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Tribal Health Insurance Plans

for Individuals from

Blue Cross of IdahoChoose coverage

that fits.

Form No. 3-1031 (04-15) Policy Form Numbers: 18-063 (01-15) 3-075P (10-10) 3-073P (10-10) 18-070 (01-15) 18-080 (01-15) 3-074P (10-10)

1 HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Individuals

BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS

The Affordable Care Act offers Native Americans new health insurance benefits and greater access to healthcare. The Affordable Care Act (ACA) includes specific provisions dedicated to Native Americans including financial assistance that may greatly reduce your monthly health insurance costs. If your household income falls between 133 and 300 percent of the federal poverty level, and you buy a health insurance plan through Your Health Idaho, may have lower out-of-pocket costs. Your costs will be reduced when you visit the doctor or the emergency room. Yourhealthidaho.org has an easy application process to help you learn what financial benefits are available.

Let’s say your family of four has a yearly income of $50,000. Under the ACA, you are eligible for financial help with your premium costs and your out-of-pocket expenses as long as you buy a plan through Your Health Idaho. This means your monthly premium payments are reduced. Some families may even qualify for a zero-dollar premium payment.

We know your access to Indian Health Services, tribal programs, and other urban Indian programs are critical to you. But a private health plan with Blue Cross of Idaho does not impact your eligibility for these critical programs. In fact, a private health insurance plan provides you and your family greater access to services IHS may not provide, such as emergency room services, maternity and newborn care, annual doctors visits and medical screenings. You might even qualify for health coverage through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).

You are eligible for these new benefits and a new plan any time of year. So, you can research plans, find coverage that fits your budget and your family’s medical needs and apply when you are ready.

Tribal health insurance plans are only available through Your Health Idaho, the state health insurance marketplace. Visit yourhealthidaho.org to learn more and to sign up for coverage.

2CHOOSE COVERAGE THAT FITS – bcidaho.com

Keep your eligibility for Indian Health ServicesYou and your family probably use Indian Health Services, tribal programs, and other urban Indian health programs for annual check-ups or minor illnesses. The ACA does not impact your access to these critical programs. In fact, a private health plan offers you greater access to doctors, specialists and hospitals.

A new Blue Cross of Idaho plan allows you to choose a doctor from our long list of primary care providers in Idaho. Your new plan also allows you to visit a hospital in case of a medical emergency, such as a broken bone or illness.

Dental InsuranceGood oral health is an important part of your overall health. Our flexible and affordable dental plans include varying degrees of coverage so you can select a dental plan that best fits your health and financial needs. Whatever plan you’re looking for, we’ve got you covered. You can choose a plan directly from Blue Cross of Idaho or through the Idaho health insurance exchange at yourhealthidaho.org.

The cost-sharing reduction for members of federally recognized tribes with qualifying incomes does not apply to dental coverage. You can still receive dental services through your Indian healthcare provider.

A note about provider networksBlue Cross of Idaho offers the largest Preferred Provider Organization (PPO) network in the state, with every acute care hospital and 96 percent of all Idaho physicians. Our Choice product is a PPO, and uses a wide network of hospitals, doctors and specialists in Idaho. Our ConnectedCareSM product is a managed care plan supported by exclusive network of providers located in service areas in the southwest and southeast corners of Idaho. The advantage of Connect over other health insurance plans is specialized, coordinated treatment and a lower monthly payment. If you enroll in a Connect plan, you must follow some additional requirements to get the full benefit of your coverage.

• First, you must visit doctors and hospitals that are part of the applicable network in your service area. • Second, you must choose one doctor as your primary care provider (PCP). Your doctor coordinated treatment when needed.• Finally, your PCP must provide referrals to specialists within your network. • You can easily search for a provider at bcidaho.com/ findaprovider.

No matter what plan you choose, it is important that you access the hospitals, doctors and specialists in our network. This helps keep your costs down. If you visit a doctor not listed in our network, you may owe the financial difference between what the physician bills and what we allow for the service. If you have questions, or you are not finding a doctor in the network, please give us a call. We’d love to help you find the care you need. 1-888-462-7767



GET A BREAK ON COSTSDepending on your income and family size, you may be eligible for financial assistance with your monthly health insurance costs or out-of-pocket expenses. Monthly Premium Tax Credit This new kind of tax credit can save you money by lowering your monthly premium payments when you purchase a plan through Your Health Idaho. If your household income is below 400 percent of the federal poverty level, and you purchase a health insurance plan through yourhealthidaho.org, you qualify for financial assistance with your monthly premium.

