BasicBlue provides basic coverage at the lowest price. It provides coverage for hospitalization, surgery, testing and emergency medical services, but does not cover outpatient doctor office visits and prescriptions. BasicBlue is a good choice for those seeking the lowest cost, but needing coverage for health services most likely to involve catastrophic expenses.
Key BasicBlue® plan features include:
- Inpatient hospitalization services
- Outpatient diagnostic testing for same-day emergency surgery
- Your choice of a $500, $1,000 or $2,500 annual deductible for individuals (3x for families)
- 20% coinsurance
- Optional dental coverage
- Unlimited lifetime maximum
BasicBlue® may be right for you if you are an individual or family who:
- Are healthy
- Do not regularly visit a doctor
- Don’t usually take prescription medication
- Want a safety net for unanticipated hospitalization expenses
Learn more about valuable member services and features you get when you join the Blue Cross and Blue Shield of Illinois family.
Health insurance costs include monthly premium payments, individual/family deductibles, out-of-pocket expenses, copayments, and coinsurance. Here is what you can expect with BasicBlue® plans:
- Individual in-network deductibles options of $500, $1,000, or $2,500 – customize your plan by choosing a deductible amount that works best for your situation
- You pay 20% coinsurance of covered services in-network, after deductible is met
- Annual out-of-pocket maximum of $1,000 for individuals and $3,000 for families
What’s Included with BasicBlue®
- Coverage for major hospital expenses incurred as a result of a covered accident or sickness
- Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care
- Although you can go to the hospital or doctor of your choice, your benefits under a BasicBlue® plan will be higher, and your costs lower, when you use the services of participating PPO or BlueChoice® providers.
Prescription Drug Coverage
For the BasicBlue plans, prescription drugs are not covered.
Your BCBSIL policy can ONLY be terminated for the following reasons:
- Failure to pay
- The plan is discontinued (90 days notice given with an option to convert to any plan we offer)
- Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)
- If you no longer reside, live or work in an area where we are authorized to do business
Every insurance plan has limitations. These limits are there to keep health care costs down for everyone. A pre-existing condition is just one example of a plan limitation. For example:
- A pre-existing condition may limit or exclude your participation in a plan.
- This means your health care expenses related to that specific condition will not be covered by the plan during the specified time.
It’s important to know the limitations of your health plan. For a list of exclusions and limitations, see the benefit summary.
Add-ons and Plan Options
The maternity option is not available with the BasicBlue plans. If this is an important benefit for you, it is available with all individual plans except BasicBlue and SelectTemp PPO.
Optional Dental Coverage
- Covers cleanings, check-ups and other preventive procedures immediately – no waiting period
- One of the highest maximum benefit amounts available – up to $1,500 per person per year
- Up to 20 percent discount for orthodontic services at participating providers
- Learn more about optional dental coverage
BasicBlue – Outline of Coverage
|PPO Network||Blue Cross and Blue Shield of Illinois PPO Hospital Network||N/A|
|Lifetime Maximum Benefit||$5,000,000 per person|
Per individual, per calendar year. (If two or more family members receive covered services as a result of injuries received in the same accident, only one Deductible will apply.)
| $500 individual / $1,500 family1
$1,000 individual / $3,000 family1
$2,500 individual / $7,500 family1
|Hospital Admission Deductible
Per admission, per individual
The level of coverage provided by the plan after the calendar year Deductible has been satisfied.
|Out-of-Pocket Expense Limit
The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year.
|Family Out-of-Pocket Expense Limit||$3,000||$15,000|
Includes semi-private room and board; intensive care and related miscellaneous expenses for services and supplies including pre-admission testing; prescription drugs; services of a registered 80%physical, occupational, or speech therapist; initial expense for artificial limbs; prosthetic devices; oxygen and its administration; blood and blood plasma.
Includes but is not limited to X-rays, lab tests, EKGs, ECGs, pathology services, pulmonary function studies, radioisotope tests, and electromyograms ONLY(1) when rendered on the same day as and in connection with Surgery, or (2) as part of covered emergency care.
|Inpatient Physician Charges (Medical/Surgical Services)
For treatment due to accident or illness while an inpatient in a Hospital, Skilled Nursing Facility, or Coordinated Home Care Program; surgeon, assistant surgeon, and anesthetist fees.
Mental illness and substance abuse charges are NOT covered. Outpatient physician medical services are covered ONLY when related to (1) emergency care, and (2) post-mastectomy care within 48 hours after discharge from the hospital.)
|Emergency Care (Hospital & Physician)
Co-payment applies to Covered Services received in a Hospital emergency room or a Physician’s office. Co-payment does not apply to Covered Services provided for the treatment of criminal sexual assault or abuse.
|80% after you pay $125 co-payment1,2|
Includes surgeon, assistant surgeon, and anesthetist fees; also includes surgical and anesthetic services and supplies; pre-operative tests related to the surgery.
|Other Outpatient Services
Includes radiation therapy, chemotherapy, and renal dialysis treatments; and mammograms; and local ambulance service when related to covered Hospital admission or covered emergency care.
|Human Organ Issue Transplant
Includes expenses for cornea, kidney, bone marrow, heart valve, muscular/skeletal, parathyroid, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and inpatient and outpatient immunosuppressive drugs related to transplant.
