sample member handbook

blueshieldca.com/bluegroove

groovecare

With Care+ Groove, you’ll have an expert team led by a Personal Physician from Hill Physicians who will champion your holistic care according to research-based treatment guidelines for your condition − with lower costs than either of the other Blue Groove® options.

Welcome to the next generation of health coverage, exclusively for Blue Groove members in select parts of Sacramento, El Dorado, Placer, and Yolo counties.

Blue Shield of California’s Care+ Groove offers you access to quality care at affordable, predictable rates, and personalized, coordinated care from a select group of quality physicians.

For information about the coverage and specific benefits of Care+ Groove, please refer to your Evidence of Coverage and Disclosure Form (EOC&D) booklet. You may also call your dedicated Blue Groove Member Services team at the number listed on your member ID card.

WE’ll HElP YOu CHOOSE YOur PErSONAl PHYSICIAN FrOM HIll PHYSICIANSWith Care+ Groove, we’ll help you select a Personal Physician from a subset of Hill Physicians medical group, with proven experience in treating your condition, who will provide and coordinate your care. In fact, the Standards of Excellence Program of the California Association of Medical Groups recently designated Hill Physicians an “Elite” medical group, its highest rating based on patient-centered care, care management practices, health information technology, and accountability and transparency.

If you have one of the conditions listed below and are interested in enrolling in Care+ Groove − or have a family member who may qualify − please call (877) 275-6565 to request enrollment in Care+ Groove.

• Heart failure

• Cancer

• End-stage renal disease

• Diabetes

• Hypertension

• Osteoarthritis

If you are a prospective member, you can request enrollment in Care+ Groove on the effective date of your coverage, if you apply for transition of care assistance from Blue Shield medical management staff during open enrollment.

If you enroll in Care+ Groove prior to satisfying the incentive requirements in Main Groove, you will not receive your employer incentive. However, by enrolling in Care+ Groove, you will receive the added features of this plan, including lower costs, a “physician champion,” and holistic care coordination.

Also note that, unlike Main Groove, there is no PPO network access for Care+ Groove due to Care+ Groove’s specialized team approach.

Please note:

CArE+ GrOOvE quAlIFICAtIONS AND ENrOllMENtIf you’re not already enrolled in Care+ Groove, you may qualify if you have one or more of these conditions:

• Heart failure

• Cancer

• End-stage renal disease

• Diabetes

• Hypertension

• Osteoarthritis

If you’re already enrolled, be sure to read about the Care+ Groove benefits and requirements in this booklet.

If you have one of these conditions and are interested in enrolling − or have a family member who may qualify − please call (877) 275-6565 to request enrollment in Care+ Groove. We’ll ask questions to identify the condition and review the requirements to enroll and remain in Care+ Groove. If you (or your qualifying dependent) decide Care+ Groove is the right choice, we’ll request the name and contact information of the treating physician to confirm diagnosis.

Your condition and all medical information will be kept private between you, your physician, and your care team.

We’ll then assist you with selecting a Personal Physician who can meet your unique needs and introduce you to your care team, who will work with you to create a personalized care plan.

qualifying individuals who are considering enrollment in Care+ Groove can choose to meet the physician before enrollment to get acquainted, and we’ll help set up that appointment. If after meeting with the physician, you or your qualifying dependent chooses to enroll with Care+ Groove, please call (877) 275-6565.

Once enrolled, the effective date for Care+ Groove coverage is the first day of the month following your enrollment. then, we’ll send written confirmation of enrollment along with information about the member’s new Personal Physician. We’ll also facilitate the transfer of medical records to the new Personal Physician.

Creating and complying with your care plan

Your Personal Physician will work with you and your care team to create a personalized care plan based on a holistic approach that considers all your health needs in light of your condition. Once your care plan is developed, you’ll need to do your part: You’ll need to follow your care plan to remain in Care+ Groove and take advantage of its team treatment and lower costs.

You’ll be an important partner with your Personal Physician and care team toward improving your health. using hypertension as an example, you will need to:

• Have all your non-emergency care delivered or coordinated through your Personal Physician

• Take your hypertension or other medications as prescribed and directed

• Keep your scheduled physician appointments

• Complete all the assessments and/or screenings outlined in your care plan

• Check and record the results of your blood pressure self-monitoring three times a week, and report those results to your care team

YOur PArt FOr rEMAINING IN CArE+ GrOOvEYou’re a big part of getting better care through Care+ Groove.

to remain in Care+ Groove, you will need to comply with your care plan, as determined by your Personal Physician. After helping to create your care plan, you will sign it. Your Personal Physician will notify you if you don’t comply, providing specific actions you need to do. If, after 30 days, you are still non-compliant, your Personal Physician will notify Blue Shield and give you written documentation on your lack of compliance. You will then be given 60 days to be in full compliance. If you are not in full compliance with your care plan after 90 days, you will be moved from Care+ Groove to the Blue Groove in which you were enrolled prior to enrolling in Care+ Groove, which has higher copayments than you are enjoying now.

