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Health Options

Members can choose from Preferred Provider Organization (PPO) options or a Consumer-driven Health Plan (CDHP) option.

Each option has different cost sharing—your out-of-pocket costs for copays, deductibles, coinsurance and out-of-pocket maximums.

For all options, you won’t pay anything for eligible preventive care — it’s covered at 100% as long as you use an in-network provider.

Members can choose from the following health insurance options (if you qualify):

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All healthcare options cover the same services and treatments, but medical necessity decisions may vary by network carrier. Below is information about costs and how plan options work.

For more detailed information, member handbooks are available on the Benefits Administration website.

 

CDHP

Consumer-driven health plan, a type of medical insurance or plan that generally has a higher deductible and lower monthly premiums. Typically, you take responsibility for covering your health care expenses until your deductible is met. Once you meet your deductible, coinsurance applies up to the out-of-pocket maximum

Deductible

A fixed dollar amount that you must pay each year before the plan pays for services that require coinsurance.

Coinsurance

Some services require that you pay coinsurance after you meet a deductible.  Coinsurance is the percentage of a dollar amount that you pay for certain services. Unlike a fixed copay, coinsurance varies, depending on the total charge for a service.

Cost sharing

The share of costs covered by your insurance that you pay out of your own pocket.

Copay

A flat dollar amount you must pay each year before the plan pays for services like doctor’s office visits and prescriptions.

Network

A group of doctors, hospitals and other healthcare providers contracted with a health insurance carrier to provide services to plan members for set fees.

Out-of-Pocket Maximum (OOPM)

The out-of-pocket maximum is the most you will pay for your copays and coinsurance each year. Does not include premiums. Once you reach your out-of-pocket maximum, the plan pays 100% of covered medical expenses for the rest of the year. There are separate maximums for in-network and out-of-network services.

In-Network vs. Out-of-Network Providers

You can see any doctor or go to any healthcare facility you want. However, if you use an “in-network” provider, you will always pay less. That’s because an in-network provider agrees to provide services to our members at discounted rates. Broad networks of doctors and hospitals are available.

Plan

Provides or pays a portion of the cost of medical care and determines how much you pay in premiums, copays and coinsurance.

PPO

Preferred provider organization, gives plan participants access to a network of doctors and facilities that charge pre-negotiated (and typically discounted) fees for the services they provide to members. Plan participants may self-refer to any doctor or specialist in the network. The benefit level covered through the plan typically depends on whether the member visits an in-network or out-of-network provider when seeking care.

Network Options

You have three insurance networks of doctors and facilities to choose from:

All three networks have providers (doctors and facilities) available across Tennessee. Doctors and facilities in the networks can change. Check the networks carefully for your preferred doctor(s) or hospital when making your selection.

Medical Service Appeals

If you are a plan member in disagreement with a decision or the way a claim has been paid or processed, you or your authorized representative should first call member service to discuss the issue:  BlueCross BlueShield of Tennessee 800-558-6213 or Cigna 800-997-1617.

First Level Appeal — If the issue cannot be resolved through member service, you or your authorized representative may file a formal request for internal review or member grievance by completing the appropriate form or as otherwise instructed. All requests must be filed within the specified timeframes. When your request for review or member grievance is received, you will get an acknowledgement letter advising you what to expect regarding the processing of your grievance. Once a determination is made, you will be notified in writing and advised of any further appeal options including information about how to request an external review of your case from an independent review organization (IRO).

Second Level Appeal — If the first level appeal is denied, you or your authorized representative may file a second formal request for internal review or member grievance by completing the appropriate form or as otherwise instructed. All requests must be filed within the specified timeframes. When your request for review or member grievance is received, you will get an acknowledgement letter advising you what to expect regarding the processing of your grievance. Once a determination is made, you will be notified in writing and advised of any further appeal options including information about how to request an external review of your case from an independent review organization (IRO).

External Review — If your first and/or second level internal appeal is denied, you or your authorized representative may choose to request that an IRO review the case and make a final determination. The IRO will communicate their decision to you. This decision will be final and binding on you, the plan and the carrier. The IRO will communicate their decision to you. This decision will be final and binding on you, the plan and the carrier.

The appeals/grievance form can be found at www.bcbst.com/members/tn_state  or www.cigna.com/sites/stateoftn/index.html. Members will have 180 days to initiate an internal appeal following notice of an adverse determination. Notification of decisions will be made within the following time frames and all decision notices shall advise of any further appeal options: