Download The Micron Select PPO Medical Plan offers

Select U.S. Health Plan
2015
The Micron Select U.S. Health Plan offers medical, dental, and vision coverage for you and
your eligible dependents when you are traveling at Micron’s request in the U.S. for greater
than six months. The Select U.S. medical, dental, and vision Plan is an ERISA plan and is
administered by Blue Cross of Idaho Health Services, Inc. The group number is 10020950.
ERISA
The Select U.S. health plan is subject to ERISA. See the Additional Administrative Facts and
Statement of ERISA Rights sections of this Benefits Handbook for details.
HIPAA
The Select U.S. Health Plan is subject to Health Insurance Portability and Accountability
Act’s (“HIPAA”) privacy rules. When the plan provides benefits for health care, the Plan shall
comply with the HIPAA privacy rules. For a complete statement of your HIPAA rights, please
refer to the HIPAA Privacy Notice section of this Benefits Handbook.
Grandfather Status
This plan believes it is a “grandfathered health plan” under the Patient Protection and
Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a
grandfathered health plan can preserve certain basic health coverage that was already in
effect when that law was enacted. Being a grandfathered health plan means that your plans
may not include certain consumer protections of the Affordable Care Act that apply to other
plans, for example, the requirement for the provision of preventive health services without
any cost sharing, although these plans do provide certain preventive care services without
any cost sharing. However, grandfathered health plans must comply with certain other
consumer protections in the Affordable Care Act, for example, the elimination of lifetime
limits on benefits.
Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered
health plan status can be directed to the plan administrator at 1-800-358-5527. You may
also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing
which protections do and do not apply to grandfathered health plans.
Your Eligibility
Team Members are eligible to participate in this Plan if you meet the following
requirements:
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You are employed by a non U.S.-based Micron Technology, Inc. subsidiary
(“Micron”); and
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You are assigned by Micron to work in the U.S. for more than 6 consecutive months;
Definition of a Team Member. Team members are those individuals who are considered
an employee of Micron as classified by Micron under its standard personnel practices in your
country of employment.
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2015
Your Dependent’s Eligibility
You may enroll eligible dependents that accompany you on assignment to work in the U.S.
The following are Eligible Dependents in this Plan.
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Spouse
Child Under age 26
Child with Mental or Physical Disabilities
Spouse. Your spouse by a marriage between persons of the opposite sex, your legally
registered domestic partner legally valid under the applicable law in the country of your
regular employment, or your same-gender spouse legally married in any state or foreign
jurisdiction that recognizes such marriages, regardless of where you currently live, is eligible
to participate in this Plan.
Please note that only married spouses are eligible; dependents living in a civil union, civil
partnership, domestic partnership, registered partnership, unregistered partnership, and
unregistered cohabitation are not eligible.
Child Under Age 26. A child who is under age 26 is eligible to participate in this Plan if
they meet the following criteria:
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A son, daughter, stepson, stepdaughter, or child placed with you by judgement decree or
other order of any court of competent jurisdiction. A legally adopted child or child placed
with you for adoption through a legally enforceable agreement under applicable law is
considered your son or daughter.
Child with Mental or Physical Disability. A child who meets the "child under age 26"
eligibility requirements listed above except for age is still eligible to participate in this Plan if
they meet all of the following criteria:
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The child has a permanent mental or physical disability
The child is incapable of self-sustaining employment because of the disability and
The child became incapacitated prior to reaching age 26.
Special Rule for a Child of Divorced or Separated Parents. For purposes of this Plan, if
you are divorced or legally separated, your son and/or daughter is considered to be a
dependent of both you and your divorced or legally separated spouse.
Dependents That are Not Eligible. You may not enroll any individual who does not meet
the definition of an Eligible Dependent. Ineligible dependents include but are not limited to
the following:
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Dependents living in a civil union, civil partnership, domestic partnership, registered
partnership, unregistered partnership, and unregistered cohabitation.
An ex-spouse from whom you have obtained a legal divorce, legal separation, or an
annulment of the marriage.
A child who has reached age 26, unless disabled as described above.
A child for whom a court ordered custodial arrangement or guardianship as described
above is terminated or superseded, for example, because the child turns 18.
A stepchild if your marriage with the natural parent terminates. However, the stepchild
may be eligible as an adopted child, child placed for adoption or child over whom you
have court-ordered custody or guardianship.
Your parent.
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Your eligible dependent’s spouse.
Your grandchild
Individuals under your care or living in your home that do not meet the requirement of
Eligible Dependent.
Determination of Dependent Eligibility. Micron will rely upon information provided by
you and your dependents when determining eligibility for this Plan. Once enrolled, you are
required to notify Micron as soon as possible if you have reason to believe that your Enrolled
Dependent has become no longer eligible for participation in this Plan.
You may be requested to provide evidence of eligibility of any dependent at any time,
including but not limited to marriage certificates, birth certificates, divorce decrees and tax
forms. If you do not provide proof of eligibility within the time limit specified, your
dependent may be deemed ineligible for part or all of the Plan Year.
Misrepresentation. You and/or your dependent’s coverage may be terminated for any
misrepresentation, omission or concealment of facts that could have impacted the Plan’s
determination of eligibility for coverage.
Initial Enrollment
You are automatically enrolled in this Plan. You do not need to complete and return an
enrollment form to have coverage. In order to receive a personalized identification card,
you may be requested to complete an Initial Insurance Enrollment form if your work
assignment is greater than 180 days or in the event you or your Eligible Dependent have
received or anticipate receiving a Covered Service. You will be notified by Micron if this
request applies to you.
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Contact the HR Customer Service Center if you were requested to complete an Initial
Insurance Enrollment form and you need to add Elgible Dependents that were not
orginally listed on your form. You may contact the HR Customer Service Center by
emailing [email protected] or by calling (800) 336-8918 or (208) 368-4748.
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No team member or Eligible Dependent is entitled to receive benefits for Covered
Services under more than one Micron enrollment.
Enrollment Effective Date. The Effective Date of you and your Eligible Dependent’s
coverage is the first day you or your Eligible Dependents arrive in the U.S.
Team members and their eligible dependents will be enrolled in the Select U.S. Health Plan
at six month plus one day when an international assignment of less than six months is
extended beyond six months. When your assignment ends, you will be disenrolled from the
Select U.S. Health Plan.
Premiums. There are no premiums associated with this plan.
When Your Spouse Works at Micron
You can set up your enrollment in one of the following ways if you are married to another
Micron team member.
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Coverage may be set up in either you or your spouse’s name where one of you is
enrolled as the Participant and the other is enrolled as an Eligible Dependent.
Coverage may be set up where both you and your spouse are separate Participants.
Under either option you may enroll Eligible Dependents.
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If you or your spouse’s employment changes during the Plan Year, and either you or your
spouse no longer works at Micron, contact the HR Customer Service Center to change your
enrollment. You may contact the HR Customer Service Center by emailing
[email protected] or by calling (800) 336-8918 or (208) 368-4748.
Your Identification Card
To facilitate billing, present your card to your hospital, Pharmacy, Physician, Dentist or other
Covered Provider at the time of service.
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If you are requested to complete an Initial Insurance Enrollment form, you will be sent
two medical ID cards and two prescription ID cards after your enrollment is processed.
The card will have your name and unique identification numbers.
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Contact Blue Cross of Idaho, Inc. if you ever need to request a new medical and dental
ID card by calling (800) 358-5527. Contact SelectHealth if you ever need to request a
new prescription ID card by calling (800) 422-3127. There is no vision card.
How to Find Medical Providers.
Team members and their dependents enrolled in the Select U.S. medical plan are eligible to
use the Micron Family Health Center and the MTV Health Center. Also, enrolled team
members and their enrolled dependents are encouraged to utilize Contracting Providers.
Contracting Providers are Covered Providers who have agreed to recognize the applicable
Maximum Allowance as their fee for Covered Services by entering into an agreement with
one of the provider networks available under the Plan. The Blue Cross National Provider
Network is the contracting provider network for the Select US Plan. Go to
www.micronhealth.com to find contracting providers.
When you receive medical services, be sure to present your ID card. After you have received
medical attention, the Contracting Provider may submit your claim electronically to Blue
Cross of Idaho, Inc. for processing. If the provider does not submit your claim you will be
required to complete a claim form found on www.micronhealth.com and submit the claim to
Blue Cross of Idaho, Inc., at the following address:
Blue Cross of Idaho
P.O. Box 7408
Boise, ID 83707
FAX (208) 363-8748
Providers may be added or deleted at any time and without notice.
Payment to Contracting Providers. All Contracting Providers are paid directly.
Using a Non-Contracting Provider. If you choose to use a non-Contracting Provider, you
must pay up front for Covered Services. You will be responsible for all charges exceeding the
maximum allowance for services obtained at a Non-Contracting provider. You will be
required to complete a claim form, found on www.micronhealth.com, and submit the claim
to Blue Cross of Idaho, Inc., at the following address:
Blue Cross of Idaho
P.O. Box 7408
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2015
Boise, ID 83707
FAX (208) 363-8748
Medical Benefits
The plan will pay 100% of the cost of covered services received from a covered provider
subject to the following features.
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Maximum Allowance
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Prescription Drug Maximum Allowance
Maximum Allowance
For Covered Services, the Maximum Allowance is the lesser of the billed charge or the
amount established as the highest level of reimbursement for a Covered Service. The
Maximum Allowance varies based on provider network affiliation.
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If Covered Services are provided by a Contracting Provider you are not responsible for
amounts over the Maximum Allowance.
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If Covered Services are provided by a Non-Contracting Provider you are responsible
for any amounts billed over the Maximum Allowance. Non-Network Providers
are not obligated to accept the Maximum Allowance as payment in full.
The Maximum Allowance may be determined using many factors, including without
limitation, negotiated payment amounts; diagnostic related groupings (DRG’s); a resource
based relative value scale (RBRVS); the Provider’s charge(s); past charge(s) of Providers;
Medicare reimbursement amounts; the cost of providing the Covered Service; administrative
efficiency and desired Plan cost savings. The Maximum Allowance varies based on network
affiliation and Contracting and Non-Contracting reimbursement schedules and may not be
the same. The Maximum Allowance varies over time, is subject to change without notice,
and may be significantly less than your providers actual charge.
Establishment of the Maximum Allowance is a decision reserved to the sole and absolute
discretion of the Plan and either the applicable provider network or Blue Cross and/or Blue
Shield, as applicable.
Prescription Drug Maximum Allowance
The Prescription Drug Maximum Allowance is the maximum amount established by
SelectHealth as reimbursement for each Prescription Drug. Establishment of the Prescription
Drug Maximum Allowance is a decision reserved to the sole and absolute discretion of
SelectHealth. Both Contracting and non-Contracting Pharmacies are subject to the
Prescription Drug Maximum Allowance.
Rejection of Generic Substitute. If you are prescribed a medication that has a medically
appropriate generic substitute, the physician allows for the generic equivalent, and you
choose the brand name drug over the generic equivalent, you will pay the brand name
copay plus the difference between the cost of the brand name and the generic.
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Plan Year
The Plan Year is January 1 through December 31.
Medical Necessity
Benefits are paid only for Covered Services when they are Medically Necessary. To be
Medically Necessary the Covered Services or supplies that are required to identify or treat a
Participant’s condition, Disease, Illness or Accidental Injury, or as outlined in the “Preventive
Care” section, as recommended by the treating Physician or other Covered Provider must
meet the following criteria.
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The Covered Services must be the most appropriate supply or level of service,
considering potential benefits and harms to the Participant.
The Covered Services must be proven to be effective in improving health outcomes. For
new treatments, effectiveness is determined by scientific evidence. For existing
treatments, effectiveness is determined first by scientific evidence, then by professional
standards, then by expert opinion.
The Covered Services must not be primarily for the convenience of the Participant or
Covered Provider.
The Covered Services must be cost- effective for this condition, compared to alternative
treatments, including no treatment. Cost-effectiveness does not necessarily mean lowest
price.
When applied to the care of an Inpatient, Medical Necessity also means that the Participant's
medical symptoms or condition are such that the services cannot be safely and effectively
provided to the Participant as an Outpatient.
The fact that a Covered Provider may prescribe, order, recommend, or approve a service or
supply does not, in and of itself, necessarily establish that such service or supply is
Medically Necessary under these plans.
The term Medically Necessary as defined and used in these plans is strictly limited to the
application and interpretation of these plans, and any determination of whether a service is
Medically Necessary is made solely for the purpose of determining whether services provided
are Covered Services.
Covered Providers
Covered Services must be rendered by Covered Providers acting within the scope of their
applicable license to be eligible for reimbursement under these plans.
Facility Providers. The following Facility Providers are the only type of Facility Providers
covered by these plans. A Facility Provider is an entity that is licensed, where required, to
render Covered Services within the scope of their license.
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Alcoholism or Substance Abuse Treatment Facility
Ambulatory Surgical Facility
Birthing Center
Cardiac Rehabilitation Facility
Diagnostic Imaging Provider
Free Standing Diabetes Facility
Free Standing Dialysis Facility
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Free Standing Diagnostic Imaging Center
Home Health Agency
Home Intravenous Therapy Company
Hospice
Independent Laboratory
Licensed General Hospital
Licensed Rehabilitation Hospital
Pharmacy
Prosthetic and Orthotic Supplier
Psychiatric Hospital
Radiation Therapy Center
Rehabilitation Hospital
Skilled Nursing Facility
Professional Providers. The following Professional Providers are the only type of
Professional Providers covered by these plans. A Professional Provider is a person or entity
that is licensed, where required, to render Covered Services within the scope of their
license.
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Ambulance
Audiologist
Cardiac Rehabilitation Therapist
Certified Nurse Midwife
Certified Registered Nurse Anesthetist
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Certified Registered Nurse First Assistants
Certified Social Worker with Private Practice Endorsement
Certified Speech Therapist
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Certified Surgical Assistants
Chiropractic Physician
Clinical Nurse Specialist
Clinical Psychologist
Dentist
Denturist
Durable Medical Equipment Supplier
Electroencephalogram (EEG) Provider
Licensed Marriage and Family Therapist
Licensed Occupational Therapist
Licensed Professional Counselor with Private Practice Endorsement
Lithotripsy Provider
Nurse Practitioner
Ocularist
Optometrist
Pharmacist
Physical Therapist
Physician
Physician Assistant
Podiatrist
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Non-Covered Providers. Services by all other providers are not covered by these plans.
For example, the following providers are not covered:
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Acupuncturist
Christian Science Service Provider
Convalescent Home
Facility that is primarily a place for treatment of the aged
Homeopathic Physician
Massage Therapist
Naturopaths
Nursing Home
Rest Home
Contracting Providers
Contracting Providers are Covered Providers who have agreed to recognize the applicable
Maximum Allowance as their fee for Covered Services by entering into an agreement. The
Blue Cross and/or Blue Shield Provider Network is the contracting provider network for the
Basic and Select Plans. Go to www.micronhealth.com to find contracting providers.
Blue Cross of Idaho participates in the BlueCard program, which is administered by
the Blue Cross and Blue Shield Association. This allows you to use the designated PPO
networks of all Blue Cross and/or Blue Shield plans. For example, you can use the following
PPO networks:
• Blue Cross of California PPO Network
(Blue Cross PPO) or Blue Shield of California
PPO Network (PPO Preferred Network)
if you receive medical care in California.
• Anthem Blue Cross and Blue Shield PPO
Network (Anthem Key Care PPO) if you
receive medical care in Virginia.
• Blue Cross Blue Shield of Minnesota Network if you receive medical care in
Minnesota.
• Blue Cross Blue Shield of Texas Network
(Health Care Service Corporation) if you
receive medical care in Texas.
When you receive medical services, be sure to present your ID card. After you have received
medical attention, the Contracting Provider may submit your claim electronically to Blue
Cross of Idaho for processing. If the provider does not submit your claim you will be
required to complete a claim form and submit the claim to Blue Cross of Idaho at the
following address:
Blue Cross of Idaho
P.O. Box 7408
Boise, ID 83707
Provider Choice.
The choice of a provider is solely the Participants. Neither the Health Plans nor its
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administrators furnish Covered Services. They only make payment for Covered Services
received by Participants. Neither the Micron Health Plans, Micron or its subsidiaries, Blue
Cross of Idaho, shall be liable for any act or omission or competence of any provider and
none of them have responsibility for a provider’s failure or refusal to provide Covered
Services to a Participant.