Cost Sharing Reduction The ACA also provides financial assistance to help lower your out-of-pocket expenses (like your deductible and copayments) when you purchase a plan through Your Health Idaho. If your household income is below 300 percent of the federal poverty level, you may not have to pay copayments or other cost-sharing when you choose the Tribal Bronze Connect – No Deductible or the Tribal Bronze Choice – No Deductible plans.

* For families with more than eight persons, add $4,020 for each additional person.

Free Subsidy CalculatorVisit our subsidy calculator at bcidaho.com to get an estimate on how much money you might be able to save. Remember, this is just an estimate. To get a more detailed number, you’ll need to apply for coverage at yourhealthidaho.org.

IDAHO HEALTH INSURANCE EXCHANGEYou need to enroll in health coverage through Idaho’s Health Insurance Exchange, yourhealthidaho.org to qualify for financial assistance. The exchange has an easy application process to determine what benefits are available to you and your family.

YEAR-ROUND OPEN ENROLLMENTThe ACA allows Native Americans to enroll in a QHP anytime during the year. So, you can research plans, evaluate your budget and purchase a plan that fits your needs whenever you are ready.

THE FEDERAL INCOME GUIDELINES (2014)

Family Size and Income

Cost Sharing Reduction

300% of FPL

If you make less than this, you may qualify for

help paying expenses such as deductible and coinsurance payments.

Monthly Premium Tax Credit

400% of FPL

If you make less than this, you may qualify

for help paying your monthly premiums.

1 $11,670 $35,010 $46,6802 $15,730 $47,190 $62,9203 $19,790 $59,370 $79,1604 $23,850 $71,550 $95,4005 $27,910 $83,730 $111,6406 $31,970 $95,910 $127,8807 $36,030 $108,090 $144,1208 $40,090 $120,270 $160,360


Key termsPREMIUM

The amount you pay each month for your health insurance plan.

DEDUCTIBLE

The amount you pay each year for out-of-pocket expenses before the health insurer picks up expenses. You won’t have to pay any deductible for some services.

COPAYMENT

A flat fee you pay for services such as a doctor visit, emergency room visit, or prescription medication.

NETWORK

The group of physicians, hospitals and other providers that an insurer has contracted with to deliver medical services to its members.

OUT-OF-POCKET EXPENSES

Money you pay for health-related services in addition to your monthly premium. Depending on your health insurance plan, these may include an annual deductible, coinsurance, and copayments for doctor visits and prescriptions.

THE COST OF YOUR CARE

When you use in-network providers, your cost of care is lower because even when you are paying your deductible, you only pay Blue Cross of Idaho’s discounted fee.


Visit bcidaho.com/SBC for a Summary of Benefits and Coverage.

The benefits outlined here are for individuals or families with a yearly income less than 300 percent of the federal poverty level. If your income is greater than 300 percent of FPL, we pay 100 percent of covered services when you visit an Indian Health Services or tribal organization provider, or are referred by an IHS physician.

1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.

Keep in Mind For Tribal members with a yearly income less than 300 percent of the federal poverty level (FPL), we pay 100 percent of covered services. If you visit an out-of-network provider, you may be responsible for the difference between what is billed and what we allow.

For Tribal members with a yearly income greater than 300 percent of FPL, we pay 100 percent of covered services when you visit an Indian Health Services or tribal organization provider, or are referred by an IHS physician. Network benefits apply if you do not receive a referral.

METAL LEVEL BRONZEPlans CHOICE

NO DEDUCTIBLEIn-Network Out-of-Network

Deductible Individual – $0 Family – $0

Annual Out-of-Pocket

Maximum Costs Includes deductible

Individual – $0 Family – $0

Coinsurance You pay no coinsurance for covered services.

WHAT YOU’LL PAY UP TO YOUR ANNUAL OUT- OF - POCKET MAXIMUM

Preventive Care Services

You pay nothing for covered services.