A Care+ Groove member who is reassigned to another Blue Groove due to non-compliance will not be eligible for re-enrollment in Care+ Groove until the next plan year.

We don’t want that to happen, and neither do your Personal Physician and your care team. You’ll be missing out on much more than lower costs. You’ll be losing the holistic care team approach and your personalized clinical pathway to treating your condition, based on practice guidelines developed and tested by top experts from throughout the country.

Below is an example of compliance requirements, using hypertension to illustrate the type of actions you’ll need to take:

Care+ Groove: Hypertension compliance requirements (Example only)

Agreement to have all care coordinated through the PCMH, with the exception of emergency services.

Agreement to keep physician appointments, as scheduled, not missing more than two office visits without prior notification and re-scheduling, in any one quarter.

Agreement to maintain compliance with recommended vaccinations, as identified by the care team, unless doing so is medically contraindicated, as determined by the care team.

Agreement to complete requested screenings and assessments as required by the care team and defined in the care plan. these assessments include, but are not limited to, Patient Activation questionnaire, Depression Screening, Smoking Status, and Health risk Assessments.

Agreement to maintain adherence and persistence to prescribed medications (both rx and OtC) as prescribed by the care team.

Agreement to check and record blood pressure three times a week with home-supplied blood pressure cuff and share results with the care team at each provider visit.

Here are key benefits and features of Care+ Groove: to learn more about this program, please see the Blue Groove EOC&D.

HIGHlIGHtS OF YOur BENEFItS

Member calendar-year medical deductible1 Deductible responsibility

Calendar-year medical deductible

Option 1: [$0-$1,500] per member

Calendar-year deductible per member for the following facility services only:

Ambulatory Surgery Center Services; Inpatient Hospital Services;

Outpatient Hospital Services; Outpatient Partial Hospitalization; and

Skilled Nursing Facility Services

Option 2: there is no calendar-year deductible under this plan

Member maximum calendar-year copayment2

Member maximum calendar-year copayment responsibility $[0-3,000] per member

Choosing a doctor

Care+ Groove utilizes a subset of high-performing providers who will act as the designated patient-centered medical

home, which describes a continuous relationship with a personal physician “champion” and comprehensive

care team. the personal physician will be responsible for coordinating all member care and will engage you as an

active participant.

Benefit3 Member copayment services by preferred, participating, and other providers

Preventive health benefits You pay nothing

Emergency room Copay for the Er room Facility [$0-$100] plus [0%-30%] per visit

Outpatient x-ray, pathology, and laboratory You pay nothing

Physician office visits $[0-45] per visit

Specialty office visits $[0-45] per visit

Hospital benefits (in-patient facility services)Option 1: [$0-$1,000] per admission; or

Option 2: [$0-$250] plus [0%-20%] per admission; orOption 3: [0%-40%]

Pregnancy and maternity care benefitsPrenatal and postnatal physician office visits, including

prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy

$[0-45] per visit

All necessary inpatient hospital services for normal delivery, cesarean section, and complications of pregnancy

Option 1: [$0-$1,000] per admission; orOption 2: [$0-$250] plus [0%-20%] per admission; or

Option 3: [0%-40%]

1. If your plan includes a plan deductible as shown on the Summary of Benefits, before the plan provides benefit payments for the covered facility services to which the deductible applies, the deductible must be satisfied once during the calendar year by or on behalf of each member separately. Payments applied to your calendar-year deductible accrue toward the member maximum calendar-year copayment.

2. the member maximum calendar-year copayment applies to all covered services except for: Outpatient routine newborn circumcision; durable medical equipment;

Internet-based consultations; outpatient prescription drug benefits; and, the following optional benefits: additional infertility benefits, chiropractic services, acupuncture services, and vision plan and dental plan benefits, if covered under this plan.

3. All benefits must be provided or authorized by your Personal Physician and/or the medical group/IPA except in an emergency or as otherwise specified. unless otherwise specified, copayments are calculated based on allowed charges.

1. this plan’s prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan’s prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.

2. Drugs obtained at a non-participating pharmacy are not covered, unless medically necessary for a covered emergency, including drugs for emergency contraception. For details, see Care+ Groove Plan Benefits.

