Frequently Asked Questions:
Health Savings Account (HSA)
Arkansas Blue Cross and Blue Shield Self-Funded Open Access Point of Service
Health Savings Account (HSA) Information
- What is a Health Savings Account (HSA) plan?
- How does the HSA work in conjunction with a high deductible
- Who owns my HSA account?
- Who is eligible to open an HSA?
- How do I make deposits to my HSA?
- How much can I contribute to my HSA?
- Can I ever contribute more than the annual limit?
- Who may contribute?
- When can I make HSA contributions?
- What if my spouse has an HSA, too?
- How do I access my HSA account?
- What are the tax benefits of an HSA?
- Is there a time restriction on when I may use the funds in the
- If I change employers, what happens to my HSA?
- Can I pay out of pocket for my medical expenses instead of
using my HSA?
- What if I receive covered services and I do not have funds
available in my HSA account?
- What should I do with my receipts?
- Do I need a referral for any service?
- If I meet the individual deductible and I'm on a family plan, do I have to meet the family deductible?
- How are pharmacy expenses handled under the HSA plan?
Eligibility and Enrollment
- Who is eligible for health-care coverage with Health Advantage?
- When can I apply for coverage?
- Can my dependents be added to my plan after it is in effect?
- What if my application for coverage is completed after the
enrollment period has expired?
- What if I receive a court order to cover my child?
- How will my coverage be affected if I am called to active
- What is a Certificate of Credible Coverage (COC)?
- If I change jobs, how can I get a COC as evidence of my coverage
with Health Advantage?
Health Plan Information
- Do I need to take my member ID card each time I go to the doctor
or have a prescription filled?
- What if I lose my ID card?
- What is an open-access plan?
- What is a point-of-service plan?
- What is the difference between in-network and out-of-network
- Does Health Advantage provide online services for members?
- What does my health plan cover and what will I need to pay?
- What is a deductible?
- What services are subject to the deductible?
- What is a copayment?
- What is coinsurance?
- What is applied to the annual coinsurance maximum?
- How can I make sure I receive covered services from in-plan
physicians or plan providers?
- What is a coverage policy?
- What can I do to reduce my out-of-pocket expenses?
- Why would a health plan ask for additional information such as
- What are my wellness benefits?
- Are weight-loss programs covered?
- I am pregnant; what should I do concerning my health-care
- What is case management?
- Are FluMist and flu shots covered?
- Are diabetic supplies covered??
- What services are limited on the open-access POS plan?
- Am I required to select a primary care physician (PCP)?
- If I decide to select a PCP, must I select the same PCP for all
- What is the proper procedure for seeing my PCP?
- If I select a PCP, may I change my PCP?
- What if I become ill or am injured and my PCP office is not
- Do I need a referral to receive medical care from a plan
- What if the medical care recommended by a PCP is not available
through a plan specialist or plan provider?
Emergency Care and Urgent Care
- If I am out of the Health Advantage service area and have an
unexpected illness or injury, what should I do?
- What medical conditions are considered an emergency?
- What is the BlueCard program?
- What is the time limit for filing a claim for benefits?
- When will I receive an EOB and how will I know what amount I need
- How long should it take for me to receive an EOB from the date of
- How can I find out if Health Advantage has processed a claim?
- How can I find out my financial responsibility for a claim?
- Why does my provider send me a billing statement?
- What do I need to look at closest when I receive an EOB?
- What if I receive an Explanation of Benefits (EOB) and the claim
has not been paid?
- What should I do if any of my services were denied?
- What if I do not agree with the Explanation of Benefits (EOB)
- How do I appeal a claim or benefit determination?
- What if I disagree with a determination but am not able to file
the appeal of a claim or benefit determination myself?
- What if I have to pay for covered medical services or medical
Other Insurance and Coordination of Benefits
- Does Health Advantage coordinate benefits?
- If I have secondary coverage, how can I get a copy of my
Explanation of Benefits from Health Advantage?
- How do I update other insurance information?
If your plan includes a Health Advantage prescription drug
- Do I have a choice between brand-name and generic medications?
- I am taking a medication on a continuing basis; can I get a
refill for more than one month?
- Should prescriptions written by a non-plan physician before I
became a Health Advantage member be rewritten?
- Are contraceptives covered by Health Advantage?
Other Helpful Information
For additional information on the following
subjects, refer to your Health Advantage Evidence of Coverage and Schedule of
Benefits for the terms, conditions, limitations and exclusions of your benefit
plan, or call Health Advantage Customer Service. Information and forms on the
website may use the term "member" instead of "participant."
- Contact information
- Important Information about your plan
Health Plan Information
1. What is a Health Savings Account (HSA) plan?
A Health Savings Account is a bank account held by a bank or custodian that can
be used to pay for medical care. Money may be deposited into the account by
individuals and/or employers on a tax-free basis and used to pay for qualified
medical services. In order to open and contribute to a Health Savings Account,
an individual must be covered by a high-deductible health plan that meets
certain government-mandated requirements.
2. How does the HSA work in conjunction with a high
deductible health plan?
Here's how it works:
Preventive services: The high-deductible health plan covers 100 percent of
covered preventive services, with no out-of-pocket cost to you when using
participating providers. A copy of the Health Advantage preventive health
guidelines is included in all new member packets and can be found at
Routine care: You and/or your employer can deposit funds tax free into an
HSA t to cover the cost of medical services received before you reach your
health Plan deductible. For each covered service you receive, the Health
Advantage allowed amount is applied towards your deductible, even though you may
be paying for the service from your HSA. There are no copayments as there are
with traditional HMO coverage. Unused dollars are saved from year to year to
reduce the amount you may have to pay out-of-pocket in future years.
