeductibleMaximum Out-ofPocket Responsibility(does not includeprescription drugs)In-Network Cost SharingYou pay nothing because of your Medicaid eligibility.This plan does not have a medical deductible.You pay nothing.In this plan, you may pay nothing for some services, depending on your level of IdahoMedicaid eligibility. 3,000 for services you receive from in-network providers for Medicare-coveredservices.Contact the plan for details regarding cost sharing for Medicaid services that do nothave a yearly limit.Emergency CareYou pay nothing.Urgently NeededServicesCost sharing for necessary urgently needed servicesfurnished out-of-network is the same as for suchservices furnished in-network.You pay nothing.BLUE CROSS IDAHO MEDICAID PLUS) SUMMARY OF BENEFITS5

YOUR BENEFITSMedicare is your primary insurance. Blue Cross of IdahoMedicaid Plus is your secondary insurance. Medicare willpay for most of your covered services first. Blue Cross ofIdaho will pay covered Medicaid services that are left.This includes your Medicare coinsurance and deductible.Blue Cross of Idaho Medicaid Plus covers all medicallynecessary Medicaid benefits.Blue Cross Idaho Medicaid Plus plan must provideevery prospective enrollee, prior to enrollment, acomprehensive written statement that describes: The benefits that the individual is entitled to underTitle XIX (Medicaid) The cost-sharing protections that the individual isentitled to under Title XIX (Medicaid) A description of the benefits and cost-sharingprotections that are covered under Blue Cross IdahoMedicaid PlusCoordination of servicesMedicaid currently covers coordination of services forthose who are unable, or have limited ability to gain accessor coordinate or maintain services on their own or throughother means. Blue Cross Idaho Medicaid Plus coveragereplaces the State of Idaho Medicaid coverage, exceptfor the Medicaid services listed below, which are provideddirectly by the State of Idaho Medicaid program: Medicaid Dental ServicesNon-emergency Medical TransportationDevelopmental Disability ServicesIntermediate Care Facility ServicesFor information regarding these Medicaid-providedservices, call the Idaho Care Line at 211 or visithealthandwelfare.idaho.gov.6SUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUSThe following pages show benefits and services providedby the State of Idaho Medicaid program and Blue CrossIdaho Medicaid Plus.

SUMMARY OF MEDICAID-COVERED BENEFITSThe benefits described below are covered by Medicaid.What you pay for covered services may depend on your level of Medicaid eligibility.BenefitsBehavioralHealth CaseManagementServicesBlue Cross Idaho Medicaid PlusIn-Network Cost SharingWhat You PayNo prior authorization is required. You pay nothing.In addition to the currentMedicare benefits, Blue CrossIdaho Medicaid Plus covers casemanagement that includes thefollowing assistance: Assessment and periodicreassessment of an individualto determine the need for anymedical, educational, social orother services.Care Care coordination is covered forCoordination all participants.You pay nothing.You will have a care coordinatorassigned as your primary contactwho helps coordinate your care.They will work with your doctor,caregivers and family members toassist in getting you services youmay need.Inpatient CareInpatient Mental 0 copay for mental healthcareHealth Care servicesIn-NetworkYou get up to 190 days of inpatient psychiatric hospitalcare in a lifetime. Inpatient psychiatric hospital servicescount toward the 190-day lifetime limitation only ifcertain conditions are met. This limitation does notapply to inpatient psychiatric services furnished in ageneral hospital. 0 annual service category deductible 0 copayExcept in an emergency, your doctor must tell the planthat you are going to be admitted to the hospital.Long-Term Care ServicesNursing Facility A supervised nursing serviceServices provided on a daily basis by alicensed care facility.The service may help withrehabilitative care and assistancewith daily living needs.You may be responsible for a cost share for nursing facilityservices, after the Medicare nursing facility benefit isused. The Idaho Department of Health and Welfare willdetermine if your income and certain expenses requireyou to have a patient liability.Continued next page.BLUE CROSS IDAHO MEDICAID PLUS SUMMARY OF BENEFITS7