You may owe the difference between what you are billed

and what we allow.Doctor’s Office

Visit/Urgent CareYou pay nothing

for covered services. You may owe the difference between what you are billed

and what we allow.Prescription Drugs You pay nothing for covered prescriptions.

Immunizations You pay nothing for covered services.


and what we allow.Inpatient Hospital

ServicesYou pay nothing


and what we allow.Emergency Room

VisitYou pay nothing


and what we allow.1

Maternity You pay nothing for covered services.


and what we allow.Outpatient Mental

Health ServicesYou pay nothing


and what we allow.Physician, Surgical & Medical Services



and what we allow.Diabetes

Education ServicesYou pay nothing


and what we allow.Chiropractic Care You pay nothing


and what we allow.Up to a combined total of 18 visits

per member, per benefit period.

Outpatient Rehabilitation

Services



and what we allow.Physical Therapy (PT) Occupational

Therapy (OT) Speech Therapy (ST) Limited to a combined total of 20 visits per member, per benefit period.

Diagnostic X-Ray and Lab Services



and what we allow.

< 300 percent

> 300 percent


METAL LEVEL BRONZEPlans CONNECT EAST

NO DEDUCTIBLE*CONNECT SOUTHWEST

NO DEDUCTIBLE*In-Network Out-of-Network In-Network Out-of-Network

Deductible Individual – $0 Family – $0


Annual Out-of-Pocket

Maximum Costs Includes deductible



Coinsurance You pay no coinsurance for covered services. You pay no coinsurance for covered services. WHAT YOU’LL PAY UP TO

YOUR ANNUAL OUT- OF - POCKET MAXIMUMPreventive Care


for covered services. You may owe the difference

between what you are billed and what we allow.



and what we allow.Doctor’s Office

Visit/Urgent CareYou pay nothing





and what we allow.Prescription Drugs You pay nothing for covered prescriptions. You pay nothing for covered prescriptions.

Immunizations You pay nothing for covered services.

You may owe the difference between what you are billed and

what we allow.You pay nothing


and what we allow.Inpatient Hospital






and what we allow.Emergency Room

VisitYou pay nothing


between what you are billed and what we allow.1



and what we allow.1

Maternity You pay nothing for covered services.




and what we allow.Outpatient Mental

Health ServicesYou pay nothing





and what we allow.Physician, Surgical & Medical Services





and what we allow.Diabetes

Education ServicesYou pay nothing





and what we allow.Chiropractic Care You pay nothing





and what we allow.Up to a combined total of 18 visits

per member, per benefit period.Up to a combined total of 18 visits

per member, per benefit period.

Outpatient Rehabilitation

Services





and what we allow.Physical Therapy (PT) Occupational

Therapy (OT) Speech Therapy (ST) Limited to a combined total of 20 visits per member, per benefit period.

Limited to a combined total of 20 visits per member, per benefit period.

Diagnostic X-Ray and Lab Services





and what we allow.

Our Connect plans are supported by select provider networks in southwestern and eastern Idaho. When you choose managed care through ConnectedCare networks, you must choose a primary care physician (PCP) from these networks to serve as your care coordinator. You must obtain a referral from your PCP to see a specialist.

* Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator. You must obtain a referral from your PCP to see a specialist.

1 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.



DENTAL PLANSGood oral health is an important part of overall health. Our flexible and affordable dental plans include varying degrees of coverage so you can select a dental plan that best fits your health and financial needs.Our Dental ChoiceSM and Dental Choice PlusSM plans offer low deductibles and out-of-pocket maximums and meet all of the Affordable Care Act (ACA) requirements. We also offer flexible, affordable dental coverage in three benefit levels with our Healthy SmilesSM Preventive, Plus, and Preferred plans.*

Whatever plan you’re looking for, we’ve got you covered.

DENTAL CHOICE (Under Age 19)

DENTAL CHOICE (Age 19 and Over)

In-Network Out-of-Network In-Network Out-of-Network

Individual Deductible

$50 per member, per benefit period




Annual Out-of-Pocket Maximum

$350 Individual/ $700 Two or more $10,000 None None

Benefit Period Maximum None None $1,000

Preventive Dental Services (No waiting period)

You pay $50 copayment. Once you’ve met your deductible, you pay 50%. You pay $25 copayment. Once you’ve met your

deductible, you pay 50%.

