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Your Benefit Guide New State Health Plan PPO for Employees Hired Or Rehired on Or After April 1, 2010

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Your Benefit Guide New State Health Plan PPO for Employees Hired Or Rehired on Or After April 1, 2010 Your Benefit Guide New State Health Plan PPO For employees hired or rehired on or after April 1, 2010 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. New State Health Plan PPO Welcome Welcome to the New State Health Plan PPO (NSHP PPO), a self-insured benefit plan administered by Blue Cross Blue Shield of Michigan (BCBSM) under the direction of the Michigan Civil Service Commission (MCSC). MCSC is responsible for implementing the NSHP PPO benefits and any future benefit changes. BCBSM will provide certain services on behalf of MCSC through an administrative-service-only contract. Your benefits are not insured with BCBSM, but will be paid from funds administered by MCSC. BCBSM is committed to providing you with excellent value and quality service and we want you to understand how your health coverage works. With this in mind, we have designed this booklet as an easy-to-read guide to your health program. Please read it and make sure you understand what health care services are covered and when you are responsible for out-of-pocket costs. If you have any questions about your NSHP PPO coverage after reading this booklet, please call the BCBSM State of Michigan Customer Service Center. The toll-free number is 800-843-4876 (TTY 800-240-3050). Our customer service representatives are available Monday through Friday from 8 a.m. to 6 p.m., excluding holidays. This document is not a contract. Rather, it is intended to be a summary of your NSHP PPO benefits. Every effort has been made to ensure the accuracy of this information. However, if statements in this description differ from the applicable coverage documents, the terms and conditions of those documents will prevail. Your Benefit Guide New State Health Plan PPO New State Health Plan PPO Table of Contents Blue Cross Blue Shield of Michigan contact information ....................................................................... 1 Calling ............................................................................................................................................... 1 Special servicing numbers .......................................................................................................... 1 Writing ............................................................................................................................................... 1 Visiting ............................................................................................................................................... 2 Additional BCBSM walk-in centers ............................................................................................. 2 Internet access .................................................................................................................................. 2 State of Michigan contact information ..................................................................................................... 2 Your Blue Cross Blue Shield of Michigan ID card ................................................................................... 3 Explanation of benefits payments ............................................................................................................ 4 Eligibility guidelines .................................................................................................................................... 5 Enrolling for coverage ............................................................................................................................. 5 Dual eligibility .......................................................................................................................................... 5 Dependent coverage .............................................................................................................................. 6 Continuing coverage for incapacitated children ............................................................................... 6 Coverage for spouses legally recognized under Michigan law ......................................................... 6 Coverage for Other Eligible Adult Individuals (OEAI) .............................................................................. 7 Enrolling an OEAI or an OEAI’s dependent children ......................................................................... 7 Dependent exclusions ....................................................................................................................... 7 Canceling dependent coverage ........................................................................................................ 7 Making coverage changes ...................................................................................................................... 8 Open enrollment period .................................................................................................................... 8 Address changes .............................................................................................................................. 8 Terminating coverage ............................................................................................................................. 9 Employees ........................................................................................................................................ 9 Dependent coverage ......................................................................................................................... 9 Continuing health care coverage ............................................................................................................ 9 Continuing coverage under COBRA ................................................................................................. 9 COBRA notification and application ............................................................................................... 10 Continuing coverage while on a leave of absence or layoff ............................................................ 10 Continuing coverage when you retire ............................................................................................. 10 Continuing coverage under BCBSM’s individual plans .................................................................. 10 Certificate of creditable coverage ......................................................................................................... 10 Value‑added programs............................................................................................................................. 11 BlueHealthConnection® ........................................................................................................................ 11 Healthcare AdvisorTM ............................................................................................................................ 11 Healthy Blue XtrasSM and Blue365SM ..................................................................................................... 11 Your Benefit Guide New State Health Plan PPO i New State Health Plan PPO Table of Contents Selecting providers when using your New State Health Plan PPO ..................................................... 12 Network providers ................................................................................................................................ 12 If your PPO physician leaves the network ...................................................................................... 12 Non-network participating providers .................................................................................................... 12 Participating providers .................................................................................................................... 12 Referrals to non-network providers ................................................................................................ 12 Non-PPO network hospitals and facilities ...................................................................................... 13 Nonparticipating providers ................................................................................................................... 13 Nonparticipating hospitals and facilities ............................................................................................... 13 Exceptions to the rule ........................................................................................................................... 13 BlueCard PPO program ........................................................................................................................ 13 Within the United States ................................................................................................................. 14 Around the world ............................................................................................................................. 14 Health care benefit summary .................................................................................................................. 15 Explanation of cost-share .................................................................................................................... 18 Out-of-pocket costs ........................................................................................................................ 18 Deductibles ..................................................................................................................................... 18 4th quarter carryover of in-network
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