SUMMARY OF MEDICAID-COVEREDBENEFITS cont.BenefitsBlue Cross Idaho Medicaid PlusPersonal Care Medically focused services forServices those with special physical orfunctional needs.CommunityBasedOutpatientBehavioralHealth ServicesDurable MedicalEquipment(Includeswheelchairs,oxygen, etc.)You pay nothing.Prior authorization may berequired.In addition to current Medicarebenefits, Blue Cross IdahoMedicaid Plus will also cover: Treatment planning Psychotherapy Partial care treatment Behavior health nursing Drug screening Peer support/Family supportYou pay nothing.Prior authorization is required foritems and rentals that exceed 1,000.You pay nothing.A valid prescription from yourphysician is required.Family Planning Blue Cross Idaho Medicaid PlusServices will cover: Basic fertility screenings Contraceptives Birth control pills Condoms Diaphragms Emergency contraception Injectable methods IUD NuvaRing Counseling and education onbirth control, sexual health andpregnancy planning Sterilization services A valid prescription from yourphysician is required for over-the counter items8In-Network Cost SharingWhat You PaySUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUSYou pay nothing.

AGED & DISABLED WAIVER SERVICES*Coverage of the benefits described depends upon your level of Medicaid eligibility. No matter whatyour level of Medicaid eligibility is, Blue Cross Idaho Medicaid Plus will cover the benefits describedin the Medicaid-Covered Benefits section of the Summary of Benefits. If you have questions about yourMedicaid eligibility and what benefits you are entitled to, call Customer Service at 1-800-289-7921 orTTY 1-800-377-1363, 8 a.m. to 6 p.m. MST, Monday through Friday.Not all participants will qualify for theses services.BenefitsBlue Cross Idaho Medicaid PlusAdult Day Health General InformationServices*A supervised service is usually for four or more hours per day ona regular basis. It is provided outside the home in a communitysetting and includes activities of daily living.Adult day health services provided under this waiver will notinclude room and board payments.Type of ServiceA&D Waiver. Authorization rules may apply.In-NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Adult Residential General InformationCare Services* A range of services provided in a homelike setting that includesresidential care or assisted living facilities and certified familyhomes.Payment is not made for the cost of room and board, includingthe cost of building maintenance, upkeep and improvement.Type of ServiceA&D Waiver. Authorization rules may apply.In-NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Continued next page.BLUE CROSS IDAHO MEDICAID PLUS SUMMARY OF BENEFITS9

BenefitsBlue Cross Idaho Medicaid PlusAttendant Care General InformationServices* Services that involve tasks dealing with functional needs andaccommodating those needs for long-term maintenance,supportive care or activities of daily living.These services may include personal assistance that can be doneby unlicensed persons. Services are based on personal abilitiesand limitations, regardless of age, medical diagnosis or othercategory of disability.This assistance may take the form of performing a task for themember or helping the member to perform a task.Type of ServiceA&D Waiver. Authorization rules may apply.In-NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Chore Services* General InformationServices necessary to maintain the functional use of the home, or toprovide a clean, sanitary, and safe environment including: Washing windows Moving heavy furniture Shoveling snow Chopping wood for primary source of heat Intermittent assistance such as yard work, minor home repair, heavyhousework, sidewalk maintenance and trash removalType of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Companion General InformationServices* Non-medical care, supervision and socialization given to a functionallyimpaired adult.These are in-home services to ensure the safety and well-being of aperson who cannot be left alone because of their health, or inability torespond in an emergency situation.The service provider may help with occasional assistance with toileting,personal hygiene, dressing and other activities of daily living.Providers may also perform light housekeeping tasks.The primary responsibility is to provide companionship and be there incase they are needed.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.10SUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUS

BenefitsBlue Cross Idaho Medicaid PlusConsultation General InformationServices* Services are provided by a personal assistance agency to a memberor family member to increase their skills as an employer or manager oftheir own care.These services attempt to reach the highest level of independence andself-reliance possible by gaining a better understanding of the needs ofthe enrollee and the role of the caregiver.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Day Habilitation General InformationServices* Services that help with improvement in self-help, socialization, andadaptive skills that take place outside the home. Services will focus onenabling the enrollee to get or maintain his or her maximum functionallevel and will be coordinated with any physical therapy, occupationaltherapy or speech-language pathology services.Services will normally be furnished four or more hours per day on aregular basis, for one or more days per week.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Environmental General InformationAccessibility These services include minor housing modifications that are necessaryAdaptations* to enable greater independence in the home.Without these modifications, the enrollee would requireinstitutionalization or pose a risk to their health and safety.Type of ServiceA&D Waiver. Authorization rules may apply.In Network 0 cost share for Medicaid-covered environmental accessibilityadaptationsHome Delivered General InformationMeals* Meals delivered to the enrollee’s home to promote good nutrition.One or two meals per day may be provided to those who are alone forsignificant parts of the day, have no caregiver for extended periods oftime, or are unable to make a meal without assistance.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Continued next page.BLUE CROSS IDAHO MEDICAID PLUS SUMMARY OF BENEFITS11

