Certificate and Rider Description #67800-003

Blue Cross Blue Shield Basic Certificates and Riders

Certificate/Rider Number

Benefit Description

Comprehensive Hospital Care Certificate 0959
Provides basic hospital services, covered at 100% of the Blue Cross Blue Shield approved amount, when received by participating hospitals or approved facilities. Coverage includes:

    • 120 inpatient days for general medical conditions
    • 30 inpatient days for mental health care
    • Inpatient hospital services
    • Outpatient hospital care

Rider D45NM 2288 Increased General Medical and Mental Health Care Days
Increases the number of inpatient hospital days to 365 days for general medical conditions and 45 days for mental health care.

PSG 1879 Professional Services Group Benefit Certificate
Provides basic medical and surgical care covered at 100% of the Blue Cross Blue Shield approved amount. Coverage includes:

    • Unlimited visits for general medical conditions
    • 45 medical visits for mental health care
    • Surgical services including surgical and anesthesia
    • Obstetrical care - delivery only
    • Laboratory, pathology, and radiology services with a member liability of $5 or 10% (whichever is greater) per test

Rider ASFP 5821 Ambulatory Surgical Facility Program
Extends benefits to cover outpatient surgery performed in Blue Cross Blue Shield-approved freestanding facilities.

Rider AS-1 4848 Ambulance Services
Adds benefits for medically necessary air or ground ambulance services provided by a licensed ambulance operator. Services must be provided for the purpose of the patient to a hospital or transferring from a hospital to another treatment location.

Rider BCP 7822 BlueCard Program
Clarifies how health care services received by BCBSM members in other states are processed through the Blue Card Program.

Rider BMT 4398 Bone Marrow Transplants
Establishes the criteria and clarifies which conditions are payable for bone marrow transplants. Donors must meet genetic marker criteria. Requires prior approval by Blue Cross Blue Shield.

Rider CC 2286 Convalescent and Long Term Illness Care
Adds facility benefits for convalescent care in Blue Cross Blue Shield approved skilled nursing care facilities. Coverage is limited to 730 days of care for the treatment of general conditions and 90 days for mental health care. Each two days of care takes away one day of available inpatient care days.

Rider CLC-2 0662 Convalescent and Long Term Care
Adds physician benefits for convalescent care in Blue Cross Blue Shield-approved skilled nursing care facilities. Coverage is limited to two visits per week, per month, not to exceed 730 days of care for the treatment of general conditions and 90 days for mental health care.

Rider CNM 6600 Certified Nurse Midwife
Allows for specific services provided by a Certified Midwife Nurse including normal vaginal delivery in an inpatient hospital setting or Blue Cross Blue Shield approved birthing center. Pre- and post-natal care and PAP smear during the six week visit are also covered when these services are a part of the member's coverage.

Rider CNP 3687 Certified Nurse Practitioner
Allows payment to participating Certified Nurse Practitioners for services covered by the member's group health plan when provided in any location except a hospital inpatient setting.

Rider CRNA 5385 Certified Registered Nurse Anesthetist
Includes certified registered nurse anesthetists (CRNA) as professional providers and pays them directly for covered anesthesia services.

Rider DC 4656 Dependent Continuation
Allows members to continue group coverage for dependent children between the ages of 19-25 when eligibility requirements are met.

Rider EBMT 4397 Experimental Bone Marrow Transplants
Establishes the criteria and clarifies which conditions are payable for experimental bone marrow transplants. Donors must meet genetic marker criteria. Requires prior approval by Blue Cross Blue Shield.

Rider ECIP 5216 Extended Coverage for Inpatient Psychologists' Services
Allows fully licensed psychologists with hospital privileges to receive direct reimbursement for certain covered inpatient mental health care services.

Rider EF 1991 Exact Fill
Complements Medicare Part B benefits according to the benefit level provided under the group's regular coverage for members under age 65.

Rider ESRD 5423 End Stage Renal Disease
Clarifies when Blue Cross Blue Shield benefits for hemodialysis and peritoneal dialysis are available for members with End Stage Renal Disease (ESRD).

Rider FAE-RC 0218 Emergency First Aid
Increases the payment amount for accidental injuries from $15 to the Blue Cross Blue Shield approved amount and adds benefits for the treatment of life-threatening medical.

Rider GCO 9770 Group Continuation Option
Clarifies a member's eligibility rights to continue group coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

Rider GLE-1 9930 General Limitations and Exclusions
Excludes benefits for services, care, devices, or supplies considered experimental or research in nature.

Rider HC 4791 Hearing Care
Adds specific hearing care benefits, including one hearing aid, when provided by participating providers.

Rider HCB-1 7021 Hospice Care Benefits
Clarifies federal law regarding hospital lengths of stay for mothers or newborn children following childbirth.

Rider NC 4359 Name Change
Amends existing MVF and Comprehensive Hospital Care certificate riders to amend the Professional Group Benefit (PSG) and Comprehensive Hospital Care Group Benefit.

Rider OPC 2290 Outpatient Psychiatric Care
Adds outpatient mental health care in Blue Cross Blue Shield-approved facilities, up to a maximum of $400 per member per calendar year.