Covered Services
A Covered Service is a service, supply or procedure listed below that is both Medically
Necessary and provided by a Covered Provider. The following services are the only services
covered under these plans:
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Ambulance Services
Ambulatory Surgical Facility Services
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Bereavement Counseling
Birthing Center Services
Chiropractic Care Service
Dentistry Services related to an Accidental Injury
Diabetes Education Services
Diagnostic Services
Durable Medical Equipment
Home Health Skilled Nursing Care Services
Hospice Home Care Services
Hospital Services
Orthotic Devices
Pain Rehabilitation Service
Post Mastectomy Reconstructive Surgery Services
Prescription Drugs
Preventive Care Services
Professional Provider Services
Prosthetic Appliances
Rehabilitation Hospital Services
Skilled Nursing Services
Therapy Services
Transplant Services
Ambulance Services
What is Covered. Ambulance Services are Covered Services. Ambulance Services include:
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Transportation from a Participant’s home or scene of Accidental Injury or emergency
medical condition to a local Licensed General Hospital,
Transportation between Licensed General Hospitals,
Transportation between a Licensed General Hospital and a Skilled Nursing Facility,
Transportation from a Licensed General Hospital to a Participant’s home,
Transportation from a Skilled Nursing Facility to a Participant’s home,
Transportation to the closest facility outside the local community that can provide the
necessary service if there is no facility in the local community that can provide the
appropriate Covered Services, and
Medically Necessary on-site treatments by Ambulance personnel, which do not result in
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transportation.
Specific Limitations and Exclusions. Ambulance Services are subject to general
exclusions. See the "General Exclusions" section for more information.
Ambulatory Surgical Facility Services
What is Covered. The following services and supplies provided by an Ambulatory Surgical
Facility are Covered Services:
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Outpatient Surgery including the removal of sutures and
Anesthesia and anesthesia supplies and services rendered by an employee of the
Ambulatory Surgical Facility who is not the surgeon or surgical assistant.
Specific Limitations and Exclusions. Ambulatory Surgical Facility Services are subject to
the following limitation:
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Specially constructed braces and supports provided during a procedure at an Ambulatory
Surgical Facility are considered Orthotic Devices and are subject to the specific
limitations for Orthotic Devices. See the "Orthotic Device" section for more information.
Ambulatory Surgical Facility Services are also subject to general exclusions. See the
"General Exclusions" section for more information.
Birthing Center Services
What is Covered. Services and supplies provided by a Birthing Center are Covered
Services.
Specific Limitations and Exclusions. Birthing Center Services are subject to general
exclusions. See the "General Exclusions" section for more information.
Chiropractic Care Services
What is Covered. Any Covered Service that is rendered, referred or prescribed by a
Chiropractic Physician when practicing within the scope of their license, including
acupuncture, are Covered Services.
Specific Limitations and Exclusions. Chiropractic Care Services are also subject to
general exclusions. See the "General Exclusions" section for more information.
Dentistry Services Related to an Accidental Injury
What is Covered. The treatment of teeth and supporting structures including the
replacement of teeth are Covered Services when all of the following criteria are met:
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Services must be provided by a Physician or Dentist and
Services must be required as a result of Accidental Injury to the jaw, sound natural
teeth, mouth or face.
Specific Limitations and Exclusions. Dentistry is subject to the following limitations:
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There are no Covered Services for dentistry that is provided after 12 months from the
date of injury unless the delay in treatment was Medically Necessary, and
There are no Covered Services for dentistry related to Accidental Injuries due to chewing
or biting.
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Dentistry Services related to an Accidental Injury are subject to General Exclusions. See the
"General Exclusions" section for more information.
Diabetes Education Services
What is Covered. Outpatient diabetes education for a Participant who is either newly
diagnosed with diabetes or has had a recent complication of diabetes is a Covered Service.
Outpatient diabetes education includes instruction in the basic skills of diabetes
management through books and educational material as well as an individual or group
consultation with a certified diabetes educator, nurse or dietitian.
Diabetes Education is a Covered Service when all of the following criteria are met:
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The program is hospital based and meets the standards of the American Diabetes
Association or is supervised by a certified diabetes educator or nurse educator with
documented credentials,
The Participant is referred to the program by a Physician,
The program provides written communication back to the referring Physician, and
The Participant completes the program.
Specific Limitations and Exclusions. Diabetes Education Services are also subject to
general exclusions. See the "General Exclusions" section for more information.
Diagnostic Services
What is Covered. Tests or procedures are Covered Services when both of the following
criteria are met:
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Tests or procedures must be performed on the order of a Physician or other Professional
Provider, and
Tests or procedures must be performed either because of specific symptoms in order to
identify a particular condition, Disease, Illness or Accidental Injury, or as part of
Preventive Care Services. See the "Preventive Care Services" section for more
information.
Diagnostic Services include the following:
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Radiology services,
Laboratory and pathology services, and
Cardiographic, encephalographic and radioisotope tests.
Specific Limitations and Exclusions. Diagnostic Services are also subject to general
exclusions. See the "General Exclusions" section for more information.
Durable Medical Equipment
What is Covered. The rental or purchase of Medically Necessary Durable Medical
Equipment is a Covered Service when all of the following criteria are met:
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The equipment must be prescribed by a Physician or other Professional Provider within
the scope of their license,
The equipment must be primarily used for therapeutic use,
The equipment can withstand repeated use,
The equipment is generally not useful to a person in the absence of Accidental Injury,
Disease or Illness, and
The equipment is appropriate for use in a home.
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Durable Medical Equipment includes the following:
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Blood glucose meters,
Control solutions, and
Glucose/dextrose.
Specific Limitations and Exclusions. Durable Medical Equipment is subject to the
following limitations:
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The Plan will pay the lesser of either the purchase or rental of Durable Medical
Equipment. For assistance in determining the lowest cost option call Blue Cross of Idaho
at (800) 358-5527.
Eyeglasses and contact lenses are not Covered Services.
Hearing aids are not Covered Services.
Items for personal hygiene, comfort, beautification or convenience even if prescribed by
a Physician are not Covered Services. For example, air conditioners, air purifiers,
humidifiers, physical fitness equipment or programs, spas, hot tubs, whirlpool baths,
waterbeds, swimming pools, wigs, and cold therapy units are not Covered Services.
Specifically constructed braces and supports are considered Orthotic Devices and are
subject to specific limitations. See the "Orthotic Device" section for more information.
Special clothing is not Covered Services. This includes shoes unless they are permanently attached to a brace.
Replacement of Durable Medical Equipment is limited to the lesser of five years or the
product’s warranty period.
Durable Medical Equipment is subject to payment limitations. See the "Yearly Benefit
Maximums and Other Limitations" section and the "Chart of Special Provisions" for more
information.
Durable Medical Equipment is also subject to general exclusions. See the "General
Exclusions" section for more information.
Home Health Skilled Nursing Care Services
What is Covered. Professional nursing services provided in a Participant’s home are
Covered Services when all of the following criteria are met:
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The services must be provided by a licensed registered nurse (R.N.) or a licensed
practical nurse (L.P.N.),
The services provided are services that can only be provided by an R.N. or an L.P.N.,
The R.N. or L.P.N. does not ordinarily reside in the Participant’s household,
The R.N. or L.P.N. is not related to the Participant by blood or marriage, and
The services must not constitute Custodial Care, or 24 hour care, to be Covered
Services.
Specific Limitations and Exclusions. Home Health Skilled Nursing Care Services are
subject to the following limitation:
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Home Health Skilled Nursing Care Services provided while a Participant is receiving
Hospice home care visits are not Covered Services.
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Home Health Skilled Nursing Care Services includes oroviding training to a family
member or non-professional caregiver when a Participant’s condition is expected to
require Custodial Care.
Home Health Skilled Nursing Care Services are also subject to general exclusions. See the
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"General Exclusions" section for more information.
Hospice Home Care Services
What is Covered. Hospice Home Care Services are Covered Services. Hospice Home Care
Services include:
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Hospice nursing care visits, which include Skilled Nursing Care and care provided by a
home health aide,
Hospice nursing care visits during a period of crisis when a Participant’s needs demand
Skilled Nursing Care in order to maintain a terminally ill Participant at home (also known
as continuous crisis care),
Medical care provided by a Contracting Physician,
Therapy Services provided by a Hospice,
Medical social services, psychological social assessment and counseling of a Participant
provided by a Certified Social Worker with Private Practice Endorsement,
Individual and group counseling services for immediate family members or primary care
giver related to coping with the Participant’s condition,
Initial and follow-up dietary counseling sessions provided by a certified dietitian,
Medical and surgical supplies,
Durable Medical Equipment,
Oxygen and its administration, and
Care provided to a home bound Participant for the purpose of providing the primary care
giver a temporary period of rest from the stress and physical exhaustion involved in
caring for the Participant at home (also known as respite care).
