Quesenberry Insurance Agency - Montana YouthCare, Blue Cross Blue Shield of Montana

Quesenberry Insurance Agency

Blue Cross Blue Shield Montana YouthCare

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Intro General Info Covered Services Participating Providers
Benefit Highlights Waiting Period Rates

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	Introduction The following information is a summary of benefits provided for Montana YouthCare. For a more comprehensive explanation of your benefits, please refer to your Member Contract. Montana YouthCare is available to children ages 3 months to 18 years.

General Information

Lifetime Maximum Benefit	$5 million except for specified services
Benefit Period	Calendar Year (January 1 through December 31)
Deductible (Applies to all services except well-child care and mammograms.)	$1,000 Individual
Co-payment	BCBSMT pays 75% of the allowable fee. Member pays 25% of the allowable fee
Maximum Member Liability *	$2,500 Individual
Eligibility	Children ages 3 months up to 18 years are eligible to apply for Montana YouthCare.

*Maximum Member Liability is the total amount you would pay in a single benefit period. Once the total of your copayments reaches this amount, Montana YouthCare pays 100% of the allowable fee on most covered services. Any amount you pay for balances owed to nonparticipating providers does not apply to the maximum member liability.

The Primary Care Benefit
Montana YouthCare is a traditional benefit plan with a $400 Primary Care benefit. The Primary Care benefit covers the first $400 in covered services by Blue Cross and Blue Shield of Montana (BCBSMT) participating professional providers. Once the Primary Care benefit maximum is reached, your annual deductible applies to covered services. Preventive services may not be covered if they are received after the Primary Care benefit maximum is met. Additional details are under the BENEFIT HIGHLIGHTS portion of this web page.

Primary Care Benefit

Covered Services

The first $400 in covered services provided by a participating professional provider is paid at 100% of the allowable fee. Once the $400 maximum is met, then the deductible applies to covered services.

•	Office calls, including any services and supplies provided during the office call.
•	Physical examinations
•	Visual examinations
•	Gynecological exam, including routine Pap smears
•	Immunization and vaccinations not covered under the Well-Child Care benefit
•	Diagnostic x-ray and laboratory services (performed in a professional provider's office).
•	Services provided for treatment of an accident, including charges from a facility.

The Blue Cross and Blue Shield of Montana Participating Provider Network...An Important Feature

BCBSMT Participating Providers
A BCBSMT Participating Provider is either an individual (e.g., physician, physical therapist, nurse practitioner) or a facility (e.g., a hospital) that has contracted with BCBSMT to provide services to our members.

Participating Providers accept the BCBSMT allowable fee plus any deductible and co-payment as payment in full for covered services. There is no billing to you over your co-payment and deductible amount. BCBSMT sends payments directly to Participating Providers.

Nonparticipating Providers
Nonparticipating providers have not contracted with BCBSMT. you will receive payment for claims received from a nonparticipating provider. These providers are under no obligation to send claims in for you. Most importantly, nonparticipating providers are subject to a differential. This means that BCBSMT reduces the allowable fee by the following amounts before we calculate your benefits:

Professional (e.g., doctors, physical therapists, nurse practitioners, radiologists) providers are subject to a 10% differential.
Facility (e.g., hospitals, hospice, home health) providers are subject to a 15% differential.

Nonparticipating providers can bill you the difference between the allowable fee and their total charge, including the differential, plus any deductible and co-payment potentially making your out-of-pocket significantly higher.

Finding Participating Providers
Fortunately, a majority of healthcare providers in Montana are participating providers. To find the participation status of a provider:

Check our on-line provider directory at www.bluecrossmontana.com
Contact Customer Service at 1.800.447.7828. Be sure to have your subscriber ID available when you call.

