My Coverage Explained
Hello and welcome! Understanding how your health insurance works can be confusing. We hope that engaging in this fun series will leave you empowered to use your health insurance wisely and feel satisfied with the amount of coverage you get for the payments you make every month. We’ll show you how if you have a higher cost every month upfront, you may get more coverage when you need it. On the flip side, if you choose a less expensive plan upfront, you’ll pay more out of pocket if you get hurt or sick. We want you to know why it works that way. Maybe this information will even help to shape how you choose to buy your health insurance next year, or help you decide to start investing in your health this year. We want you to be safe and be covered so you have a better quality of life with the peace of mind that you will be taken care of if a major health incident happens in your life.
We want you to be happy with the service you receive from us here at Blue Cross and Blue Shield of Illinois, and we are dedicated to making sure that your coverage is transparent so you know where your health care dollar goes. In this “Cost of Care” series, we will be discussing the cost of health care in pieces, and breaking them down so it’s easier for you to understand. We hope that talking about where your monthly payment goes will help you to understand and be more comfortable with the cost of care. At the end of this series, you’ll see how the breakdown of your monthly payment works to cover your doctor’s appointments, hospital visits, prescription drugs, physical therapy, durable medical equipment like wheelchairs, medical tests and more.
Throughout the series please feel free to engage us with your questions, comments and concerns. We encourage you to get every uncertainty on the table so you will feel more confident in the coverage you are receiving from us.
Next up, Where do My Payments Go?
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Please explain why my Doctor is being told that my BS/BS plan does not cover implants. I quote the following from both the coverage statement AND your SPD:
Why are you lying to my doctor?
From our Coverage Statement:
Implants In Network
80% covered after deductible. Call your plan for prior authorization for specific medical conditions
Out of Network
60% covered after deductible. Call your plan for prior authorization for specific medical conditions
From our SPD:
Dental Implant Coverage under this Medical Plan
The medical plan covers dental implant body placement, associated bone grafting, barrier membrane placement & removal, sinus augmentation surgery, and soft tissue grafting when each service is shown to be medically necessary for:
Reconstruction of a dental ridge, distorted as a result of removal of a benign or malignant tumor. Bone
grafting following treatment of tooth-related cysts confined to the dental alveolus is a dental service and is not covered under the medical plan.
Replacement of previously sound natural teeth (stable, functional, free of decay, free of periodontal disease)
• lost or damaged solely by external, accidental injury, including falls
• when conventional crowns, bridges, and/or removable dental prosthesis alone cannot restore adequate function.
• Note: a tooth or teeth lost or damaged in the course of biting or chewing are not covered under the
Securing or stabilizing a facial prosthesis which is placed to camouflage or cover an area of tissue missing due to trauma, disease or birth defect, e.g. an implant supported ear, nose, or cheek prosthesis.
Securing or stabilizing an upper jaw obturator following ablative tumor surgery or trauma.
Replacement of an anterior maxillary tooth or teeth, directly within a congenital alveolar bone cleft, when the tooth failed to form or is non-functional due to malformation or impaction.
Replacement of a single missing tooth when:
• the other remaining teeth are sound natural teeth (stable, functional, free of decay, free of periodontal disease) and
• a conventional bridge, crown, and/or denture cannot restore adequate function and
• a dental implant is medically necessary to restore adequate function.
Medical necessity for the restoration of alveolar ridge atrophy by bone grafting and the placement of multiple dental implants will be assessed on a case-by-case basis. If conventional dentures, partial dentures, crowns, bridges, and dental restorations can be expected to adequately restore function, dental implants will not be covered by the medical plan.
Note: smoking, exposure to intravenous and oral bisphosphonates, exposure to other anti-resorptive medications, use of steroids, external beam radiation therapy, implanted radiation sources, implantation into previously infected bone, and other circumstances may increase the risk of implant failure and may be among the reasons for denial
of certain implant procedures.
Hi Groggo, I wanted to let you know we received your other message and I have responded to you there. ~ Kayla
I am trying to understand why, after my doctor receiving approval for a cat scan, BCBS only paid $179.61 for a $2628.00 test. I understand co-pays and deductibles, but what about this is ''affordable''? Do I have any recourse? If I died and my children were planning my funeral, they would be entitled to up front pricing. I never had these type of charges before medical insurance was mandatory. I already pay $86.08 per week, through my employer, for health care coverage. I expected $500-$1000, but $2400?! If I didn't work and had Medicaid, hospitals would take what Medicaid paid and never even send me a bill for the rest. Is there anything I can do?
Hi Marlene, If you'd like to send us a private message our team can take a look at your claim and see what's going on. ~ Kayla
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