Specific Limitations and Exclusions. Hospice Home Care Services are subject to the
following limitation:
• Services must be provided by a Contracting Hospice.
Hospice Home Care Services are also subject to general exclusions. See the "General
Exclusions" section for more information.
Hospital Services
What is Covered. The following services and supplies are Covered Services when provided
by a Licensed General Hospital or Psychiatric Hospital for treatment of a Participant’s
Pregnancy or Related Condition, Accidental Injury, Disease, Illness or Mental Health and
Substance Abuse. Services and supplies include the following:
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Bed (includes a bed in a special care unit or a nursery), board, special diets, the services
of a dietician and general nursing services,
Use of emergency room, operating room, delivery room, cast room and other treatment
rooms and equipment,
Prescribed drugs,
Administration and processing of whole blood and blood products used in a transfusion,
and whole blood and blood plasma that is not donated on behalf of the Participant or
replaced through contributions by or on behalf of the Participant,
Anesthesia and anesthesia supplies and services,
Medical and surgical dressings, supplies, casts and splints that have been ordered by a
Physician,
Oxygen and the administration of oxygen,
Diagnostic Services provided by a Physician under contract with the Facility Provider,
Therapy Services provided by a Physician under contract with the Facility Provider, and
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•
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Preadmission testing including tests and studies required in connection with a
Participant’s admission to a Licensed General Hospital for Surgery.
Partial Hospital Program (PHP) when medically necessary and approved as a cost
effective alternative to inpatient hospitalization to treat a covered service.
Intensive Outpatient Program (IOP) when medically necessary and approved as a cost
effective alternative to inpatient hospitalization to treat a covered service.
Specific Limitations and Exclusions. Hospital Services are subject to the following
limitations and exclusions:
•
•
•
•
Most medical and Surgical Inpatient Hospital Services require preauthorization. See the
"Pre-Service Claim" section for more information.
Preadmission testing must be performed within seven days of the Inpatient admission.
Preadmission testing is only covered if the tests are not repeated when the Participant is
admitted to the Licensed General Hospital and if the tests are included in the Inpatient
medical records.
Specially constructed braces and supports provided during an In-patient hospital stay
are considered Orthotic Devices and are subject to the specific limitations. See the
"Orthotic Device" section for more information.
Preadmission testing if the Participant cancels or postpones admission to the Licensed
General Hospital is not a Covered Service.
•
Maternity services for Participants who are dependent children are not Covered Services.
•
Behavior modification programs such as boot camps, military schools, wilderness
therapy and similar programs are not Covered Services.
The extraction of teeth or other dental procedures unless necessary to treat an
Accidental Injury or unless an attending Physician or Dentist certifies in writing that the
Participant is under age 10 and requires general anesthesia, or has a non-dental, lifeendangering condition which makes Inpatient or Outpatient hospitalization necessary to
safeguard the Participant’s health and life are not Covered Services.
Inpatient admissions that are primarily for Diagnostic Services, Therapy Services, and
bed rest are not Covered Services.
Charges by a Licensed General Hospital for the Participant’s failure to vacate a room on
or before the established discharge hour are not Covered Services.
A Hospital admission that begins one plan year and continues into the following plan
year will be covered under the active Medical plan at the time of the admission, and will
not be subject to a new hospital admission copayment or new calendar year deductible.
Future hospital admissions will be subject to copay and deductible.
•
•
•
•
•
Preauthorization is not required for inpatient hospital admissions outside the United
States.
Hospital Services are also subject to general exclusions. See the "General Exclusions"
section for more information.
Orthotic Devices
What is Covered. Rigid or semi-rigid supportive devices that restrict or eliminate motion of
a weak or Diseased body part are Covered Services.
Orthotic Devices include Medically Necessary braces, back or special surgical corsets, splints
for extremities, and trusses, arch supports, orthotics, orthopedic or corrective shoes and
other supportive appliances for the feet, when prescribed by a Physician, Chiropractic
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Physician, Podiatrist or Physical Therapist.
Specific Limitations and Exclusions. Orthotic Devices are subject to the following
limitation:
•
•
Garter belts are not Covered Services.
Coverage for arch supports, orthopedic or corrective shoes are limited to one pair, or two
singles, every 12 months.
Orthotic Devices are also subject to general exclusions. See the "General Exclusions" section
for more information.
Pain Rehabilitation Services
What is Covered. Pain Rehabilitation Services that are intended to teach the Participant
how to control and cope with pain and regain normal function are Covered Services when all
of the following criteria are met:
•
•
•
Services must be provided on an Inpatient basis by qualified health care professionals,
Services must be provided under the order of an attending Physician, and
Services must be provided to a Participant who is suffering chronic, intractable pain
which has failed to respond to medical or surgical treatment.
Specific Limitations and Exclusions. Pain Rehabilitation Services are subject to general
exclusions. See the "General Exclusions" section for more information.
Post Mastectomy Reconstructive Surgery Services
What is Covered. Reconstructive Surgery in connection with a mastectomy is a Covered
Service. Reconstructive Surgery includes the following services:
•
•
•
Reconstruction of the breast on which the mastectomy was performed,
Surgery and reconstruction of the other breast to produce a symmetrical appearance,
and
Prostheses and treatment of physical complications at all stages of the mastectomy,
including lymphedemas.
Specific Limitations and Exclusions. Post Mastectomy Reconstructive Surgery Services
are subject to general exclusions. See the "General Exclusions" section for more information.
Prescription Drugs
What is Covered. FDA approved Prescription Drugs dispensed by Pharmacists either at a
retail pharmacy or through a mail order program are Covered Services.
Open Formulary. The Plan has an open formulary which means your use of the formulary
(or Formulary brand) is optional. However, costs are higher for non-formulary products. The
formulary is designed as a reference guide to assist Physicians in the selection of
pharmaceutical products and is not intended as a substitute for your Physician’s clinical
knowledge and judgment. The formulary is reviewed on an ongoing basis by a SelectHealth
committee of Physicians and Pharmacists. A Prescription Drug is added to the formulary only
after the committee evaluates it for safety and effectiveness. Only Prescription Drugs that
have been approved by the Food and Drug Administration are reviewed by the Committee.
When two or more Prescription Drugs are equally effective in treating or curing a specific
Disease or Illness, other factors such as ease of dosing, cost and availability are considered
when deciding which Prescription Drug to put on the formulary. The formulary list can be
found by following this menu path on Micron’s intranet: MERC > HROnline , or call the HR
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Customer Service Center at (800) 336-8918 or (208) 368-4748.
How to Use the SelectHealth Home Delivery/Mail Order. Some Prescription Drugs are
not available through mail order. Contact SelectHealth to verify availability. To have your
prescriptions delivered to your home you should complete the Home Delivery form and mail
it to SelectHealth. You can obtain a Home Delivery order form at www.micronhealth.com >
SelectHealth Pharmacy and follow the prompts to activate your account on-line, change
prescriptions to home delivery or fill a new prescription. You will receive your prescription in
7-10 days.
Your order will be processed and delivered to you with free standard shipping.
Your order may be delayed if you do not provide all information requested on the form and
submit payment with your order.
Reimbursement of Prescription Drugs Purchased Outside the United States. FDA
Approved Prescription Drugs purchased outside the U.S. will need to be paid for at the time
of service and submitted to SelectHealth for reimbursement. Submit claims to the address
on the back of your pharmacy ID card. The Plan will reimburse covered Prescription Drugs
for Participants living or traveling outside the United States when new drug therapy is
initiated for acute conditions or where emergency replacement of drugs originally prescribed
and purchased in the United States is necessary. The reimbursable supply of drugs in travel
situations will be limited to an amount necessary to assure continuation of therapy during
the travel period and for a reasonable period thereafter.
If a service, supply, drug, or other charge would not be a Covered Service in the United
States, then it also will not be a Covered Service outside the United States.
