INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. Thank you for choosing Blue Cross & Blue Shield of Rhode Island (BCBSRI) for your healthcare coverage. We appreciate the trust you’ve placed in us and want to help you make the most of your health plan. In this Subscriber Agreement (agreement), you’ll find valuable information about your plan, including: • how your health coverage works; • how BCBSRI processes claims for the health services you receive; • your rights and responsibilities as a BCBSRI member; • BCBSRI’s rights and responsibilities; and • tools and programs to help you stay healthy and save money. We encourage you to read this agreement to learn about all the advantages of being a BCBSRI member. How to Use This Agreement Below are some helpful tips on how to find what you need in this agreement. • As a member, you are responsible for understanding the benefits to which you are entitled under this agreement and the rules you must follow to receive those benefits. • The Table of Contents will help you find the order of the sections as they appear in the agreement. • The Summary of Benefits, included in this agreement, shows the amount you pay out of your own pocket. • Important contact information, such as, telephone numbers, addresses, and websites are located at the end of this document. • Some words and phrases used in this agreement are in italics. This means that the words or phrases have a special meaning as they relate to your healthcare coverage. Please see Section 8 for definitions of these words. • When we use the words “we,” “us,” and “our,” we are referring to BCBSRI. When we use the words “you” and “your” we are referring to the enrolled subscriber and/or member. These words are also defined in the Glossary. • Many sections of this document are related to other sections. You may need to reference more than one section to find the information you need.
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 13 About This Agreement 14
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 11 How to Use This Agreement 11 Contact Us If You Have a Question 11 Your Member Identification Card 12 Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers 12 Programs to Keep You Healthy 12 About This Agreement 14 SECTION 2: ELIGIBILITY 15 Who Is an Eligible Person 15 When Your Coverage Begins 16 Coverage for Members Who Are Hospitalized on Their Effective Date 18 How to Add or Remove Coverage for Family Members 18 When Your Coverage Ends 18 Continuation of Coverage 19 SECTION 3: COVERED HEALTHCARE SERVICES 21 Ambulance Services 21 Autism Services 22 Behavioral Health Services 23 Cardiac Rehabilitation 24 Chiropractic Services 24 Dental Services 24 Dialysis Services 28 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 28 EARLY INTERVENTION SERVICES (EIS) 30 Education - Asthma 31 Emergency Room Services 31 Experimental or Investigational Services 31 Gender Reassignment Services 32 Hearing Services 32 Home Health Care 32 Hospice Care 33 Human Leukocyte Antigen Testing 33 Infertility Services 33 Infusion Therapy 33 Inpatient Services 34 Mastectomy Services 34 Observation Services 35 OFFICE VISITS (OTHER THAN PREVENTIVE CARE SERVICES) 35 Organ Transplants 35 Physical/Occupational Therapy 36 Pregnancy and Maternity Services 36 Prescription Drugs 37 Preventive Care and Early Detection Services 41 Private Duty Nursing Services 43 Radiation Therapy/Chemotherapy Services 43 Respiratory Therapy 43 Skilled Care in a Nursing Facility 43 Speech Therapy 43 Surgery Services 44 Telemedicine Services 45 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 45 Urgent Care 46 Vision Care Services 47 SECTION 4: EXCLUSIONS 49 Air and Water Ambulance Services 49 Behavioral Health Services 49 Chiropractic Services 49 Dental Services 49 Dialysis Services 50 Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and HAIR PROSTHESIS (WIGS) 50 Experimental or Investigational Services 51 Gender Reassignment Services 51 Hearing Services 51 Home Health Care 51 Infertility Services 51 Inpatient Services 51 Organ Transplants 51 Pregnancy and Maternity Services 52 Prescription Drugs and Diabetic Equipment or Supplies 52 Private Duty Nursing Services 53 Surgery Services 53 TESTS, LABS, AND IMAGING AND X-RAYS (DIAGNOSTIC) 54 Therapies 54 Vision Care Services 55 Providers 55 Services Available or Provided from Other Sources 55 All Other Exclusions 56 SECTION 5: ...
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. Thank you for choosing Blue Cross & Blue Shield of Rhode Island (BCBSRI) for your dental coverage. We appreciate the trust you’ve placed in us and want to help you make the most of your dental plan. In this Subscriber Agreement (agreement), you’ll find valuable information about your plan, including: • how your dental coverage works; • how BCBSRI processes claims for the dental services you receive; • your rights and responsibilities as a BCBSRI member; • BCBSRI’s rights and responsibilities. We encourage you to read this agreement to learn about all the advantages of being a BCBSRI member. How to Use This Agreement Below are some helpful tips on how to find what you need in this agreement. • As a member, you are responsible for understanding the benefits to which you are entitled under this agreement and the rules you must follow to receive those benefits. • The Table of Contents will help you find the order of the sections as they appear in the agreement. • The Summary of Benefits, included in this agreement, shows the amount you pay out of your own pocket.
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 4 How to Use This Agreement 4 Contact Us If You Have a Question 4 Your Member Identification Card 5 Your Guide to Selecting a Dentist 5 About This Agreement 6
INTRODUCTION TO YOUR SUBSCRIBER AGREEMENT. 9 How to Use This Agreement 9 Contact Us If You Have a Question 9 Your Member Identification Card 10 Your Guide to Selecting a Dentist 10 Programs to Keep You Healthy 10 About This Agreement 11