OutPAtIENt PrESCrIPtION DruG BENEFItS1

Member calendar-yearbrand-name drug deductible

Deductible responsibility

Per memberOption 1: No brand-name deductible requirement

Option 2: Applicable to all covered brand-name drugs, including brand-name specialty drugs

Participating pharmacy Non-participating pharmacy

Option 1: NoneOption 2: [$0-$250] per member

Not covered

Benefit Member copayment

Retail prescriptions for non-selected chronic conditions Participating pharmacy Non-participating pharmacy2

Formulary generic drugs [$0-$15] per prescription

Not coveredFormulary brand-name drugs [$10-$40] per prescription

Non-formulary brand-name drugs[$25-$50] or [25%-50%] of the Blue shield

contracted rate, whichever is greater, up to a maximum of [$50-$100] per prescription

Mail-service prescriptions for non-selected chronic conditions

Mail-service formulary generic drugs [$0-$45] per prescription

Not coveredMail-service formulary brand-name drugs [$10-$120] per prescription

Mail-service non-formulary brand-name drugs

$125 or 30% of the Blue Shield contracted rate, whichever is greater, up to a maximum

of $250 per prescription

Specialty pharmacies for non-selected chronic conditions

Specialty drugs[20%-30%] of the Blue Shield

contracted rate up to a maximum of [$100-$150] per prescription

Not covered

retail prescriptions for selected chronic conditions

Formulary generic drugs [$0-$15] per prescription

Not coveredFormulary brand-name drugs [$10-$40] per prescription

Non-formulary brand-name drugs[$25-$50] or [25%-50%] of the Blue Shield

contracted rate, whichever is greater, up to a maximum of [$50-$100] per prescription

Mail-service prescriptions for selected chronic conditions

Mail-service formulary generic drugs $7.50 per prescription

Not coveredMail-service formulary brand-name drugs $50 per prescription

Mail-service non-formulary brand-name drugs

$100 or 25% of the Blue Shield contracted rate, whichever is greater, up to a maximum

of $200 per prescription

Specialty pharmacies for selected chronic conditions

Specialty drugs [20%-30%] of the Blue Shield contracted rate up to a maximum of [$100-$150] per prescription

Not covered

MOrE INFOrMAtION ABOut YOur PHArMACY BENEFItS

MOrE ADvANtAGES OF BluE GrOOvE

Check the Care+ Groove formulary

It’s easy to access the Care+ Groove Drug Formulary to see if your medication is in our list of preferred prescription drugs. Once you log in to blueshieldca.com/bluegroove, click on Pharmacy to get to the Drug Database & Formulary. If you don’t have access to the Internet or need help, simply call your dedicated Care+ Groove Member Services team at (877) 275-6565 for personal assistance or to request a copy of the formulary.

Prescriptions by mail

Members who take stabilized doses of covered long-term maintenance medications for conditions such as diabetes can order a mail-service refill of up to a 90-day supply. You may save money on your copayment, and there is no charge for shipping. It’s easy to get started. All you will need is a prescription from your doctor and a completed PrimeMail New Order form. You can download the PrimeMail New Order form by logging in to blueshieldca.com/bluegroove, clicking on Pharmacy, and then Mail-Service Pharmacy. Or, you can call PrimeMail at (866) 346-7200 to request a form. After you send your order form and prescription to PrimeMail, you can order refills online by going to www.MyPrimeMail.com.

In addition to the unique advantages of Care+ Groove, there are many other advantages available to you and all Blue Groove members.

Advanced member engagement tools

With Care+ Groove you also get access to next-generation member engagement tools and resources to help you personalize and reach your health goals.

When you register on blueshieldca.com/bluegroove, you’ll have the opportunity to build your own personal health page. You can track your screening and health risk assessment results, create your personal health goals, and receive inspiration and support to help you change or maintain your health habits and help you reach optimal well-being.

You’ll have advanced member engagement tools such as:

• Mobile reminders and alerts

• Interactive content specific to your care plan and goals

• Individual and group games and challenges

• Ability to build team competitions with other Blue Groove online users

• Ability to track your ongoing progress toward your health goals

• Ability to find support from other Blue Groove online users

Manage your health and benefits online

log in to blueshieldca.com/bluegroove to access My Health Plan for important benefits information:

Verify eligibility – Confirm coverage effective dates for you and your family.

Explore your benefits – view benefit highlights, including copayment and annual deductible amounts.

Contact us – Find phone numbers, addresses, or send email to a Blue Groove Member Services representative.