Special Rules and Specific Prescription Drug Limitations. Certain Prescription Drugs
require Preauthorization. Call SelectHealth at (800) 442-3127 or view their Website through
www.micronhealth.com, or call the HR Customer Service Center at (800) 336-8918 or (208)
368-4748 to determine if a particular prescription drug requires preauthorization.
Your provider must call SelectHealth at (800) 442-3129 to obtain approval for a
prescription drug that requires preauthorization. Participants cannot initiate a prescription
drug preauthorization. For prescription drug preauthorizations that are subject to the
general medical benefit, you may also obtain the Pre-Authorization form from
www.micronhealth.com. Fax the Pre-Authorization form to SelectHealth at (801) 442-3006.
Verbal or written communication will be given to the provider’s office.
Oral contraceptive prescription drugs and other prescription hormonal contraceptives, such
as NuvaRing and Ortho Evra patch dispensed by a Pharmacist either at a retail pharmacy or
through a mail order program are Covered Services under the Prescription Drug program.
Devices, injectable and insertable methods of temporary contraception, such as diaphragms,
IUDs, Depo-Provera, and implantable contraceptive hormone methods, including but not
limited to Implanon, that are prescribed by a Covered Provider are Covered Services under
the preventive care medical benefit.
•
Prescription birth control is covered under the preventive care benefit at a pharmacy or
physician office visit depending on the type/form of birth control being utilized.
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•
Prescriptions will be available for refill after 75% of the current prescription has been
used. There are two exceptions to this rule. If you are planning to travel away from
home and are concerned about obtaining a Prescription Drug refill while away, you may
request up to a maximum 90 day supply for a "vacation early refill override" prior to
your departure. To obtain a "vacation early refill override", call SelectHealth at (800)
442-3127 with the medication name, strength, directions and dates of travel.
•
If you are going on an International work assignment for Micron, you may request a one
year supply of a prescribed maintenance medication for you or your eligible dependents
who will be on assignment with you. To request a "1 year international assignment
advance fill", call SelectHealth at (800) 422-3127 with the medication name, strength,
directions and dates of travel. SelectHealth will verify your Micron international
assignment prior to authorizing the transaction.
•
All requests will be reviewed by SelectHealth Pharmacy Management staff, and if
appropriate, the Physician that wrote the prescription. Please allow five business days for
the completion of the review.
Prescriptions that are lost, accidentally destroyed, spilled or stolen, are not eligible for an
“early refill override”.
•
•
A prescription for the same medication as a Participant’s current prescription, except
that the dosage is different, will be considered by the Plan to be a new prescription, and
will not be considered a refill.
•
SelectHealth reviews Prescription Drug usage. If there are patterns of over-utilization or
other facts that appear to suggest over-utilization or misuse of Prescription Drugs, the
enrolled Participant’s Physician and Pharmacist will be notified by SelectHealth. They
may also contact law enforcement if criminal conduct is suspected.
Certain new maintenance prescriptions require a 30 day fill prior to filling a 90 day
supply.
•
•
Certain new prescriptions for Tier 3 medications may require trying less-expensive
generics or generic alternatives before using a brand-name drug.
•
Certain oral specialty medications may be limited to a two-week supply prior to filling a
one month supply.
•
Compound medications will be covered under Tier 3 Prescription (Brand Name NonFormulary).
Prescription Drug Exclusions.
The following are not covered under the Prescription Drug program.
•
Refills in excess of the number prescribed are not Covered Services.
•
Refills after one year from the original date of the prescription are not Covered Services.
•
Over-the-counter drugs or vitamins other than insulin even if prescribed by a Physician
are not Covered Services.
•
Non-sedating antihistamines including but not limited to, Clarinex, Clarinex D, Claritin,
and Xyzal are not Covered Services.
•
Brand name prescription Prozac, Prozac Weekly, and Serafem are not Covered Services.
•
Replacement of supplies or medications that are used inappropriately including
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medications determined to be abused or otherwise misused are not Covered Services.
•
Emergency contraception agents are not Covered Services.
•
Over the counter contraception agents are not Covered Services.
•
Prescription Drugs prescribed primarily to retard the rate of hair loss or aid in the
replacement of lost hair are not Covered Services.
•
Prescription Drugs prescribed primarily for cosmetic purposes, including Renova, and
injectable cosmetics are not Covered Services.
•
Prescription Drugs used to treat impotency or regulate fertility are not Covered Services.
•
Certain glucometer supplies are not Covered Services.
•
Homeopathic medications, including medical marijuana, taken separately or in
combination with a prescription medication are not Covered Services.
•
Nutraceuticals are not Covered Services.
•
Ketek is not a Covered Service.
•
Certain leukotriene inhibitors are not Covered Services.
•
Certain proton pump inhibitors are not Covered Services.
•
Lotronex (if age is less than 18 years) is not a Covered Service.
•
Depigmentation Agents are not Covered Services.
•
•
Serum, toxoids, vaccines are not Covered Services.
Prescription Drugs prescribed primarily to aid or assist in weight loss, including all
anorectics, are not Covered Services.
•
Prescription Drugs included on the “SelectHealth Non-Covered Prescription Products”
document.
•
Medications not meeting the minimum levels of evidence based upon one or more of the
following:
•
Food and Drug Administration (FDA) approval;
•
The medication has no active ingredient and/or clinically relevant studies as
determined by the SelectHealth Pharmacy and Therapeutics Committee;
•
National Comprehensive Cancer Network (NCCN); or
•
As defined within SelectHealth’s preauthorization criteria or medical policy.
This list is subject to change without notice.
If abuse of Prescription Drugs is suspected, these plans may notify you and your prescribing
providers and future Prescription Drugs limited to those pre-authorized by SelectHealth.
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Limitations and exclusions of the Plan apply. Contact SelectHealth at (800) 422-3127 if you
have any questions about prescription drug exclusions. Prescription Drugs are also subject
to Micron’s general exclusions. See the "General Exclusions" section for more information.
Preventive Care Services
Preventive care services including diagnostic testing and lab tests provided by a Covered
Provider are included in well-care services. The greatest savings will be achieved by using a
Contracting Provider.
Annual well-care services provided to participants do not require an office visit copay,
coinsurance, or deductible, up to the Maximum Allowance, if recommended by current
evidence-based guidelines approved by Blue Cross of Idaho. Each service is limited to once
per year in association with a wellness visit except as otherwise indicated. On subsequent
visits, the normal plan provisions apply regarding office visit copays, coinsurance, and
deductibles.

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Normal Physical Examinations for children and adults, including all well-baby care for
infants
Gynecological Examinations including pap test and fecal occult blood test
Immunizations/Vaccinations, including flu shots (not limited to once per year)
Lipid panel including cholesterol screening
Complete blood count (CBC)
Comprehensive metabolic panel or general health panel
Electrocardiogram (EKG)
Urinalysis (UA)
Breast cancer screening (mammogram)
Prostate cancer screening and associated PSA test
Bone density screening
Lung cancer screening
Colon and rectal cancer screening (limited to once every 5 years)
Devices, injectable and insertable methods of temporary contraception, such as
diaphragms, IUDs, Depo-Provera, and implantable contraceptive hormone methods,
including but not limited to Implanon
Cystic Fibrosis testing, provided any one of the following criteria is met;
o Mother age 35 or older,
o Mother has another natural child with a Genetic disorder or major
malformations,
o Known family history of genetic disorder (either parent)
o History of 3 or more miscarriages,
o Either parent is a known carrier
Breast Pump Benefit
What is Covered. The Select U.S. Plan will reimburse up to $150 maximum toward the
purchase of a breast pump for nursing mother participants. The $150 maximum benefit
limit does not apply to nursing mothers where a breast pump is medically necessary due to
the mother or infant health condition. The breast pump benefit is only available to
Participants who are mothers or expectant mothers. The breast pump must be purchased
within 180 days of a pre-natal or delivery claim by the covered Participant. Any amounts
paid in excess of $150 for the breast pump purchase will be the member responsibility.
Participant must purchase the breast pump and submit a direct reimbursement claim form
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to Blue Cross of Idaho.