Specialty care or major expenses: Once your deductible has been met,
major medical expenses are covered by the open-access point-of-service plan. A
referral is not required. Remember, more of your bill will be paid by the health
plan if you receive care from in-plan providers.
3. Who owns my HSA account?
You do. Just like any other checking account, this account is held by a bank in
your name. If your employer makes a contribution or allows payroll deduction,
they may require you to use the custodian of the account that they use. You can
withdraw funds from that account and transfer to an account with another
custodian of your choice. Regardless of where the funds are held, once deposited
they belong to you and can only be accessed by you.
4. Who is eligible to open an HSA?
To be eligible, you must meet these criteria:
- You must be covered by an HSA-qualified plan, and you cannot be covered by any
other medical plan that is not an HSA-qualified health plan.
- You must not be claimed as a dependent on another individual's tax return.
- You must be a U.S. resident, and not a resident of Puerto Rico or American
- You may not be active military, or have received veterans' benefits within the
last 3 months.
- You must not be enrolled in Medicare.
5. How do I make deposits to my HSA?
Your employer may allow you to contribute through payroll deductions, or you may
make deposits directly to your account.
6. How much can I contribute to my HSA?
The total contribution for the year cannot exceed the statutory limits. For
2009, the individual plan contribution maximum is $3,000 and $5,950 for a family
7. Can I ever contribute more than the annual limit?
Yes, if you are 55 or older and not enrolled in Medicare, you are eligible to
contribute an additional amount above the regular limits (referred to as a
catch-up contribution). In 2009, this amount is $1,000.
8. Who may contribute?
Anyone may contribute to your HSA. Your employer, family members or other
persons may contribute to your HSA on your behalf, provided combined
contributions to your account do not exceed the contribution limits.
9. When can I make HSA contributions?
You can make contributions at any time. Remember, deposits from any source
cannot exceed the maximums allowed by law. You can make contributions any time
up to April 15 of the following year and count those deposits toward your
contributions for this year. No deposits can be made until you have a qualified
high-deductible health plan in place.
10. What if my spouse has an HSA, too?
If your spouse has an HSA family plan and you have an HSA family plan, and both
of you are covered under the other's plan, both of your HSA contributions are
limited to the total statutory limit for one family plan. For 2009, the maximum
is $5,950. If the policy holder and spouse are eligible and each has an HSA
plan, they may divide the maximum contribution among the two as they agree.
11. How do I access my HSA account?
You make withdrawals using a check or debit card, like you do from any other
12. What are the tax benefits of an HSA?
There are several benefits:
- Contributions to the account are tax-free.
- Withdrawals from the account for qualified medical expenses are tax-free.
- Any investment and interest earnings in your account are tax deferred.
- Depending on the state where you live, you may save on your state tax as well.
13. Is there a time restriction on when I may use the
funds in the account?
No, you may reimburse yourself for an eligible medical expense any time. The
only restriction is that the service must have occurred after the HSA was
14. If I change employers, what happens to my HSA?
You own your HSA. So, if you change employers, you can take the account with
you. You can even use it after you retire, for example, to pay for medical
15. Can I pay out of pocket for my medical expenses
instead of using my HSA?
Yes. You may pay out-of-pocket expenses with after-tax dollars and let your HSA
balance grow tax-free.
16. What if I receive covered services and I do not have
funds available in my HSA account?
You will be responsible for any remaining out-of-pocket amount needed to satisfy
your deductible before the Plan begins paying benefits. Then, if your plan has
coinsurance, you will pay only the appropriate coinsurance for covered services,
up to your coinsurance maximum.
17. What should I do with my receipts?
You should retain all of your receipts for any medical services paid for through
your HSA. You may need this documentation to support those payments to the IRS.
18. Do I need a referral for any service?
Your HSA plan is an open-access, point-of-service plan so no referrals are
required. However, a participating provider must be used in order for in-plan
benefits to apply.
19. If I meet the individual deductible and I'm on a
family plan, do I have to meet the family deductible?
Yes. If anyone else is on your policy, you must meet the family deductible
instead of the individual deductible. The individual deductible only applies to
people that are on an individual plan.
20. How are pharmacy expenses handled under the HSA plan?
Pharmacy expenses are handled just like any medical expense, except you use your
drug card for most medications. The Health Advantage allowed amount is applied
to your deductible and can be paid for using your HSA funds. Once your
deductible has been satisfied, the Plan pays pharmacy costs at 80 percent of the
allowed amount until the out-of-pocket coinsurance maximum is met.
Eligibility and Enrollment See above section
"Who is eligible to open an HSA?"
Notice: Establishing a personal health account has important tax and legal
consequences for both employers and employees. Arkansas Blue Cross and Blue
Shield, a mutual insurance company, does not provide legal or tax advice, nor
does Arkansas Blue Cross recommend particular financial institutions as trustees
or custodians of Health Savings Accounts. You should consult with your tax
and/or legal advisor if you have any questions about tax or legal issues
concerning your HSA.