Out-Of-State and Worldwide Services
The "BlueCard Program" gives Blue Cross Blue Shield of Montana members access to Participating Provider arrangements between Blue Cross and Blue Shield Plans in other states and providers in those states. If you choose a Participating Provider in another state for health care services, you may have discounts and hold-harmless provisions (no balance billing except for your deductible and co-payment) available to you. These providers will file your claims for you. To find out-of-state or out-of-country Participating Providers, call the toll-free BlueCard Access line at 1.888.810.Blue (2583) or check via the Internet at www.bcbs.com/healthtravel/.

BENEFIT HIGHLIGHTS (For more detailed information, please refer to your Contract.)

Deductible Applies to all services
listed below unless otherwise indicated

BENEFIT	COVERED SERVICES
PARTICIPATING PHYSICIAN SERVICES	Once the $400 Primary care benefit is met, covered charges apply to the deductible.
INPATIENT HOSPITAL	Room and board, special care units, ancillary charges, and transplant coverage.
OUTPATIENT HOSPITAL	Accidental injury, x-ray and lab, surgery, chemotherapy, respiratory therapy, radiation therapy, medical emergency, surgicenter, oxygen and equipment for use in the home, blood transfusion services, ambulance, medical supplies for use outside the hospital, orthopedic devices.
TRANSPLANTS	$10,000 for ambulance or air transport to the transplant site per transplant. $25,000 maximum for organ procurement per transplant. $500,000 lifetime maximum.
HOSPICE	Inpatient and outpatient care, home care, skilled nursing, counseling and other support services. Deductible does not apply.
INDIVIDUAL THERAPIES	Physical, occupational, speech, and cardiac rehabilitation therapies. $2,000 maximum per benefit period, combined, for outpatient professional and facility charges.
REHABILITATION THERAPY	Lifetime maximum $100,000 per Member for inpatient and outpatient rehabilitation therapy services. Deductible does not apply.
CHIROPRACTIC SERVICES	Not a benefit.
DURABLE MEDICAL EQUIPMENT AND PROSTHESES	Initial purchase, replacements and repair. Prior authorization is recommended if charges are over $500. Deductible does not apply.
MENTAL ILLNESS	Note: Severe Mental Illness is processed under regular medical benefits.
OUTPATIENT	$2,000 maximum per benefit period.
INPATIENT	21 days for professional, hospital and/or freestanding inpatient facility charges, per member per benefit period, combined with chemical dependency. Partial hospitalization for mental illness is covered on a two-for-one-basis--two days of partial hospitalization equals one day of inpatient care. Inpatient day maximum applies. Plan notification is required.
CHEMICAL DEPENDENCY	$1,000 per 12 months for outpatient services. 21 days for professional and/or freestanding impatient facility charges, per member per benefit period, combined with mental illness. $4,000 maximum benefit per 24-month period. $8,000 lifetime maximum benefit.
WELL-CHILD CARE	Well-child exams at approximately the following ages: 1, 2, 4, 6, 9, 15, 18 and 24 months and routine immunizations through two years of age. Lab tests as recommended for routine well-child care between birth and two years of age. Deductible does not apply. Paid at 75% of the allowable fee.
MAMMOGRAMS	Paid at the actual charge or $70, whichever is less, for each covered mammogram. Deductible does not apply.
DIABETIC EDUCATION BENEFIT	Up to $250 per benefit period for outpatient services. Deductible does not apply.
PRESCRIPTIONS DRUGS	$100 deductible, separate from the medical deductible, then BCBSMT pays 75%.

Waiting Period for Preexisting Conditions is 12 months. If you had creditable coverage that was continuous within 63 days of your application for coverage, credit toward satisfaction of the waiting period will be provided for the period of time during which you have been previously covered by Creditable Coverage.

This information is only a summary of benefits. Benefits and general provisions described herein are subject to the terms of the Contract.

Dues Schedule for Montana YouthCare
Age	Monthly Premium Per Person
3 months - 5 years	$146.65
6 - 14	$114.46
15 - 18	$166.93

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Quesenberry Agency
1313 West Park Street, #9
Livingston, Montana 59047
(800) 784-6931 or (406) 222-6931
mike@quesenberryagency.com