Professional Provider Services
What is Covered. The following services and supplies are Covered Services when provided
by a Professional Provider for treatment of a Participant’s Accidental Injury, Disease, Illness,
pregnancy or related condition, Alcoholism, Mental Health and Substance Abuse or
Addiction:
•
•
•
Inpatient medical services provided to a Participant receiving Covered Services in a
Licensed General Hospital, Rehabilitation Hospital, Skilled Nursing Facility, Alcoholism or
Substance Abuse Treatment Facility, or Psychiatric Hospital,
Consultation services provided to a Participant who is receiving Covered Services in a
Licensed General Hospital, Rehabilitation Hospital, Skilled Nursing Facility, Alcoholism or
Substance Abuse Treatment Facility or Psychiatric Hospital,
Outpatient medical services provided to a Participant receiving Covered Services in an
emergency room, office, clinic or home,
•
Therapy Services in an office setting,
•
•
•
•
•
Psychiatric Therapy services and procedures in an office setting,
Surgical Services and surgical assistant services,
Sterile suture or Surgery trays used by a Professional Provider during Surgical Services,
Administration of anesthesia, and
Second and third Surgical opinions for elective Surgery.
Specific Limitations and Exclusions. Professional Provider Services are subject to the
following limitations:
•
If you receive inpatient or emergency covered services provided by hospital-based, nonnetwork physician specialties when you are receiving care at a contracting facility,
benefits will be provided at the benefit level of the contracting facility (PPO or noncontracting).
•
Benefits are subject to the applicable deductible, copay and maximum out-of-pocket
expense provisions of the plan. Hospital-based physician specialties are
anesthesiologists, emergency room physicians, hospitalists, neonatologists, pathologists
and radiologists. Emergency room physicians are physicians staffed in the emergency
room. This does not include physicians who may be called in to treat a participant or
provide follow-up care. Physicians who are not one of the hospital-based specialties
listed above will be covered based on the providers' network affiliation at the time of
service (PPO or non-contracting).
•
Multiple Surgical procedures performed during the same operative session by one or
more Physicians or other Professional Providers shall be paid based upon Blue Cross of
Idaho payment guidelines concerning multiple surgical procedures.
Administration of anesthesia is a Covered Service only when provided by a Physician or
other Professional Provider other than the surgeon or Surgical assistant in conjunction
with the Covered Service.
Sterile suture or Surgery trays are Covered Services only when Surgery is performed by
a Physician or other Professional Provider in an office setting.
Second surgical opinions are Covered Services only when the second opinion is given by
a Physician other than the Physician who first recommended elective Surgery.
Third Surgical opinions are Covered Services only when the first Surgical opinion
•
•
•
•
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•
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•
•
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2015
conflicts with the second Surgical opinion, and only when the third opinion is given by a
Physician other than the Physician who first recommended elective Surgery or the
Physician who made the second Surgical opinion.
Maternity and pregnancy termination services for covered dependent children are not
Covered Services.
Staff consultations that are required by Professional Facility rules and regulations are not
Covered Services.
Vision examinations are not Covered Services.
Surgical procedures that alter the refractive character of the eye including radial
keratotomy, myopic keratomileusis and other surgical procedures of the refractive-keratoplasty type are not Covered Services even if Medically Necessary.
Reversals, revisions or complications of surgical procedures that alter the refractive
character of the eye are not Covered Services except those required to correct an
immediately life-endangering condition.
Examinations for the prescription or fitting of hearing aids are not Covered Services.
Pastoral and spiritual counseling are not Covered Services.
Marriage counseling is not a medical service and is not covered by the Plan, but the Plan
will cover medical services provided by Covered Licensed Marriage and Family
Therapists.
Telephone consultations are not Covered Services.
Charges for the use of treatment rooms or equipment located in a Professional Provider’s
office are not Covered Services.
Charges for failure to keep a scheduled visit or appointment are not Covered Services.
Charges for completion of a claim form are not Covered Services.
Your expenses for mileage, transportation, food or lodging while seeking medical care
are not Covered Services.
Expenses for mileage, transportation, food or lodging billed by a Physician or other
Professional Provider are not Covered Services.
Services provided by a Professional Provider who is related to the Participant by blood or
marriage and who ordinarily dwells in the Participant’s household are not Covered
Services.
See the "Other Limitations" section and the "Chart of Special Provisions" for more
information.
Professional Provider Services are also subject to general exclusions. See the "General
Exclusions" section for more information.
Specialty Injectable Medications
What is Covered. Outpatient infusion services, where the primary service being performed
is the infusion of medication, will require preauthorization of the out-patient infusion
services and the medication by Blue Cross of Idaho. For example, if a member is prescribed
intravenous therapy for the treatment of rheumatoid arthritis that is administered on an
outpatient basis, the service of infusion therapy will require preauthorization. Certain
Specialty Injectable Medications, if self-administered, may be covered under a Member’s
Pharmacy benefit. A Member’s provider may inquire as to whether a Specialty Injectable
Medication and/or out-patient infusion services is covered as a pharmacy benefit or medical
benefit, at the time Preauthorization is being obtained from Blue Cross of Idaho. To obtain
preauthorization contact Blue Cross of Idaho at 1-800-358-5527.
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Specific Limitations and Exclusions. Infusion services where the primary service being
performed is the infusion of medication is subject to the following limitations:
•
Outpatient infusion services, where the primary service being performed is the infusion
of medication, will require preauthorization of the out-patient infusion services, and
possibly the medication or both. See the "Pre-Service Claim" section for more
information, including information on penalties for failure to preauthorize.
Outpatient infusion services, where the primary service being performed is the infusion of
medication is subject to payment limitations. See the "Yearly Benefit Maximums and Other
Limitations" section and the "Chart of Special Provisions" for more information.
Prosthetic Appliances
What is Covered. The purchase, fitting, necessary adjustment, repair and replacement of
Prosthetic Appliances are Covered Services. Prosthetic Appliances are appliances that
replace all or part of an absent body organ, including contiguous tissue, or the function of a
permanently inoperative or malfunctioning body organ. Prosthetic Appliances include post
mastectomy prostheses.
Specific Limitations and Exclusions. Prosthetic Appliances are subject to the following
limitations:
•
•
•
•
•
With the exception of mastectomy prostheses, prosthetic Appliances require preauthorization. See the "Pre-Service Claim" section for more information, including information
on penalties for failure to preauthorize a prosthetic appliance.
The standard, most economical Prosthetic Appliance that is consistent with your
condition, according to generally accepted medical treatment practices, are Covered
Services. If a more expensive Prosthetic Appliance than is consistent with generally
accepted medical treatment practices is chosen, there are no Covered Services for the
excess charge. For assistance in determining the lowest cost option call Blue Cross of
Idaho at (800) 358-5527.
The first required contact lens and/or the first pair of eyeglasses following cataract
Surgery are Covered Services only when purchased within 90 days of the cataract
surgery.
The rental or purchase of any synthesized or artificial speech or communication output
device or system or any similar device, appliance or computer system designed to
provide speech output or to aid an inoperative or unintelligible voice, except for voice
boxes used to replace all or part of a surgically removed larynx are not Covered Services.
Dental appliances and major Artificial Organs, including but not limited to, artificial
hearts and pancreases, are not Covered Services.
Prosthetic Appliances are subject to payment limitations. See the "Yearly Benefit Maximums
and Other Limitations" section and the "Chart of Special Provisions" for more information.
Prosthetic Appliances are also subject to general exclusions. See the "General Exclusions"
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section for more information.
Rehabilitation Hospital Services
What is Covered. Services and supplies provided by a Rehabilitation Hospital are Covered
Services when the following criteria is met:
•
Services and supplies must be intended to restore physical health and well-being as
close as possible to the level that existed immediately prior to the Disease, Illness or
Accidental Injury.
Specific Limitations and Exclusions. Rehabilitation Hospital Services are subject to the
following limitations:
•
•
Inpatient care must begin within 120 days of discharge from a Licensed General
Hospital, and
npatient admissions that are primarily for Diagnostic Services, Therapy Services, bed
rest, special diet and behavioral problems are not Covered Services.
Rehabilitation Hospital Services are also subject to general exclusions. See the "General
Exclusions" section for more information.
Skilled Nursing Services
What is Covered. The following services and supplies are Covered Services when provided
by a Skilled Nursing Facility for treatment of a Participant’s Accidental Injury, Disease, or
Illness:
•
•
•
•
•
•
Bed, board, special diets, the services of a dietician and general nursing services,
Use of treatment rooms and equipment,
Prescribed drugs,
All medical and surgical dressings and supplies,
Oxygen and the administration of oxygen, and
Therapy Services prescribed by a Physician.