1. Who is eligible for health-care coverage with Health
Full-time employees of enrolled groups that live or work in the state of
Arkansas and their eligible dependents. Eligible dependents include a legal
spouse, an unmarried child under the age of 19 (or your group's maximum
dependent age), a full-time student under the limiting age specified in the
group contract, or a child of any age that is certified disabled due to mental
or physical incapacity and chiefly dependent on the employee for financial
Proof of Incapacity Questionnaire (PDF)
must be submitted.
2. When can I apply for coverage?
Employees may apply for coverage for themselves and their eligible dependents
according to the following guidelines. Refer to your Evidence of Coverage for
Initial Enrollment Period: New employees may apply for coverage during
the initial enrollment period, which is 31 days within date of full-time
employment. Coverage is effective at the expiration of the waiting period
required by the employer. For newly acquired dependents, the employee must apply
for coverage when acquiring a new dependent according to the following
- Newborns: Within 90 days from date of birth to be effective on the date
of birth. (Your employer may have a different enrollment timeframe)
- Spouse: Within 31 days of date of marriage to be effective on the first
day of the month following the marriage.
- Adopted children: Within 60 days of placement for adoption or petition
for adoption to be effective on date of placement for adoption or petition for
adoption or date of birth if the newborn application is made within 60 days of
date of birth.
Open Enrollment Period: A one-month period annually for employees to make
changes to health-plan coverage. The period is the one-month period prior to the
group renewal date, or the one-month period specified by the employer. The
effective date of coverage is the group renewal date.
Special Enrollment Period: The 31-day period that an employee has to
apply for coverage after the initial enrollment period. The two instances in
which a special enrollment period occurs are: 1) after loss of coverage as a
result of loss of eligibility, and 2) addition of a new dependent.
3. Can my dependents be added to my plan after it is in
Eligible dependents can be added during your group's open enrollment period or
during a special enrollment period.
4. What if my application for coverage is completed after
the enrollment period has expired?
You are considered a late enrollee and are not eligible for coverage. You may
apply for coverage during your group's next period or a special enrollment
5. What if I receive a court order to cover my child?
If a court has ordered the employee to provide coverage for a child, coverage
will be effective on the first day of the month following the date written
notification and satisfactory proof of the court order is received by Health
Advantage. If an employee is not covered when application is made, the employee
must be enrolled at the same time as the child. This does not apply to a child
for whom the spouse of the employee is court-ordered to cover his/her child.
6. How will my coverage be affected if I am called to
active military duty?
If you are ordered to active duty in the armed services of the United States of
America for more than 30 days, your (and any covered dependents') coverage may
be continued under the Uniformed Services Employment and Reemployment Rights Act
(USERRA) or on COBRA for a period of 18 months with your group health plan. When
you are called to active duty for more than 30 days, your dependents will be
eligible for Tricare Standard benefits, effective immediately, with no premium
Upon returning from active military service, you (and any previously covered
dependents) may enroll in the plan within 90 days of your return. The effective
date of coverage will be the date of reemployment. Health Advantage may require
a copy of the military orders or other proof of the active duty or termination
7. What is a Certificate of Credible Coverage (COC)?
A Certificate of Credible Coverage (COC) lists your coverage with Health
Advantage from the initial effective date to your termination date. This
certificate is generated after your policy is terminated. Insurance companies
use this certificate to reduce pre-existing time clauses and to verify insurance
coverage with other carriers. (If a COC is generated prior to a termination
date, the end date will appear as 12/31/9999.)
8. If I change jobs, how can I get a COC as evidence of my
coverage with Health Advantage?
A COC is mailed to the member's home for every family member when your coverage
is terminated. You may request a copy by contacting Customer Service or you can
print a copy of the Certificate of Creditable Coverage at anytime from
My Blueprint under "Order Certificate of Coverage Letter."
Health Plan Information
1. Do I need to take my member ID card each time I go to
the doctor or have a prescription filled?
We strongly recommend that you carry your ID card with you at all times, and
that your family members carry their ID cards with them as well. To ensure
prompt payment of claims, please make sure that the information on your ID card
is correct and that all providers have the correct date of birth and the
spelling of your name.
2. What if I lose my ID card?
Contact Health Advantage Customer Service and request one or order one through
My Blueprint. You will receive your new card within five to seven days.
3. What is an open-access plan?
An open-access plan allows a member to receive in-network covered services at
the in-network benefit level from plan physicians and plan providers without
first having these services authorized or arranged by a primary care physician.
Although selection of a primary care physician is encouraged, it is optional and
not required. Plan physicians and providers are referred to as in-network
providers. Non-plan physicians and providers are also referred to as
4. What is a point-of-service plan?
A point-of-service (POS) plan allows a member the option to receive covered
services in addition to emergency care and urgent care services without first
receiving authorization from the member's PCP or Health Advantage. Benefits
elected through the point of service option are sometimes referred to as
"out-of-network" benefits. Health Advantage does not pay as great a part of the
cost of services through a point of service as are paid for in-network services.
On a POS plan, the member is responsible for a copayment and/or coinsurance, and
a deductible for services received. The copayment, coinsurance, and deductible
amounts for specific services are listed on the benefit summary for your plan.
5. What is the difference between in-network and
In-network services are covered services or supplies a member receives from plan
physicians or plan providers. Out-of-network services are services or supplies a
member receives from non-plan physician or other non-plan provider that is not
in the Health Advantage provider network. Emergency care and urgent care
services that meet the emergency care guidelines, are covered at the in-network
benefit level up to the allowable charge. (See definition for "emergency care"
and "urgent care" in your Evidence of Coverage). The member may be billed the
difference between billed charges and allowable charges for services received
from non-plan providers.