From age 16. Covers services associated with both an annual physical exam and an annual gynecological exam. Includes immunizations and routine diagnostic tests received or ordered on the same day as part of the exam when covered services are received in provider’s office. ($500 calendar year maximum per person)
|Prescription Drug Benefit||Not Covered1|
|Medical Services Advisory (MSA1)
The MSA helps you maximize your benefits. The Participating Provider is responsible for notifying MSA when services are rendered at a Participating Hospital. The Policyholder is responsible for notifying MSA for Hospital admissions at Non-PPO and Non-Plan Hospitals. MSA notification is required within three business days for non-emergencies and within one business day for emergencies and maternity admissions. If Policyholder does not notify MSA, Hospital benefits are reduced by $1,000.1
Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility.
1 Does not apply to out-of-pocket expense limit.
IF USING A NON-PLAN PROVIDER…
A $300 per Hospital admission Deductible will apply.* If using a Non-Plan Provider, benefit are reduced to 50%. However, with the exception of alcoholism, no benefits are available for Substance Abuse Rehabilitation Treatment. Also, Outpatient Hospital and Physician emergency care, and additional surgical opinions are paid at 100%, regardless of the coverage level or Provider selected.
PRE-EXISTING CONDITIONS LIMITATION
Pre-existing Conditions are those health conditions which were diagnosed or treated by a Provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment. Any Pre-existing Condition will be subject to a waiting period of 365 days.
Blue Cross Blue Shield of Illinois may change premium rates only if they do so on a class basis for all DB-43 HCSC policies. Premiums can be changed based on age, sex, and rating area.
Coverage under this Policy will be terminated for non-payment of premium. Blue Cross Blue Shield of Illinois can refuse to renew this Policy only for the following reasons:
A. If all Policies bearing form number DB-43 HCSC are not renewed, written notice will be provided at least 90 days before coverage is discontinued. Furthermore, you may convert to any other individual policy Blue Cross Blue Shield of Illinois offer to the individual market.
B. In the event of fraud or an intentional misrepresentation of material fact under the terms of the coverage, written notice will be given at least 30 days before coverage is discontinued.
Hospitalization, Services, and supplies which are not Medically Necessary; Services or supplies that are not specifically mentioned in this Policy; Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers’ Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits except where not required by law; Services or supplies that are furnished to you by the local, state, or federal government; Services and supplies for any illness or injury occurring on or after your Coverage Date as a result of war or an act of war; Services or supplies that do not meet accepted standards of medical or dental practice; Investigational Services and Supplies, including all related services and supplies; Custodial Care Service; Routine physical examinations, unless specifically stated in this Policy; Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline, or other antisocial actions which are not specifically the result of Mental Illness; Cosmetic Surgery and related services and supplies, except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases; Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage; Charges for failure to keep a scheduled visit or charges for completion of a Claim form; Personal hygiene, comfort, or convenience items commonly used for other than medical purposes, such as air conditioners, humidifiers, physical fitness equipment, televisions, and telephones; Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery controlled implants, except as specifically mentioned in this Policy; Eyeglasses, contact lenses, or cataract lenses and the examinations for prescribing or fitting of glasses or contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this Policy; Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot or routine foot care; Immunizations, unless otherwise stated in this Policy; Maintenance Occupational Therapy, Maintenance Physical Therapy, and Maintenance Speech Therapy; Speech Therapy when rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorder, conceptual handicap, or mental retardation; Hearing aids or examinations for the prescription or fitting of hearing aids; Diagnostic Service as part of routine physical examinations or check-ups, premarital examinations, determination of the refractive errors of the eyes, auditory problems, surveys, case finding, research studies, screening, or similar procedures and studies, or tests which are Investigational, unless otherwise specified in this Policy; Procurement or use of prosthetic devices, special appliances, and surgical implants which are for cosmetic purposes, or unrelated to the treatment of a disease or injury; Services and supplies provided for the diagnosis and/or treatment of infertility including, but not limited to, Hospital services, Medical Care ,therapeutic injection, fertility and other drugs, Surgery, artificial insemination, and all forms of in-vitro fertilization; Maternity Service, including related services and supplies, unless selected as an option (Complications of Pregnancy are covered as any other illness); Long Term Care; Inpatient Private Duty Nursing Service; Maintenance Care; Wigs (also referred to as cranial prothesis); and services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this policy.
READ YOUR POLICY CAREFULLY — This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!