Basic Dental Services

Once you’ve met your deductible, you pay 50%.




6-month waiting period for members age 19 and over

Major Dental Services






OrthodontiaOnce you’ve met your

deductible, you pay 50%.Once you’ve met your

deductible, you pay 80%. No Benefit No Benefit24-month waiting period for members under age 19; medically-

necessary, non-cosmetic treatment. Prior authorization required.*Our Healthy Smiles plans are not ACA-qualified plans and do not meet coverage requirments for people under age 19.


DENTAL PLANS

DENTAL CHOICE PLUS (Under Age 19)

DENTAL CHOICE PLUS (Age 19 and Over)

In-Network Out-of-Network In-Network Out-of-Network

Individual Deductible





Annual Out-of-Pocket Maximum

$350 Individual/ $700 Two or more $10,000 None None

Benefit Period Maximum None None $1,000

Preventive Dental Services (No waiting period)

You pay $40 copayment. Once you’ve met your deductible, you pay 50%. You pay $10 copayment. Once you’ve met your

deductible, you pay 50%.

Basic Dental Services






Major Dental Services






OrthodontiaOnce you’ve met your

deductible, you pay 50%.Once you’ve met your

deductible, you pay 80%. No Benefit No Benefit24-month waiting period for members under age 19; medically-

necessary, non-cosmetic treatment. Prior authorization required.

HEALTHY SMILES PREVENTIVE* HEALTHY SMILES PLUS* HEALTHY SMILES PREFERRED*

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Individual Deductible $0 $50 per member,

per benefit period$50 per member,

per benefit period$50 per member,

per benefit period

Benefit Maximum Period

None $1,000 per member, per benefit period

$1,000 per member, per benefit period

Preventive Dental Services

You pay $20 copayment per visit

You pay costs up to your deductible and

then 50% You pay $20

copayment per visitYou pay costs up to your deductible and

then 50% You pay $20

copayment per visitYou pay costs up to your deductible and

then 50%

Basic Dental Services Not Covered


then 20%


then 50%


then 20%


then 50%

6 month waiting period 6 month waiting period

Major Dental Services Not Covered


then 50%


then 50% 12 month waiting period

Dental Maximum Carryover

Not Included $250 per member, per benefit period (up to a maximum of $1,000, per insured)

*Our Healthy Smiles plans are not ACA-qualified plans and do not meet coverage requirments for people under age 19.


EXCLUSIONS & LIMITATIONSIn addition to the exclusions and limitations listed elsewhere in this booklet, the following exclusions and limitations apply to the entire Policy, unless otherwise specified:THERE ARE NO BENEFITS FOR SERVICES, SUPPLIES, DRUGS, OR OTHER CHARGES THAT ARE:• Not Medically Necessary. If services requiring

Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Insured. However, the Insured could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider.

• In excess of the Maximum Allowance.• For Hospital Inpatient or Outpatient care for

extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Insured has a non-dental, life-endangering condition that makes hospitalization necessary to safeguard the Insured’s health and life.

• Not prescribed by or upon the direction of a Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed General Hospitals, Physicians, and other Providers.

• Investigational in nature.• Provided for any condition, Disease, Illness, or

Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers’ Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related Injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party.

• Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefore would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Medicare Part B or would have been made if an Insured had applied for such payment except when payment under this Policy is expressly required by federal law.

• Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared.

• Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured’s household.

• Received from a dental, vision, or medical department maintained by or on behalf of an employer, a mutual benefit association, labor

union, trust, or similar person or group.• For Surgery intended mainly to improve

appearance or for complications arising from Surgery intended mainly to improve appearance, except for:

• Reconstructive Surgery necessary to treat an Accidental Injury, infection, or other Disease of the involved part; or

• Reconstructive Surgery to correct Congenital Anomalies in an Insured who is a dependent child.

• Rendered prior to the Insured’s Effective Date.• For personal hygiene, comfort, beautification

(including non-surgical services, drugs, and supplies intended to enhance the appearance), or convenience items, even if prescribed by a Physician, including, but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, massage therapy, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, homeopathic or naturopathic, massage, or music.

• For telephone consultations, and all computer or Internet communications; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider.

