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Blue Cross of Idaho Healthcare Coverage

Provider Administrative Policy

Policy Date
February 2008
Revised/February 2014
Provider Type(s)
All Providers  


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Blue Cross of Idaho Healthcare Coverage

Traditional (fee-for-service)
Blue Cross of Idaho offers non-group, small group and large group traditional coverage plans. Business BlueSM, BlueWorksSM are traditional products that provide benefits for members, when they visit a covered provider. Blue Cross of Idaho bases provider reimbursement on our maximum allowances and any coinsurance and deductible amounts that apply.

Managed Care
Blue Cross of Idaho small and large group managed care plans include HMOBlue®, Blue ValueSM and HSA BlueSM POS. These plans have a point-of-service (POS) benefit, in- and out-of network benefit, require members to select a primary care physician (PCP) and allow employers to choose from a variety of copayments, deductibles and coinsurance depending on the selected plan.

The POS feature allows members to visit non-contracting providers or coordinate care through their PCP; however, Blue Cross of Idaho applies out-of-network benefits at a reduced level, subject to deductibles and coinsurance.

Blue Cross of Idaho also offers ConnectedCareSM plans. ConnectedCareSM plans are built around smaller networks of healthcare provider organizations with a goal toward improving quality care and treatment outcomes. Designed to improve the delivery and efficiency of healthcare by coordinating services through a primary care physician, ConnectedCare provides members coverage for proactive, quality care at an affordable price.

Preferred Provider Organization (PPO)
PPO products typically offer members lower premiums and out-of-pocket expenses if they visit contracting healthcare providers. Blue Cross of Idaho non-group, small group and large group PPO plans include Preferred Blue®, Access BlueSM, HSA BlueSM, BlueCare® PPO, Essential BlueSM PPO, Essential BlueSM Plus PPO, Simply Blue, Short Term PPO and the Federal Employee Plan (FEP).

Preferred Blue, BlueCare PPO, Access Blue, Essential Blue Plus enrollees pay a copayment for physician services during office visits. Other physician services, such as diagnostic lab, x-ray, surgical trays, etc., are subject to deductible and coinsurance. Essential Blue offers basic hospital and surgical coverage. There are no benefits for outpatient services, such as physician office visits, diagnostic services or prescription medications, except as specifically listed in the policy.

HSA Blue meets federal health savings account (HSA) qualifications. Providers should only submit claims to Blue Cross of Idaho if the patient presents a Blue Cross of Idaho insurance card. If you have additional questions regarding HSAs please visit the federal government's Web site, and select Health Savings Accounts.

BlueChoice is our Federal Employee Program (FEP) PPO plan. We consider BlueChoice providers for our Federal Employee PPO plan preferred providers in Blue Cross of Idaho's PPO network.

Medicare Beneficiary Plans
Blue Cross of Idaho Medicare supplements offer individual coverage secondary to Medicare. Benefits vary with each plan, but in general, Blue Cross of Idaho reimburses providers for covered services after Medicare pays.

The following is a brief description of the five plans, effective June 1, 2010.

  • Plan A covers basic benefits (except the Medicare Part A and B deductible) including Medicare Part A hospital copayments, Part A hospice coinsurance, and the 20 percent balance on Medicare Part B approved charges.
  • Plan F covers the basic benefits described above, plus Medicare Part A and B deductibles, skilled nursing copayments, foreign travel emergencies, and 100 percent of Medicare Part B excess charges up to the limiting charge.
  • Plan K -covers 50% of basic benefits described in Plan A except Plan K covers 100% of the Inpatient Hospital Part A coinsurance, plus 50% of Medicare Part A deductible, 50% skilled nursing copayments, 100% Preventive Part B Coinsurance, and enrollees share costs until a yearly Out-of-Pocket Limit is met. Once the enrollee meets the Out-of-Pocket amount, Plan K pays 100% of the Medicare coinsurance for the remaining calendar year.
  • Plan M -covers the basic benefits described in Plan A, plus 50% of Medicare Part A deductible, skilled nursing copayments, and foreign travel emergencies,
  • Plan N -covers the basic benefits described in Plan A except enrollees pay a copayment for physician office visits and emergency room visits, plus Medicare Part A deductible, skilled nursing copayments, and foreign travel emergencies.

True Blue® HMO
True Blue is a Medicare Advantage plan we offer to Medicare beneficiaries through a contract with Centers for Medicare and Medicaid Services (CMS). True Blue members receive enhanced benefits over original Medicare such as vision and hearing aid benefits, preventive dental services, annual physical exams and a travel benefit with low copayments.

Secure BlueSM PPO
Secure Blue is a Medicare Advantage plan that Blue Cross offers to Medicare beneficiaries through a contract with the Centers for Medicare and Medicaid Services. When members use Secure Blue in-network providers, their benefits include low, fixed copayments for routine and preventative care and low coinsurance for most other covered healthcare services.

Policy History

Date Action Reason
February 2014 Revised Revised and moved ACO language
June 2012 Revised Added ACO Language
January 2012 Revised Removed product no longer marketed.
May 2011 Revised Removed "Basic" per BCBSA requirement
September 2011 Revised Removed products no longer marketed
January 2010 Revised Removed Personal Blue, Chamber Blue, Essential Blue for Chambers, and Essential Blue for groups
August 2010 Revised Additions and revisions to Medicare supplement policies
July 2009 Revised Health Living plan added, out-of-network comments added.

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