6. Does Health Advantage provide online services for
Yes. You may access
www.HealthAdvantage-hmo.com for the following:
- Health Plan information: General information about the health plan,
referral information, coverage policy guidelines, preventive health and drug
information, BlueCard Program, FAQs, and health education programs. A "Forms for
members" section is also available.
- Provider Directory: A listing of all network PCPs, specialists,
hospitals, pharmacies and other providers contracted by Health Advantage.
- Eligibility/Claim information: By registering for
My Blueprint, you may check membership eligibility and claims status,
print an Explanation of Benefits, review primary care physician information,
order a COC letter, and order a replacement member ID card.
- HealthConnect Blue: A complimentary health information service for members
who have everyday health concerns and questions, or who have ongoing (chronic)
health conditions such as diabetes, lung or breathing problems or heart
conditions. Health coaches are available 24/7 by calling 1-800-318-2384.
Specially trained health professionals, such as nurses, respiratory therapists,
and dietitians provide health information and support so you can work more
effectively with your doctor. Other benefits of the program include an audio
library on more than 470 health-care topics, personalized follow-up calls,
healthy reminders throughout the year to help you better control your health,
educational materials mailed to your home at no charge and Internet access to an
encyclopedia of valuable health information provided by HealthConnect Blue.
HealthConnect Blue can be accessed through
My Blueprint. A log-in ID and password are required.
- Health-care Cost & Quality-Health Information Guide: Allows you to search
for information on a wide range of health topics.
- Select Quality Care: A hospital quality guide that provides information
on health-care procedures, mortality rates and complications.
- Cost-of-Care Estimator: Access information that helps you to know how
much treatment for a condition may cost based on your location.
7. What does my health plan cover and what will I need to
Your health plan covers preventive and medical services as defined in your
Evidence of Coverage/Summary Plan Description. You may be responsible for any
applicable copayments, deductibles and/or coinsurance. Usually, you will be
responsible for any applicable copayments and/or deductibles at the time of
service and may receive a bill at a later date for your coinsurance
responsibility. Depending on the type of benefit plan chosen by your employer, a
referral or prior approval may be required for certain specialty services.
8. What is a deductible?
The deductible is the amount of allowable charges for out-of-network covered
services for which the member is responsible before the member pays the
copayment/coinsurance and Health Advantage makes payment for a service received.
Specific in-network and all out-of-network covered services are subject to a
deductible. Coinsurance and copayments are not applied to the member's
9. What services are subject to the deductible?
All covered services received from non-plan providers except for emergency care
are subject to the out-of-network deductible. If your plan has an in-network
deductible, certain specialty services that have a coinsurance responsibility
are subject to the in-network deductible. Copayments and coinsurance do not
count toward the deductible. Refer to your benefit summary.
10. What is a copayment?
A copayment is the predetermined fixed dollar amount a member must pay to
receive a specific service. Copayment may mean a defined percentage of charges a
member must pay to receive specific services.
11. What is coinsurance?
Coinsurance is a defined percentage of the allowable that a member pays for a
service after the copayment is paid. Once the annual coinsurance maximum is met
for each member or for the family, no further coinsurance will be charged for
the current contract year. Copayments do not count toward the annual coinsurance
12. What is applied to the annual coinsurance maximum?
The annual coinsurance maximum is the maximum amount of coinsurance payments a
member is required to make in connection with covered services or supplies in a
contract year. The deductible, copayments, and amounts a member may have to pay
in excess of contract benefit limits and benefit exclusions do not contribute to
the annual coinsurance limit. Out-of-network deductible, copayments and
coinsurance are not applied to in-network annual coinsurance limit.
13. How can I make sure I receive covered services from
in-plan physicians or plan providers?
Members may find a physician or provider by accessing the Health Advantage
provider directory at
www.HealthAdvantage-hmo.com or contact Customer Service to verify whether a
specific provider is in-network. Remember, if your plan is self-funded, you
should access the provider directory specific to your self-funded plan.
14. What is a coverage policy?
The Health Advantage coverage policy is a database of policies and/or coverage
criteria that is developed by the medical director(s) and used by Health
Advantage to make benefit determinations. The coverage policy is available to
members and health-care providers at
www.HealthAdvantage-hmo.com. Members may request a copy of specific coverage
policies for certain conditions or procedures by calling Customer Service toll
free at 1-800-843-1329 or emailing Customer Service.
15. What can I do to reduce my out-of-pocket expenses?
If you are on a specific plan that requires referrals, using participating
providers and obtaining the required referrals prior to the service will reduce
your out-of-pocket expenses. If you are on a point-of-service or open-access
plan, using participating providers will result in fewer out-of-pocket expenses
to you since there are no (or lower) deductibles and lower coinsurance
16. Why would a health plan ask for additional information
such as medical records?
Additional information may be requested when a claim is pended for review. Some
examples of this would be:
- To ensure the specific medical criteria are met. There are specific procedures
that are only covered when specific criteria are met for coverage. The Health
Advantage coverage policies are located on the website under the link "Coverage
- When a policy has a pre-existing clause, the medical records are requested
during the look-back period (This is the six-month timeframe prior to your
effective date with Health Advantage or from the first date of your waiting
period, whichever is earlier) to determine if the claims that have been
submitted are related to a pre-existing condition.