Specific Limitations and Exclusions. Skilled Nursing Services are subject to the following
limitations:
•
•
•
•
Services for care consisting primarily of room and board, routine nursing care, training,
supervisory or Custodial Care are not Covered Services.
Care for senile deterioration, mental deficiency or mental retardation are not Covered
Services.
Care for Mental Health and Substance Abuse, Alcoholism or Addiction are not Covered
Services.
Physiotherapy, hydrotherapy, Speech Therapy and Occupational Therapy when Skilled
Nursing Care is not required.
Skilled Nursing Services are also subject to general exclusions. See the "General Exclusions"
section for more information.
Therapy Services
What is Covered. The following Therapy Services are Covered Services:
•
•
•
Chemotherapy,
Enterostomal Therapy,
Intravenous Therapy,
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2015
Nutritional Formula Therapy,
Occupational Therapy,
Orthoptics (Vision Therapy),
Physical Therapy,
Radiation Therapy,
Renal Dialysis,
Respiration Therapy, and
Speech Therapy
Nutritional Formula Therapy is a Covered Service when the following criteria are met:
•
•
•
•
•
Nutritional Formula Therapy must be related to developmental and rehabilitative care
where there is a reasonable expectation that the services will maintain adequate weight
and nutrition of the Participant during the first 5 years of life,
Enteral Therapy consists of formula/nutritional solutions administered through the
Gastrointestinal tract, gastrostomy tube or jejunostomy tube. Enteral Therapy is a
covered service when it is the only means of sustaining life but it must be reviewed for
medical necessity on a case by case basis if the Participant is over age 5.
Parenteral Therapy by Intravenous tract is a covered service when the Gastrointestinal
tract is nonfunctional and must be reviewed for medical necessity on a case by case
basis when given in an outpatient setting (such as Participant’s home).
Nutritional Formula Therapy must be prescribed by a Physician, and
The nutritional formula prescribed by the Physician must not be available over the
counter.
Physical Therapy is a Covered Service when both of the following criteria are met:
•
•
The services provided must be related to developmental and rehabilitative care where
there is a reasonable expectation that the services will produce significant improvement
in the Participant’s condition in a reasonable period of time, and
Services must be provided by a Physician, a Physical Therapist or a Podiatrist.
Speech Therapy is a Covered Service when both of the following criteria are met:
•
•
Services must be related to developmental and rehabilitative care where there is a
reasonable expectation that the services will produce significant improvement in the
Participant’s condition in a reasonable period of time, and
Services must be provided by a Physician or a speech therapist.
Specific Limitations and Exclusions. Therapy Services are subject to the following
limitations:
•
Physical Therapy that is repetitive exercise to improve gait and maintain strength and
endurance is not a Covered Service.
• Physical Therapy that is range of motion and passive exercise not related to restoration
of a specific loss of function but is useful in maintaining range of motion in paralyzed
extremities is not a Covered Service.
• Physical Therapy that is assistance for walking is not a Covered Service.
• Physical Therapy provided in a health club, fitness facility or other similar setting is not a
Covered Service. Physical Therapy facility related expenses including health club dues or
fee are not Covered Services.
• Physical Therapy expense for general exercise programs, even when recommended or
provided by a Physician, Physical Therapist or Podiatrist are not Covered Services..
Therapy Services are also subject to general exclusions. See the "General Exclusions"
section for more information.
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Transplant Services
What is Covered. Hospital Services and Professional Provider Services are Covered
Services for the recipient of Medically Necessary transplants or auto transplants (the
surgical transfer of an organ or tissue from one location to another within the same
individual) of the following organs or tissue regardless of their source:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
artery,
blood,
bone marrow/stem cells,
cartilage,
cornea,
ear bone,
heart,
heart/lung combination,
heart valves,
kidney,
liver,
lung,
muscle,
pancreas/kidney combination,
skin,
tendon, and
vein.
Hospital Services and Professional Provider Services are also Covered Services for the
recipient of Medically Necessary implants of artificial or mechanical pacemakers.
The recipient must have the transplant performed at a Licensed General Hospital that has
arrangements with Blue Cross of Idaho for the delivery for the requested transplant and is
approved by Blue Cross of Idaho based on the recommendation of their medical director.
See the “Pre-Service Claim” section for more information.
Approved transplant service providers are considered to be PPO providers.
Donor costs related to donating or transplanting an organ or tissue for a recipient who is a
Participant on these plans are Covered Services.
Transplant Travel Benefit. In connection with a transplant when such travel is
preauthorized by Blue Cross of Idaho Medical Management as part of the preauthorization
requirement for Transplants. Your benefits will include reimbursement for daily expenses up
to a maximum of $50 per day for the Participant receiving the organ transplant and $50 per
day for an individual accompanying the Participant receiving the organ transplant.
Transportation and lodging expenses will also be reimbursed for the Participant and an
individual accompanying the Participant receiving the organ transplant, provided that the
expenses must comply with Micron Travel policies. The maximum aggregrate Travel Benefit
payable shall not exceed $10,000 for each procedure.
Specific Limitations and Exclusions. All Transplant Services are subject to the following
limitations:
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Transplant Services require preauthorization. See the "Pre-Service Claim" section for
more information, including information on penalties for failure to preauthorize a
transplant.
Costs related to a donor’s complications arising from transplant Surgery are not Covered
Services.
Costs for transporting the donor or the donated organ or tissue are not Covered
Services.
Costs for purchasing a human organ or tissue are not Covered Services.
Costs funded by government, foundation or charitable grants or programs are not
Covered Services.
Costs for donating or transplanting an organ or tissue for a person who is not a
Participant of these plans are not Covered Services.
Physician fees generally not charged in the absence of insurance coverage are not
Covered Services.
Transplants of adrenal gland, brain membrane, brain tissue, hair transplant, intestine,
islet tissue, pancreas, pituitary gland, or any other transplant not specifically listed, are
not Covered Services.
Transplants of Artificial Organs, including but not limited to artificial hearts or pancreases, are not Covered Services.
Transplant recipient may have to meet certain criteria, such as participation or
completion of a treatment program, or a defined number of months of being alcoholfree, to qualify for transplant services.
Travel Benefit. In limited circumstances, Blue Cross of Idaho Medical Management may
recommend travel to a distant provider to receive necessary and essential medical care at a
substantial savings for the Plan. When such travel is approved by Blue Cross of Idaho
Medical Management, your benefits will include reimbursement for daily expenses up to a
maximum of $50 per day for the Participant receiving medical care and $50 per day for an
individual accompanying a minor Participant. Transportation and lodging expenses will also
be reimbursed for the Participant and an individual accompanying a minor Participant,
provided that the expenses must comply with Micron Travel policies. The maximum
aggregrate Travel Benefit payable shall not exceed $5,000 for each procedure.
Transplant Services are also subject to general exclusions. See the "General Exclusions"
section for more information.
