Common use of BlueCard® Program Clause in Contracts

BlueCard® Program. Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, CareFirst will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside the CareFirst service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • The billed charges for Covered Services; or • The negotiated price that the Host Blue makes available to CareFirst. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price CareFirst has used for your claim because they will not be applied after a claim has already been paid.

BlueCard® Program. Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, CareFirst will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating participating/PPO providers. When you receive covered healthcare services outside the CareFirst service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: •  The billed charges for Covered Servicescovered services; or •  The negotiated price that the Host Blue makes available to CareFirst. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price CareFirst has used for your claim because they will not be applied after a claim has already been paid.