• For Inpatient admissions that are primarily for Diagnostic Services, Therapy Services, or Physical Rehabilitation, except as specifically provided in this Policy; or for Inpatient admissions when the Insured is ambulatory and/or confined primarily for bed rest, special diet, behavioral problems, environmental change or for treatment not requiring continuous bed care.

• For Inpatient or Outpatient Custodial Care; or for Inpatient or Outpatient services consisting mainly of educational therapy, behavioral modification, self care or self help training, except as specified as a Covered Service in this Policy.

• For any cosmetic foot care, including but not limited to, treatment of corns, calluses and toenails (except for surgical care of ingrown or Diseased toenails).

• For any of the following: • For appliances, splints or restorations

necessary to increase vertical tooth dimensions or restore the occlusion, except as specified as a Covered Service in this Policy;

• For orthognathic Surgery, including services and supplies to augment or reduce the upper or lower jaw;

Blue Cross of Idaho does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan including enrollment and benefit determinations.


EXCLUSIONS AND LIMITATIONS

• For implants in the jaw; for pain, treatment, or diagnostic testing or evaluation related to the misalignment or discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies;

• For alveolectomy or alveoloplasty when related to tooth extraction.

• For hearing aids or examinations for the prescription or fitting of hearing aids.

• For orthoptics, eyeglasses or contact lenses or the vision examination for prescribing or fitting eyeglasses or contact lenses, unless specifically provided as a Covered Service in this Policy.

• For any treatment of either gender leading to or in connection with transsexual Surgery, gender transformation, sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition.

• Made by a Licensed General Hospital for the Insured’s failure to vacate a room on or before the Licensed General Hospital’s established discharge hour.

• Not related directly to the care and treatment of an actual condition, Illness, Disease, or Accidental Injury.

• Furnished by a facility which is primarily a place for treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home.

• For Acute Care, rehabilitative care, diagnostic testing, except as specified as a Covered Service in this Policy; for Mental or Nervous Conditions and Substance Abuse or Addiction services not recognized by the American Psychiatric and American Psychological Association.

• For weight control or treatment of obesity or morbid obesity, including but not limited to Surgery for obesity, except when Surgery for obesity is Medically Necessary to control other medical conditions that are eligible for Covered Services under the Policy, and nonsurgical methods have been unsuccessful in treating the obesity. For reversals or revisions of Surgery for obesity, except when required to correct an immediately life-endangering condition.

• For an elective abortion, unless it is the recommendation of one consulting Physician that an abortion is necessary to save the life of the mother, or if the pregnancy is a result of rape as defined by Idaho law, or incest as determined by the court.

• For use of operating, cast, examination, or treatment rooms, or for equipment located in a Contracting or Noncontracting Provider’s office or facility, except for emergency room facility charges in a Licensed General Hospital, unless specified as a Covered Service in this Policy.

• For the reversal of sterilization procedures, including, but not limited to, vasovasostomies or salpingoplasties.

• Treatment for infertility and fertilization procedures, including, but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance an Insured’s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures.

• For Transplant services and Artificial Organs, except as specified as a Covered Service under this Policy.

• For acupuncture.• For surgical procedures that alter the

refractive character of the eye, including, but not limited to, radial keratotomy, myopic keratomileusis, Laser-in-Situ Keratomileusis (LASIK), and other surgical procedures of the refractive-keratoplasty type, to cure or reduce myopia or astigmatism, even if Medically Necessary. Additionally, reversals, revisions and/or complications of such surgical procedures are excluded, except when required to correct an immediately life-endangering condition.

• For Hospice, except as specified as a Covered Service in this Policy.

• For pastoral, spiritual, bereavement or marriage counseling.

• For homemaker and housekeeping services or home-delivered meals.

• For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence.

• Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party.

• For a routine or periodic physical examination that is not connected with the care and treatment of an actual Illness, Disease or Accidental Injury, or for an examination required on account of employment; or related to an occupational injury; for a marriage license; or for insurance, school or camp application; or for sports participation physical; or a screening examination including routine hearing examinations, except as specified as a Covered Service under this Policy.

• For immunizations, except as specified as a Covered Service in this Policy.

• For breast reduction Surgery or Surgery for gynecomastia.