17. What are my wellness benefits?
Health Advantage provides services recommended for the prevention and early
detection of disease. Promotion of these services is accomplished through direct
communication with your physician. The preventive health guidelines reflect
recommendations from leading authorities and local practitioners and are meant
to be a guide. Treatment is at the clinical discretion of your physician.
18. Are weight-loss programs covered?
We suggest that you work with your physician to develop a healthy lifestyle for
you and your family. Weight-loss programs and treatments designed to assist
weight loss, such as health club memberships, dietary supplements, surgical
procedures or complications resulting from surgical procedures, are not covered.
19. I am pregnant; what should I do concerning my
You should schedule an appointment with a participating obstetrician as soon as
possible (no referral required). Health Advantage offers a free Special Delivery
prenatal care program as an additional benefit for pregnant mothers regardless
of their pregnancy-risk status. Once registered, an assessment will be done, and
each expectant mom will receive educational materials and coupons by mail to
encourage good health practices during pregnancy. You can register by accessing
www.HealthAdvantage-hmo.com or by calling Customer Service.
20. What is case management?
The Health Advantage case management program is a personalized,
multidisciplinary process to assist patients and family members of patients who
face catastrophic illnesses and long-term recoveries in meeting health needs.
Case management promotes individual health-care management while facilitating
appropriate health-care measures within the most cost-effective environment.
Your physician will direct all care if you become part of the case management
program. Registered nurses who are case managers will follow your care and cost
of benefits, and be available to answer questions. Examples of situations in
which case management may assist in conservation of limited benefits include,
but are not limited to, emergency hospital admissions; rehabilitation services;
home-health care, including home IV; pain management; hospice; and
21. Are FluMist and flu shots covered?
Yes. When in-plan providers are used, the member may not be billed the
difference in the billed and allowed.
22. Are diabetic supplies covered?
Yes. You have the option for specific services to be covered out-of-network.
Out-of-plan providers for specific services may be used, and because of an
exception by Health Advantage, the claims will be processed on your in-network
Benefit level. Please read this carefully since it may help you to save money.
Health Advantage has in-plan providers that carry diabetic supplies and
equipment. There are also participating mail order companies that can ship your
items to you. If you need strips, lancets, and glucometers, a participating DME
supplier or mail order company can be utilized. You will not be responsible to
pay the difference in the billed and allowed amounts. If the provider is
in-plan, they are required to write off that amount. When using a participating
provider they will file the claim for you. Health Advantage processes these
claims as medical claims and you will receive an Explanation of Benefits.
Syringes are only covered at the time the insulin is purchased. The
insulin and syringes are processed through your prescription card at a
participating pharmacy. There is no additional copay for the syringes. Only the
amount of syringes to be used for that fill of insulin will be covered.
A participating pharmacy is not considered a participating DME supplier.
If you wish to obtain strips, lancets and glucometers from ANY out-of-plan
provider, you may do so. As an exception, if the ordering physician is an
in-plan provider, you may pay for the items and submit an itemized receipt to
Health Advantage. The claim will be processed as a medical claim and
processed on the in-network benefit level. The claim will be processed
with the Health Advantage allowed amount, your copay will be applied, and the
payment will be made directly to you. Health Advantage WILL NOT REIMBURSE
you for the difference in the billed and allowed amount. Therefore, it may
save you money if you use in-plan providers for your diabetic supplies. You may
access the online provider directory at
www.HealthAdvantage-hmo.com or call 1-800-843-1329 for a copy of the
provider directory. Keep in mind that the online directory is more current.
Payment for diabetic supplies does not apply towards the DME contract maximum.
There is no contract maximum amount or limit for diabetic supplies.
Diabetic shoes/inserts are covered based on Medicare guidelines. The claim will
be processed as a medical claim and the Diabetic Supplies Benefit will apply.
In-plan providers must be utilized and the ordering physician must be in-plan in
order for the claim to be paid. If you live in a region that does not have
participating providers and the region allows you to go out-of-network, the
claim will be paid on the in-network benefit level. Keep in mind, when
out-of-plan providers are utilized, you may be billed the difference in the
billed and allowed amounts. Also, diabetic shoes/inserts are only covered when
they are billed with a diabetic diagnosis.
Diabetes Management Services
Education/management training programs or services for diabetes can be obtained
by participating providers. Health Advantage will pay one global fee per member
per lifetime no matter how many times they go for education unless a significant
medical event happens where the member would need additional education. An
example of this would be if you are being taken off of oral medication and
changed to insulin. The Health Advantage allowed amount is $210.00 per member
per lifetime. When in-plan providers are used, you cannot be billed the
difference in the billed and allowed amount, however; your applicable copayment
Other supplies or durable medical equipment (DME) items
Except for the diabetic supplies listed above, DME must be obtained from an
in-plan provider and ordered by an in-plan physician. If an out-of-plan provider
is used, the claim will be denied. DME examples are crutches, wheel chairs,
Aero chambers: Some DME supply companies do not carry these. You may
purchase this at a pharmacy or from any out-of-network provider and submit an
itemized receipt to Health Advantage. Coverage will be provided based on benefit
guidelines, the Health Advantage allowed amount, and the claim will be processed
on the in-plan DME benefit level (applicable copayment will apply). The claim
will be processed as a medical/DME claim and payment will be made directly to
you. If an out-of-plan provider is used, you may be billed the difference in the
billed and allowed amounts.