BenefitsBlue Cross Idaho Medicaid PlusHomemaker General InformationServices* Services helping or assisting with the following tasks: Laundry Essential errands Meal preparation Other routine housekeeping duties if there is no one else in thehousehold capable of performing these tasksType of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Non-Medical General InformationTransportation* Transportation that allows an enrollee to gain access to waiver and othercommunity services and resources for non-medical reasons.Type of ServiceA&D Waiver. Authorization rules may apply.In Network 0 cost share for Medicaid-covered non-medical eral InformationAn electronic device that calls for help in an emergency. You may weara portable “help” button to allow for mobility. The response center isstaffed by trained professionals.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.Residential General InformationHabilitation These services and supports are designed to assist the enrollees toServices* reside successfully in their own homes, with their families or in certifiedfamily homes.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department ofHealth and Welfare.12SUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUS

BenefitsBlue Cross Idaho Medicaid PlusRespite Care General InformationServices* This service provides short-term breaks for non-paid caregivers. The caregiveror enrollee is responsible for selecting, training and directing the provider.While receiving respite care services, the enrollee cannot receive otherservices that are duplicative in nature.Respite care services do not include room and board payments. Respite careservices may be provided in the enrollee’s residence, a certified family home,a developmental disabilities agency, a residential-assisted living facility or anadult-day health facility.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department of Healthand Welfare.Skilled Nursing General InformationServices* Includes irregular or continuous supervision, training or skilled care.These services are not appropriate if they are less cost effective than a homehealth visit.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department of Health andWelfare.Specialized General InformationMedical Equipment and supplies that include:Equipment and Devices, controls or appliances that help with daily livingSupplies* Items necessary for life support or ancillary supplies and equipmentnecessary for the proper functioning of such items Durable and non-durable medical equipmentType of ServiceA&D Waiver. Authorization rules may apply.In Network 0 cost share for Medicaid-covered specialized medical equipmentand suppliesSupported General InformationEmployment* For individuals with the most severe disabilities when competitiveemployment has not traditionally occurred, or has been interrupted orintermittent as a result of a severe disability.Because of the nature and severity of their disability, these individuals needintensive supported employment services or extended services in order toperform such work.Type of ServiceA&D Waiver. Authorization rules may apply.In NetworkYour cost share, if any, will be determined by Idaho Department of Healthand Welfare.BLUE CROSS IDAHO MEDICAID PLUS SUMMARY OF BENEFITS13