Rider OPPC-2 0665 Outpatient Psychiatric Care
Adds medical care for outpatient mental health in approved facilities or in a physician's office, up to a combined (with hospital benefits) maximum of $400 per member per calendar year. Copays apply based on the number of visits.

Rider PPNVA 4639 Pre- and Post-natal Visits
Adds physician benefits for pre- and post-natal care visits.

Rider Pre-100120 7107 Predetermination of Hospital Benefits
Requires preauthorization of non-emergency inpatient hospital admissions to determine medical necessity and length of stay. Members who do not receive approval are responsible for the first $ 100 of physician charges and 20% of the hospital charges denied by Blue Cross. (In Michigan, predetermination is part of our participating hospital agreement.)

Rider PTB 5687 Pulmonary TB Days
Eliminates day limits on inpatient treatment of pulmonary tuberculosis (TB) and defines this illness as a general medical condition.

Rider PTFS 7292 Physical Therapy in Freestanding Facilities
Allows payable physical therapy, occupational or functional therapy and speech therapy services to be covered in a participating freestanding facility.

Rider PTS 6217 Physical Therapy Services
Allows payment to independent physical therapists for covered physical therapy, occupational or functional therapy and speech therapy

Rider RAPS 7469 Reimbursement Arrangement for Professional Services
Establishes reimbursement levels for covered professional services.

Rider RDC 3691 Reimbursement for Dental Care
Establishes reimbursement levels for covered dental services.

Rider RM 7562 Routine Marmmograms;
Adds benefits for one routine mammography for members age 35 to 40, then one annually for members over age 40. Services are subject to the $5 or 10% member liability for laboratory, pathology, and radiology services.

Rider RPS 4832 Routine Pap Smear
Adds laboratory and pathology services for routine pap smears, payable once in a 12-month period. Services are subject to the $5 or 10% member liability for laboratory, pathology, and radiology services.

Rider SAT-2 4081 Substance Abuse Treatment Program
Adds rehabilitation care for substance abuse when performed in Blue Cross Blue Shield-approved facilities. Inpatient Benefits services are limited to the number of unused inpatient mental health care days. Outpatient facility services are payable up to the dollar minimum as determined by state law.

Rider SD 4651 Sponsored Dependents
Allows members to continue coverage for dependents over 19 years of age who do not meet eligibility requirements for riders K or DC. Member is responsible for the additional charge per sponsored dependent member.

Rider SOT-PE 9909 Specified Organ Transplants in Approved Facilities
Adds transplant benefits for the liver, heart, heart-lung, lung and pancreas in Blue Cross Blue Shield-approved facilities. Requires prior approval by Blue Cross Blue Shield.
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Rider SUBR02 5220 Subrogation
Clarifies Blue Cross Blue Shield's subrogation rights.

Rider TSA 3693 Technical Surgical Assistance
Expands coverage for technical surgical assistance to include surgical procedures performed in an outpatient hospital setting.

Rider VST 4664 Voluntary Sterilization
Adds benefits for voluntary sterilization, regardless of medical necessity.

Rider XF 0627 Exact Fill
Complements Medicare Part A benefits according to the benefit level provided under the group's regular coverage for members under age 65.

Rider XTMJ 7103 Excluded TMJ Conditions
Clarifies payable benefits for the treatment of temporomandibular jaw joint (TMJ) disorders.

Rider XVA-2 5410 Excludes Voluntary Abortions
Excludes benefits for any services related to an abortion except for a spontaneous abortion, or to prevent the death of the woman upon whom the abortion is performed. BCBMS does pay for services or supplies to treat complications resulting from an abortion.

Master Medical (MM) Certificates and Riders

Master Medical II 4780
Provides additional benefits for services not covered under the basic plan up to a lifetime maximum of $1 million per member. Benefits are subject to a $150 per member ($300 per family) deductible each calendar year. Members are also responsible for a 10% copay for general medical services and a 25% copay for outpatient mental health care and private duty nursing.

Rider MMC-PD 4786 Prescription Drugs
Excludes coverage for prescription drugs under the Master Medical certificate.

Rider MMC-XTMJ 7106 Excluded TMJ Conditions
Clarifies payable benefits for the treatment of temporomandibular jaw joint (TMJ) disorders.

Rider RAPS-2 7057 Reimbursement Arrangements for Professional Services
Establishes reimbursement levels for covered professional services

This is intended as an easy-to-read reference guide to the certificate and riders that are Part of your Blue Cross Blue Shield health care plan. It is not a contract. An official description of the benefits, limitations and exclusions is contained in applicable Blue Cross Blue Shield certificate and riders. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed according to the laws of the state of Michigan.
Adds hospice care benefits for terminally ill individuals when certain conditions are met and services are provided in an approved hospice program.

Rider HMN 5227 Hospital Medical Necessity
Establishes the criteria Blue Cross Blue Shield uses to define hospital medical necessity.

Rider ML 1892 Waiver of Member Liability
Waives the member liability of $5 or 10% (whichever is greater) for laboratory, pathology, and radiology services.

Rider MLOS 5819 Maternity Length of Stay
Benefit Description for Group #67800-003                 08/09/99