• For nutritional supplements.• For replacements or nutritional formulas,

except when administered enterally due to impairment in digestion and absorption of an oral diet and is the sole source of caloric need or nutrition in an Insured.

• For vitamins and minerals, unless required through a written prescription and cannot be purchased over the counter.

• For alterations or modifications to the home or vehicle.

• For special clothing, including shoes (unless permanently attached to a brace).

• Provided to a person enrolled as an Eligible Dependent, but who no longer qualifies as an Eligible Dependent due to a change in eligibility status which occurred after enrollment.

• Provided outside the United States, which if had been provided in the United States would not be Covered Services under this Policy.

• Furnished by a Provider or caregiver that is not listed as a Covered Provider, including but not limited to, naturopaths and homeopaths.

• For Outpatient pulmonary and/or cardiac Rehabilitation.

• For complications arising from the acceptance or utilization of noncovered services.

• For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service.

• For arch supports, orthopedic shoes, and other foot devices.

• Any services or supplies furnished by a facility that is primarily a health resort, sanatorium, residential treatment facility, transitional living center, or primarily a place for Outpatient treatment or residential facility care of Mental or Nervous Conditions.

• For wigs.• For cranial molding helmets, unless used

to protect post cranial vault surgery.• For surgical removal of excess skin that is

the result of weight loss or gain, including but not limited to association with prior weight reduction (obesity) surgery.

• For the purchase of Therapy or Service Dogs/Animals and the cost of training/maintaining said animals.

• For dental implants, appliances (with the exception of sleep apnea devices), and/or prosthetics, and/or treatment related to Orthodontia, even when Medically Necessary, unless specified as a Covered Service in this Policy.


GENERAL EXCLUSIONS AND LIMITATIONS FOR DENTAL CHOICE AND DENTAL CHOICE PLUS PLANSIn addition to the exclusions and limitations listed elsewhere in the Policy, the following exclusions and limitations apply to the entire Policy, unless otherwise specified: • Procedures that are not included in the

Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an Insured’s covered dental condition; or that do not have uniform professional endorsement.

• Charges for services that were started prior to the Insured’s Effective Date. The following guidelines will be used to determine the date when a service is deemed to have been started:

o For full dentures or partial dentures: on the date the final impression is taken.

o For fixed bridges, crowns, inlays or onlays: on the date the teeth are first prepared.

o For root canal therapy: on the later of the date the pulp chamber is opened or the date canals are explored to the apex.

o For periodontal Surgery: on the date the Surgery is actually performed.

o For all other services: on the date the service is performed.

o For orthodontic services, if benefits are available under this Policy: on the date any bands or other appliances are first inserted.

• Cast restorations (crowns, inlays or onlays) for teeth that are restorable by other means (i.e., by amalgam or composite fillings).

• Replacement of an existing crown, inlay or onlay that was installed within the preceding five (5) years or replacement of an existing crown, inlay or onlay that can be repaired.

• Appliances, restorations or other services provided or performed solely to change, maintain or restore vertical dimension or occlusion.

• A service for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho.

• In excess of the Maximum Allowance.

• A partial or full removable denture for fixed bridgework, or the addition of teeth thereto, if involving a replacement or modification of a denture or bridgework that was installed during the preceding five (5) years.

• Orthodontic services and supplies unless otherwise specifically listed in the Closed List of Dental Covered Services.

• Replacement of lost or stolen appliances. • Ridge augmentation procedures.• Any procedure, service or supply other

than vestibuloplasty, alveoloplasty or alveolectomy required to prepare the alveolus, maxilla or mandible for a prosthetic appliance. Excluded services include, but are not limited to stomatoplasty and synthetic bone grafts to the alveolars, maxilla or mandible.

• Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome.

• Orthognathic Surgery, including, but not limited to, osteotomy, ostectomy and other services or supplies to augment or reduce the upper or lower jaw.

• Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable.

• Any service, procedure or supply for which the prognosis for success is not reasonably favorable.

• Myofunctional therapy and biofeedback procedures.

• For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures.

• Occlusal adjustments.

• Not prescribed by or upon the direction of a Provider.

• Investigational in nature.

• Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers’ Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party;

• Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefor would vary, or are or would be affected by the existence of coverage under this Policy; or

o For which payment has been made under Medicare Part A and/or Part B.

• Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared.

• Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured’s household.

• Received from a dental, vision or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group.

• For personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs.

• For telephone consultations; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, or for mileage, transportation, food or lodging expenses billed by a Dentist or other Provider.

• For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child.

• For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence.

• For treatment or other health care of any Insured in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Insured to Covered Services under this Policy, if and to the extent those benefits are payable to or due the Insured under any medical payments provision, no fault provision, uninsured motorist provision, underinsured motorist provision, or other first party or no fault provision of any automobile, homeowner’s or other similar policy of insurance, contract or underwriting plan.

o In the event Blue Cross of Idaho for any reason makes payment for or otherwise provides benefits excluded by this provision, it shall succeed to the rights of payment or reimbursement of the compensated Provider, the Insured, and the Insured’s heirs and personal representative against all insurers, underwriters, self-insurers or other such obligors contractually liable or obliged to the Insured or his or her estate for such services, supplies, drugs or other charges so provided by Blue Cross of Idaho in connection with such Illness, Disease, Accidental Injury or other condition.

• Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party.


EXCLUSIONS AND LIMITATIONS

• Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in eligibility status which occurs during the Policy term.

• Provided outside the United States, which if had been provided in the United States, would not be Covered Services under this Policy.

• Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury.

• For acupuncture or hypnosis.

• Repair, removal, cleansing or reinsertion of Implants.

• Precision or semi-precision attachments (including Implants placed to support a fixed or removable denture).

• Denture duplication.

• Oral hygiene instruction.

• Treatment of jaw fractures.

• Charges for acid etching.

• Charges for oral cancer screening which are included in a regular oral examination.

• No benefits are available for replacement and/or repair of orthodontic appliances. This includes removable and/or fixed retainers.

GENERAL EXCLUSIONS AND LIMITATIONS FOR HEALTHY SMILES PLANSIn addition to any other exclusions and limitations of this Policy, the following exclusions and limitations apply to dental services:• There are no benefits for services, supplies, or other charges that are procedures that are not included in the Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an Insured’s covered dental condition; or that do not have uniform professional endorsement.• Charges incurred for services that were started prior to the Insured’s Effective Date. The following guidelines will be used to determine the date on which a service shall be deemed to have been started: o For full dentures or partial dentures

on the date the final impression is taken.

o For fixed bridges, crowns, inlays or onlays on the date the teeth are first prepared.

o For root canal therapy on the later of the date the pulp chamber is opened or the date canals are explored to the apex.

o For periodontal surgery on the date the surgery is actually performed.

o For all other services on the date the service is performed.

• A service furnished to an Insured for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho.• In excess of the Maximum Allowance.• Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome.• Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable.• Any service, procedure or supply for which the prognosis for success is not reasonably favorable.• For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures.• Not prescribed by or upon the direction of a Provider.• Investigational in nature.• Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through an employer under state or federal Workers’ Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party.• Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefor would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Part B.• Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared.• Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured’s household.• Received from a dental, vision or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group.• For personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs.

• For telephone consultations; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, or for mileage, transportation, food or lodging expenses billed by a Dentist or other Provider.• For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child.• For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence.• Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage.• Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in Eligibility status which occurs during the Policy term.• Provided outside the United Sates, which if had been provided in the United States, would not be Covered Services under this Policy.• Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury.Blue Cross of Idaho does not discriminate on the basis of basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

P.O. Box 7408 · Boise, ID · 83707 1 888 GO CROSS (1 888-462-7677)

bcidaho.com

©2015 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield AssociationForm No. 3-1031 (04-15)

Pocatello275 S. 5th Ave., Suite 150

Pocatello, ID 83201208-232-6206

Twin Falls1503 Blue Lakes Blvd. N.

Twin Falls, ID 83301208-733-7258

STREET ADDRESS

3000 E. Pine Avenue Meridian, ID 83642-5995

MAILING ADDRESS

P.O. Box 7408 Boise, ID 83707 208-387-6683

Meridian

CLAIMS INQUIRIES

208-331-7347 800-627-1188

Idaho Falls1910 Channing Way

Idaho Falls, ID 83404208-522-8813

Coeur d’Alene1450 NW Blvd., Suite 106 Coeur d’Alene, ID 83814

208-666-1495

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