23. What services are limited on the open-access POS plan?
The following information is a listing of general limitations for your health
plan and is provided in response to the most frequently asked questions by
members. Many covered services are covered according to the Health Advantage
coverage policy, and some services may require a prior authorization. Refer to
your Evidence of Coverage and Benefit Summary for specific information on the
terms, conditions, limitations and exclusions for your health plan.
Inpatient Hospital Services: Inpatient hospital services are covered
at the semiprivate room rate. The member is responsible for the difference
between a private room and semiprivate room rate except when a private room is
medically necessary or when a hospital has only private rooms. Emergency
transportation by ambulance is covered up to a $1,000 benefit maximum per member
per contract year. In addition to the member's copayment/coinsurance (if
applicable), the member is responsible for the difference in the billed and
allowed charge when a non-participating provider is utilized.
- Vision Examinations: Coverage is provided for one routine eye examination
per member every two years by an in-plan specialist. Routine vision examinations
are not covered out-of-network. Eyeglasses and contact lenses are not covered
except for initial acquisition when purchased within six months following
cataract surgery and are subject to a maximum allowable charge of $50.
- Mammograms: Members may self-refer to a participating provider for one
breast-cancer screening test (mammogram) per contract year. Additional
mammograms that are medically necessary are covered.
- Annual GYN Visits: Annual gynecological visits with a participating
provider for cervical cancer screenings do not require a referral. Additional
pap smear tests that are medically necessary are covered.
Inpatient Rehabilitation: Inpatient rehabilitation is limited to 60
inpatient days per member per contract year.
Outpatient Rehabilitation Therapy: Physical therapy, occupational therapy,
speech therapy and chiropractic services are limited to 30 aggregate visits per
member per contract year.
Cardiac Rehabilitation: Cardiac rehabilitation is limited to 36 outpatient
visits per member per contract year.
Mental Health and Substance Abuse Services: Mental health and substance
abuse services are a combined benefit and are limited to seven inpatient or
partial hospitalization days and 30 outpatient visits, unless the group has
purchased an additional rider for additional visits/days.
Durable Medical Equipment (DME): Except for services covered under
diabetic benefits and services, DME, orthotics and prosthetics are limited to
$2,000 per member per contract year.
Skilled Nursing Facility Services: Skilled nursing facility services have
a day limit per contract year. Refer to your Benefit Summary.
Home-Health Services: Home-health visits are limited to 50 visits per
member per contract year.
Organ Transplant Services: Coverage is for no more than two transplants
per member per lifetime or a lifetime maximum amount. Refer to your Benefit
Summary for the specific lifetime maximum.
1. Am I required to select a primary care physician (PCP)?
Members are not required to select a PCP; however, Health Advantage does
encourage selection of a PCP to provide routine medical care and preventive
health services and to coordinate health care. The PCP must be listed as a PCP
in the Health Advantage provider directory. Members may call Customer Service to
select or change a PCP. All PCP changes are effective on the first day of the
2. If I decide to select a PCP, must I select the same PCP
for all family members?
You may select the same PCP for all family members, or you may select a
different PCP for each family member.
3. What is the proper procedure for seeing my PCP?
If you are a new Member, we recommend that you contact your PCP office to
schedule an appointment. You should also have your medical records transferred
to your new PCP.
4. If I select a PCP, may I change my PCP?
You may change your PCP by contacting Health Advantage Customer Service toll
free at 1-800-843-1329. All requests are effective on the first day of the
following month. NOTE: If your group is enrolled electronically, you may be
required to make the change online or contact your group administrator to make
5. What if I become ill or am injured and my PCP office is
Contact your PCP or the physician on call. He or she will instruct you on what
to do. Since you are on an open-access plan, you may see any PCP you want to
see. However, if your problem is so severe that immediate medical care is
needed, get help first at the nearest medical facility. Your PCP should be
notified of any emergency care within 24 hours.
1. Do I need a referral to receive medical care from a plan
No. Members may receive in-network covered services at the in-network benefit
level from plan physicians and plan providers without a referral.
2. What if the medical care recommended by a PCP is not
available through a plan specialist or plan provider?
If medically necessary covered services are not available through plan
physicians or plan providers, Health Advantage, on the request of a plan
physician or plan provider or the member, made within a reasonable period prior
to receiving the service, may authorize covered services by a non-plan physician
or provider at the allowable charge or an agreed rate. Even though services are
covered at the in-network benefit level, a non-plan physician or provider may
bill the member for the charges in excess of the allowable charges. The member
may have information or medical records submitted from the physician with their
Emergency Care and Urgent Care
1. If I am out of the Health Advantage service area and
have an unexpected illness or injury, what should I do?
If it is an emergency, go to the nearest medical facility. Health Advantage will
cover emergency care and urgent care outside the service area (state of
Arkansas). Urgent care is an unexpected illness or injury that cannot wait until
the member returns to the service area. The member may limit expenses to
copayment/coinsurance for emergency care and urgent care by using the BlueCard
program. The member may be billed the difference between the billed charges and
allowable charges for services received from out-of-network providers that do
not participate in the BlueCard program. NOTE: Health Advantage should be
notified within 24 hours for emergency admissions to an out-of-plan hospital.