DISCRIMINATION IS AGAINST THE LAWBlue Cross of Idaho and Blue Cross of Idaho Care Plus,Inc, (collectively referred to as Blue Cross of Idaho)complies with applicable Federal civil rights laws anddoes not discriminate on the basis of race, color, nationalorigin, age, disability or sex. Blue Cross of Idaho doesnot exclude people or treat them differently because ofrace, color, national origin, age, disability or sex.Blue Cross of Idaho: Provides free aids and services to people withdisabilities to communicate effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (largeprint, audio, accessible electronic formats, otherformats) Provides free language services to people whoseprimary language is not English, such as:o Qualified interpreterso Information written in other languagesIf you need these services, contact Blue Cross of IdahoCustomer Service Department. Call 1-800-627-1188(TTY: 1-800-377-1363), or call the customer servicephone number on the back of your card. If you believethat Blue Cross of Idaho has failed to provide theseservices or discriminated in another way on the basis ofrace, color, national origin, age, disability or sex, you canfile a grievance with Blue Cross of Idaho’s Grievancesand Appeals Department at:Manager, Grievances and Appeals3000 E. Pine Ave., Meridian, ID 83642Telephone: 1-800-274-4018 ext. 3838Fax: 208-331-7493Email: grievances&appeals@bcidaho.comTTY: 1-800-377-1363You can file a grievance in person or by mail, fax,or email. If you need help filing a grievance, ourGrievances and Appeals team is available to help you.You can also file a civil rights complaint with the U.S.Department of Health and Human Services, Office forCivil Rights electronically through the Office for CivilRights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:U.S. Department of Health and Human Services, 200Independence Avenue SW., Room 509F, HHH Building,Washington, DC 20201, 1-800-368-1019, 800-537-7697(TTY). Complaint forms are available TENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian,Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, areavailable to you. Call 1-800-627-1188 (TTY: 1-800-377-1363).Arabic: فإن خدمات المساعدة اللغوية ، إذا كنت تتحدث العربية اذكر اللغة : مملحوظة (رقم هاتف الصم 1-800-627-1188 اتصل برقم . تتوافر لك بالمجان .(1-800-377-1363: والبكم Bantu:ICITONDERWA: Nimba uvuga Ikirundi, uzohabwaserivisi zo gufasha mu ndimi, ku buntu. Woterefona1-800-627-1188 (TTY: ��。請致電 1-800-627-1188(TTY:1-800-3771363)。Farsi: تسهيالت زبانی بصورت رايگان ، اگر به زبان فارسی گفتگو می کنيد : توجه 1-800-627-1188 با . برای شما فراهم می باشد . ) تماس بگيريد TTY: 1-800-377-1363(French:ATTENTION: Si vous parlez français, des servicesd’aide linguistique vous sont proposés gratuitement.Appelez le 1-800-627-1188 (ATS : 1-800-377-1363).German:ACHTUNG: Wenn Sie Deutsch sprechen, stehenIhnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Rufnummer: 1-800-627-1188 (TTY: ��さい。Korean:주의: 한국어를 사용하시는 경우, 언어 지원 서비스를무료로 이용하실 수 있습니다. 1-800-627-1188 (TTY:1-800-377-1363)번으로 전화해 주십시오.14SUMMARY OF BENEFITS BLUE CROSS IDAHO MEDICAID PLUSNepali:ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंकोनिम्ति भाषा सहायता सेवाहरू निःशुल्क रूपमा उपलब्ध छ। फोन गर्नुहोस् 1-800-627-1188 (टिटिवाइ: 1-800-3771363) ।Romanian:ATENȚIE: Dacă vorbiți limba română, vă stau ladispoziție servicii de asistență lingvistică, gratuit.Sunați la 1-800-627-1188 (TTY: 1-800-377-1363).Russian:ВНИМАНИЕ: Если вы говорите на русском языке, товам доступны бесплатные услуги перевода. Звоните1-800-627-1188 (телетайп: 1-800-377-1363).Serbo-Croatian:OBAVJEŠTENJE: Ako govorite srpsko-hrvatski,usluge jezičke pomoći dostupne su vam besplatno.Nazovite 1-800-627-1188 (TTY- Telefon za osobe saoštećenim govorom ili sluhom: 1-800-377-1363).Spanish:ATENCIÓN: si habla español, tiene a su disposiciónservicios gratuitos de asistencia lingüística. Llame al1-800-627-1188 (TTY: 1-800-377-1363).Tagalog:PAUNAWA: Kung nagsasalita ka ng Tagalog, maaarikang gumamit ng mga serbisyo ng tulong sa wikanang walang bayad. Tumawag sa 1-800-627-1188(TTY: 1-800-377-1363).Vietnamese:CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngônngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188(TTY: 1-800-377-1363).Form No. 3-1187 (08-19)

BLUE CROSS IDAHO MEDICAID PLUS SUMMARY OF BENEFITS15

3000 East Pine Avenue Meridian, Idaho 83642-5995PO Box 8266 Boise, Idaho 83707-2406We are available Monday through Friday,8 a.m. - 6 p.m. MST1-800-289-7921 TTY 1-800-377-1363Visit bcidaho.com/bcidahomedicaidplus 2019 by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross andBlue Shield Association, with services provided by Blue Cross of Idaho

your level of Medicaid eligibility is, Blue Cross Idaho Medicaid Plus will cover the beneits described in the Medicaid-Covered Beneits section of the Summary of Beneits. If you have questions about your Medicaid eligibility and what beneits you ar

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(Corporate Officer). Full day event, get a hamper and 10 via expenses for drinks. Andrew Tamplin is doing a morning session, breakout rooms including a live band, quiz, virtual Christmas choir, guided meditation/yoga, virtual pub, pets corner, creative room (cooking workshops, magic tricks, circus skills). Dec 11th.