GEttING CArE AWAY FrOM HOMEthrough the BlueCard® Program, you can access emergency and urgent care services across the country and around the world when travelling. You can receive urgent care services from any provider; however, using the BlueCard Program can be more cost-effective and eliminate the need for you to pay for the services when you receive them and then submit a claim for reimbursement. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com and clicking on Providers outside CA.

For Care+ Groove, special arrangements may be available for dependents who are full-time students; dependents of subscribers who are required by court order to provide coverage; and dependents and subscribers who are long-term travelers. Please contact your Member Services representatives to request an Away From Home Care® (AFHC) Program brochure that explains these arrangements, including for how long AFHC coverage is available.

ExtrA SErvICES AND SuPPOrtWith Care+ Groove, you get a wealth of extra resources to help you manage your health and make more informed healthcare decisions.

NurseHelp 24/7SM − Maybe it’s not a convenient time to talk to your doctor or another member of your care team? relax. You can talk with a registered nurse anytime, day or night, to get answers to your health questions by phoning (877) 304-0504. that number also appears on your Care+ Groove member ID card.

Ask the Pharmacist − Maybe you have a non-urgent question about your medication, but your next appointment is a few days or weeks away? You can email your question to a university of California clinical pharmacist, who will send you a private answer within two business days. Just log in to blueshieldca.com/bluegroove and click on Pharmacy to get to the Ask a Pharmacist section.

Health Library − Our website also contains a wealth of easily searchable and reliable information on just about any condition or symptom − also available anytime. You’ll find it in the Health & Wellness section of the Blue Groove website.

Wellness discounts − We offer you a variety of discounts, to help you take your holistic approach to your health even further. All Blue Groove members get discounts for these services.* When you’re logged in to the website, go to the Health & Wellness section to find out how to get these discounts:

Weight Watchers − Discounts on subscriptions, kits, meeting vouchers, and more.

24 Hour Fitness − Waived fees and discounts on monthly membership dues.

Drugstore.com − Savings on a variety of wellness products.

Alternative care discount program − Save at least 25% on acupuncture, chiropractic, and massage therapy services, plus discounts on wellness products.

Vision services − Get 20% off published retail prices when you go to discount program providers for exams, frames, lenses, and more.

LASIK − Get a 15% discount off LASIK and PRK corrective surgery from discount program providers.

*Important note about the discount programs:

these discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply.

the network of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity nor efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products.

Some services offered through the discount program may already be included as part of the Blue Shield health plan covered benefits. Members should access those covered services prior to using the discount program.

Members who are not satisfied with products or services received from the discount program may use Blue Shield’s grievance process described in the Grievance Process

section of the EOC&D booklet. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through:

Alternative care discount program − American Specialty Health Networks

Vision program – MESvision

Weight control – Weight Watchers North America

Fitness facilities – 24 Hour Fitness

Health products (excluding prescription drugs) – drugstore.com, inc.

LASIK and PRK – Nvision, qualSight, and tlCvision within California and tlCvision (uSA) Corporation outside California

Opportunity to enroll or re-enroll dependents under the age of 26

If you have a dependent whose coverage ended, or who was denied coverage (or was not eligible for coverage), because coverage for dependent children under the plan previously ended before they were age 26, they are eligible to enroll or re-enroll in your employer’s health plan with Blue Shield. You may request enrollment for such children who are under age 26 during your enrollment period. Enrollment will be effective as of the first day of your employer’s first plan year beginning on or after September 23, 2010, even if that results in retroactive enrollment. For more information, contact your employer or call Blue Groove Member Services at (877) 275-6565.

Lifetime limit not applicable and enrollment opportunity

the lifetime limit on the dollar value of benefits under your employer’s Blue Shield plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. You may request enrollment during your enrollment period. For more information, contact your employer or call Blue Groove Member Services at (877) 275-6565.

IMPOrtANt HEAltH rEFOrM rIGHtS

 

NOtICE ON tHE AvAIlABIlItY OF lANGuAGE ASSIStANCE SErvICES tO ACCOMPANY vItAl DOCuMENtS ISSuED IN ENGlISH

WE’rE HErE tO HElPIf you have any questions, visit blueshieldca.com/bluegroove or call your dedicated Blue Groove Member Services team at (877) 275-6565 from 7 a.m. to 7 p.m., Monday through Friday.

Blue Groove Member Services ................................................................................................................. (877) 275-6565

BlueCard Program ...................................................................................................................................... (800) 810-BluE

NurseHelp 24/7 ............................................................................................................................................ (877) 304-0504

LifeReferrals 24/7......................................................................................................................................... (800) 985-2405

Blue Shield of California Privacy Office ................................................................................................... (888) 266-8080

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