2. What medical conditions are considered an emergency?
Conditions that are so severe as to cause serious disability if not treated are
considered emergencies. Some examples of emergencies that require immediate
|*Heart attack or severe chest pain
||*Acute abdominal pain
||*Severe shortness of breath
|*Convulsions or choking
3. What is the BlueCard program?
The BlueCard program enables a member to receive medical services outside the
service area (state of Arkansas) from a Blue Cross or Blue Shield (BlueCard)
traditional network provider and limit expenses to the member’s in-network
deductible (if applicable), copayment and coinsurance. Claims are filed with the
local Blue Cross and/or Blue Shield plan with the XCH prefix and the member's ID
number and routed electronically to Health Advantage for payment. To locate the
nearest participating BlueCard traditional network provider, members may go to
bcbs.com or bluecares.com
or call 1-800-810-2583 (BLUE). Services are covered according to the member’s
Members traveling outside the service area. Health Advantage members on
short-term travel outside the service area have access to the BlueCard Program
for emergency and urgent care at the travel location. Medical Services other
than emergency care or urgent care through the BlueCard program must first be
approved by Health Advantage to be covered at the in-network benefit level.
Subscribers and dependents that work, live, or attend school outside the service
area for more than 90 days may be eligible for a temporary out-of-area
classification. If approved by Health Advantage, the member uses his/her Health
Advantage ID card to access services covered by Health Advantage on the member's
group health plan. Services are covered at the in-network benefit level when
provided by a Blue Cross and/or Blue Shield provider listed in the BlueCard
traditional network. The subscriber must submit a signed application.
Applications for out-of-area classification are available online. Renewal is
required annually for dependents. Active employees must have application
approved by their group administrator.
1. What is the time limit for filing a claim for benefits?
A notice of claim must be made to Health Advantage by the member or the provider
within 180 days of the date on which Covered Services were first incurred.
2. When will I receive an EOB and how will I know what
amount I need to pay?
You will receive an EOB when you have a member responsibility of a deductible,
copayment or coinsurance, or when a service is denied. You should keep your EOB
to compare it with the bill that you receive from the provider. Your minimum
responsibility should match the amount requested from the provider. This may
differ if the service is denied as a non-covered service or as a benefit
limitation. If the amount indicated on your EOB does not match the amount billed
by the provider, you may call the provider or Customer Service at Health
3. How long should it take for me to receive an EOB from
the date of my service?
Once the provider submits a claim, it should be processed within 30 days. This
may be delayed if additional information is requested.
4. How can I find out if Health Advantage has processed a
An EOB is mailed to your home each time a claim is processed. You may check the
status of a claim online by going to My Blueprint and selecting "Check Claims Status." If the status shows "complete," the claim has been processed. If the status shows "in process," the claim has been received by Health Advantage, but final action has not been taken. You also may call MyBlueLine, an interactive voice response system, toll free, 24/7, at 1-800-843-1329.
5. How can I find out my financial responsibility for a
An EOB is mailed to your home each time a claim is processed. Your copayment and
coinsurance responsibility (if you have one) will be shown on the EOB. You may
print a copy of the EOB for any claim that shows "complete" from My Blueprint under "Check Claims Status." You also may call MyBlueLine, an interactive voice response system, toll free, 24/7, at 1-800-843-1329.
6. Why does my provider send me a billing statement?
If the statement date is less than 30 days old from the date of service, it is
possible that the billing statement may cross with the payment of the claim. If
adequate time has been allowed for the processing of the claim, you should
research the bill. If the claim has been processed and you received an EOB, the
amount that the provider is billing you should be matched with the amount on the
EOB that is listed as the member's responsibility. If the amount the provider is
billing you is higher, or Health Advantage has not processed the claim, a call
should be made to the provider's office. Explain the amounts shown on your EOB,
ask them to research your bill, and ask them to verify the information filed on
the claim. If the information filed doesn't match your ID card, the provider
will need to file a corrected claim to Health Advantage. If you no longer have
the EOB, you may view your claim information by using our online tools at
www.HealthAdvantage-hmo.com. If the issue cannot be resolved, you or the
provider can call the Customer Service Department at Health Advantage.
7. What do I need to look at closest when I receive an EOB?
The provider name and date of service should match a service that you received.
If you did not receive this service, please call the provider. They may have
filed an incorrect claim. If the date of service and provider information are
correct, you should review the amount shown as your responsibility such as a
copayment, coinsurance, deductible or denied charge. If you have questions or
feel the amount is incorrect, you should call the Customer Service Department.
8. What if I receive an Explanation of Benefits (EOB) and
the claim has not been paid?
If your claim has not been paid and has been put in a "hold" status awaiting
additional information or payment, your EOB will have a description of any
additional information necessary for the claim to be processed and an
explanation of why such information is necessary. If your claim has been denied,
your EOB will have a reference to a specific plan provision on which the
determination is based and a description of your plan's appeal process.
9. What should I do if any of my services were denied?
Review the service that was denied and reference the Exclusions or Benefit
Limitations in your Evidence of Coverage/Summary Plan Description. If the
service was denied correctly, you are responsible to pay the billed charge to
the provider. If you feel the claim was denied in error, you may call Customer
Service. If you wish to appeal the denial of the claim, please follow the appeal
guidelines listed in your Evidence of Coverage/Summary Plan Description.
10. What if I do not agree with the Explanation of
Benefits (EOB) determination?
If you have questions about an EOB determination, you may contact Customer
Service toll free at 1-800-843-1329 or write to: Health Advantage Customer
Service, P.O. Box 8069, Little Rock, Arkansas 72203. This is an informal request
and is not considered a formal appeal.
11. How do I appeal a claim or benefit determination?
If a claim for benefits is denied either in whole or in part, you may request a
review of a denial of benefits for any claim or portion of a claim by sending a
request marked "Appeal Request" to Health Advantage, Attention: Member Response
Coordinator, P.O. Box 8069, Little Rock, AR 72203. This request can also be sent
by fax to 501-212-8518 or by email to
appeals@HealthAdvantage-hmo.com. The request must be made within 180
days after the member has been notified of the initial denial of benefits. You
may contact the Health Advantage member response coordinator toll free at
1-800-843-1329 for assistance in making an appeal. For more information, refer
to your Evidence of Coverage.
12. What if I disagree with a determination but am not
able to file the appeal of a claim or benefit determination myself?
You may designate an authorized representative to represent you in filing an
appeal of a claim or benefit determination. For information on designation of an
authorized representative, please call Customer Service at 1-800-843-1329.
13. What if I have to pay for covered medical services or
If you make payment other than required copayments or coinsurance for services
covered by Health Advantage, a claim for reimbursement may be made by submitting
a copy of your receipt for payment for services received and a copy of the bill
to Health Advantage. The request must include the member's ID number and be made
within 180 days from the date on which expenses were first incurred. The request
for reimbursement may be sent postage paid to: Claims, Health Advantage, P.O.
Box 8069, Little Rock, AR 72203-8069.
Other Insurance and Coordination of Benefits
1. Does Health Advantage coordinate benefits?
Yes. If you or any of your dependents have other insurance coverage that
provides benefits for hospital, medical, or other expenses, your benefit
payments may be subject to coordination of benefits. Even if Health Advantage is not the primary carrier, you must still follow the plan in order for Health Advantage to coordinate benefits. It is the member’s responsibility to ensure Health Advantage has a copy of the primary carrier’s Explanation of Benefits and all itemized bills, and to inform Health Advantage of all changes in other insurance. If you need to update other insurance information, you may submit the information in writing, contact your employer benefits administrator or call Customer Service.
2. If I have secondary coverage, how can I get a copy of my
Explanation of Benefits from Health Advantage?
An Explanation of Benefits (EOB) is mailed to your home each time a claim is
processed. You may print a copy of the EOB for any claim that has been processed
Blueprint under "Check Claims Status."
3. How do I update other insurance information?
To update your Medicare information or other insurance information, you may
complete the Coordination of Benefits Questionnaire and mail it to: Health
Advantage, Attn: Claims COB, P.O. Box 8069, Little Rock, AR 72203-8069. You also
may call toll free 1-800-969-3983.
IF YOUR PLAN INCLUDES A HEALTH ADVANTAGE PRESCRIPTION DRUG
1. Do I have a choice between brand-name and generic
You may request the brand-name medication; however, you will be required to pay
an additional charge if a generic medication is available. Please refer to your
managed pharmacy benefit rider. You may access the prescription formulary and
preferred drug list under pharmacy benefits at
2. I am taking a medication on a continuing basis; can I
get a refill for more than one month?
As a service to you, certain prescriptions for maintenance medications can be
refilled for a 100-day supply. You will be charged three copayments/coinsurance.
Any new or rewritten prescription will be limited to a one-month supply the
first time it is filled. You may access a list of maintenance medications under
Pharmacy Benefits at
3. Should prescriptions written by a non-plan physician
before I became a Health Advantage member be rewritten?
It is best to have any prescriptions that you are currently using rewritten by a
Health Advantage physician as soon as possible.
4. Are contraceptives covered by Health Advantage?
Selected oral contraceptives are covered on your pharmacy benefit plan. The
self-injectable drug Depo-SubQ Provera is also covered under your prescription
benefits. Please note: Under your medical coverage, the injectable contraceptive
Depo Provera is covered. The intrauterine device (IUD) is also covered,
including insertion and removal.
Medications from non-participating pharmacies are not
covered except for emergencies
Other Helpful Information
1. Contact Information
||P.O. Box 8069, Little Rock, AR 72203-8069
|Interactive Voice Response (available 24/7)
Select "technical support" for system issues, ID, password, and registration
issues. Call 1-800-843-1329 if you have other questions.
|Trover (HealthCare Recoveries)
||1-800-685-4013 (to report a motor vehicle accident or injury that
includes third party liability)
|COB information line
||1-800-969-3983 to report other medical or pharmacy insurance
coverage or changes related to the other insurance information we have on file.
2. IMPORTANT INFORMATION ABOUT YOUR PLAN:
Advanced Diagnostic Imaging Services. Computed tomography scanning (CT
scan), magnetic resonance angiography or imaging (MRI/MRA), nuclear cardiology
and positron emission tomography scans (PET scan), collectively referred to as
advanced diagnostic imaging.
These services require prior approval from Health Advantage. Please note
that prior approval does not guarantee payment or assure coverage; it means only
that the information furnished to us at the time indicates that the CT scan,
MRI/MRA, nuclear cardiology or PET scan is medically necessary. All services,
including any advanced diagnostic imaging receiving prior approval, must still
meet all other coverage terms, conditions, and limitations, and coverage for any
advanced diagnostic imaging receiving prior approval may still be limited or
denied if, when the claims for the advanced diagnostic imaging are received by
us, investigation shows that a benefit exclusion or limitation applies, that the
member ceased to be eligible for benefits on the date services were provided,
that coverage lapsed for non-payment of premium, that out-of-network limitations
apply, or any other basis specified in this Evidence of Coverage.