General Exclusions
There is no coverage under these plans for services, supplies, equipment, devices,
procedures, tests, drugs or other charges that are:
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received before the Participant’s Effective Date,
received after the Participant is no longer eligible,
not listed as a Covered Service,
not provided by a Covered Provider,
not prescribed by a Professional Provider,
not Medically Necessary,
Behavior modification programs such as boot camps, military schools, wilderness
therapy and similar programs are not Covered Services,
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Experimental, Investigational, or unproven technologies, including Investigational
Prescription Drugs,
primarily of Custodial Care, educational therapy, behavioral modification, self-care or
self-help training,
for the extraction of teeth or other dental procedures unless necessary to treat an
Accidental Injury or unless an attending Physician or Dentist certifies in writing that the
Participant has a non-dental, life-endangering condition which makes Inpatient or
Outpatient hospitalization necessary to safeguard the Participant’s health and life,
for Surgery intended mainly to improve appearance or for complications arising from
Surgery intended mainly to improve appearance except for 1) reconstructive Surgery
Medically Necessary to treat an Accidental Injury, infection or other Disease of the
involved part; 2) reconstructive Surgery to correct a physical deformity present at or
before birth that is significantly different from normal form or function, whether caused
by a hereditary or developmental defect (Congenital Anomaly); or 3) corrective
reconstructive Surgery following a Medically Necessary mastectomy or corrective
reconstructive Surgery of a non-Diseased breast if it is needed for symmetry following a
Medically Necessary mastectomy,
for developmental malformations related to teeth or structures supporting the teeth; for
appliances, splints or restorations necessary to increase vertical dimensions or restore
the occlusion; for orthognathic surgery, except for functionally significant deformities as
defined in Blue Cross of Idaho’s orthognathic medical necessity criteria; for services or
supplies to augment or reduce the upper or lower jaw; for implants in the jaw; for pain,
treatment or diagnostic testing or evaluation related to the misalignment or discomfort
of the temporomandibular jaw (jaw hinge), including splinting services and supplies; or
for alveolectomy or alveoloplasty when related to tooth extraction,
for weight control or treatment of obesity, even if Medically Necessary, including but not
limited to gastric bypass Surgery and other Surgery for obesity or surgical removal of
excess skin resulting from weight loss; for reversals, revisions or complications of
Surgery for obesity, except those required to correct an immediately life-endangering
condition,
for care, services or treatment required as a result of complications from a treatment not
covered under the Plan, except those required to correct or stabilize an immediately lifeendangering condition,
for treatment in connection with transsexual Surgery, gender transformation, sexual
dysfunction or sexual inadequacy, including erectile dysfunction and/or impotence, even
if Medically Necessary,
treatment for infertility and fertilization procedures, even if Medically Necessary, after a
diagnosis of infertility, or delay or difficulty in conception has been documented,
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 a Participant's reproductive ability
except when required to correct a life endangering condition,
for reversal of sterilization procedures including but not limited to vasectomies or tubal
ligations,
for treatment of any condition arising from or related to Pregnancy, childbirth, delivery,
or an involuntary complication of Pregnancy or elective abortion for an enrolled
dependent child,
for services related to molecular genetic testing (specific gene identification) or related
genetic counseling, except when medically necessary and all of the following
requirements are met:
a. The Member displays clinical features or is at direct risk of inheriting the mutation
in question (pre-symptomatic); and
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b. After history, physical examination, pedigree analysis, genetic counseling, and
completion of conventional diagnostic studies, a definitive diagnosis remains
uncertain; and
c. The results of the genetic test will impact the medical management of, and
treatment being delivered to, the Member,
d. Cystic Fibrosis testing as outlined under the preventive benefits section of this
handbook,
You or your provider can call Blue Cross of Idaho at (800) 358-5527 for clarification and
determination if certain tests meet the requirements listed above.
for personal hygiene, comfort, beautification or convenience items or therapies including
educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation,
massage, music, or purchase and cost of care for therapy or service dogs,
for homemaker and housekeeping services or home-delivered meals,
for alterations or modifications to the home or vehicle,
for computer or internet communications,
for foot care that is not Medically Necessary including but not limited to treatment of
corns, calluses and toenails,
in excess of the Maximum Allowance or actual charge, whichever is less,
provided or paid for by any law or government except when payment under these plans
is required by federal law,
provided or paid for by any state or local government where the charge could vary due
to coverage under these plans,
paid by occupational coverage provided by any employer under state or federal Workers'
Compensation Acts, Employer Liability Acts or other laws providing compensation for
work-related injuries or conditions,
payable by 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,
provided by a medical clinic maintained by an employer, a mutual benefit association,
labor union, trust or similar person or group, including the Micron Family Health Center
or MTV Health Center,
when a Participant has no legal obligation to pay in the absence of health insurance,
when a Participant would not be charged or would be charged differently in the absence
of health insurance,
provided outside the United States which if had been provided in the United States
would not be a Covered Service,
for the treatment of injuries sustained while committing a felony, voluntarily taking part
in a riot, or engaging in an illegal act or occupation, or
for the treatment of any condition, Accidental Injury, Disease or Illness suffered as a
result of any act of terrorism, war, declared or undeclared,
for blood storage charges.
Massachusetts Work Sites
In order for the Micron Select U.S. Health Plan to meet Massachusetts credible coverage
requirements, the following additional plan benefits apply to Participants who have coverage
through a team member whose work site in the Micron Employee Database is in the State of
Massachusetts:
 Maternity services for Participants who are dependent children are Covered Services.
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Types of Claims
A claim is a request for benefits under the Plan, made by a Participant or by a
representative of a Participant, that complies with the Plan’s reasonable procedures for
making benefit claims. The times listed for determination of a claim are maximum times
only. A period of time begins at the time the claim is filed. Decisions will be made within a
reasonable period of time appropriate to the circumstances. “Days” means calendar days.
There are different kinds of claims and each one has a specific timetable for either approval,
payment, request for further information, or denial of the claim. It is very important to
follow the requirements that apply to your particular type of claim. If you have any
questions regarding the type of claim or what claims procedure to follow, contact Blue Cross
of Idaho at (800) 358-5527.
Post Service Claim. A post-service claim is a claim that is a request for payment under the
Plan for Covered Services already received by the Participant.
Pre-Service Claim. A pre-service claim is a claim when you must seek preauthorization in
advance of receiving care in order to receive full benefits under these plans.
Preauthorization is an evaluation of Medical Necessity. There are five types of Covered
Services under these plans that must be preauthorized:
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Inpatient hospital admissions,
Partial Hospital Program (PHP),
Intensive Outpatient Program (IOP),
Prosthetic Appliances (excluding mastectomy prostheses),
Transplant Services,
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Infusion services where the primary service being performed is the infusion of
medication,
Certain Prescription Drugs
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There are two exceptions to Inpatient hospital admissions:
• You must only preauthorize a maternity stay greater than 48 hours for a normal delivery
or 96 hours for a cesarean section, and
• You must preauthorize an emergency admission within 24 hours of the admission, or the
next business day if the admission occurs on a weekend or holiday.
See the “Prescription Drug” section for information on how to preauthorize certain
prescription drugs.
To preauthorize In-Patient hospital admissions, Partial Hospital Program (PHP, Intensive
Outpatient Program (IOP), Prosthetic Appliances, Infusion services where the primary
service being performed is the infusion of medication, and Transplant Services, or authorize
a Non-Contracting Specialty Provider, submit a request to the Medical Management
Department of Blue Cross of Idaho. They will make a determination based on Medical
Necessity.
Concurrent Care Claim. A concurrent care claim is a claim when an ongoing course of
treatment that has been preauthorized for a period of time or for a specified number of
treatments is re-evaluated for Medical Necessity. There are two ways a claim can be re-
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evaluated:
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You or your Physician can request an extension beyond the preauthorized period of time
or number of treatments or
Blue Cross of Idaho can review the course of treatment and can reduce or end the
preauthorized period of time or number of treatments.
An Inpatient hospital stay is the only type of Covered Service under these plans that is
subject to re-evaluation.
Urgent Care Claim. An urgent care claim is a type of pre-service claim or concurrent care
claim when the time period that applies to reviewing your claim could jeopardize your life,
health or ability to regain maximum function or would in the opinion of your Physician with
knowledge of your condition cause you severe pain that couldn’t be adequately managed
without immediate treatment. If any Physician with knowledge of your medical condition
determines that a claim involves urgent care, the claim will be treated as an urgent care
claim.
When is the Type of Claim Determined. The claim type is determined when the claim is
filed.
Can the Type of Claim Change. If the nature of the claim changes as it proceeds through
the claims procedure the claim may be re-characterized. For example, a claim may initially
be an urgent care claim. If the urgency goes away, it may be re-classified as a pre-service
claim.
Post Service Claim
How to File a Post Service Claim. The Plan will not make any payment to you or a
Covered Provider unless a completed claim is submitted in a timely manner. Either you or a
Covered Provider can submit a claim, but it must be submitted to Blue Cross of Idaho within
one year from the date a Covered Service is provided.
Follow these steps if you are filing the claim:
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Print out the claim form by following this menu path on Micron’s Intranet: MERC >
HROnline or call the HR Customer Service Center at (800) 336-8918 or (208) 368-4748
to request a form.
Ask the Covered Provider for an itemized billing suitable for insurance. This should show
the name of the patient, each service or Prescription Drug received, the date the service
was provided or the Prescription Drug was dispensed and the charge for each service or
Prescription Drug. A billing that says only “balance due”, “payment received”, or
something similar is not an itemized billing and cannot be processed.
Attach your billing to the claim form and send it to Blue Cross of Idaho at the address
shown on the form.
Covered Providers should send the claim directly to Blue Cross of Idaho for processing.
Pharmacies do not submit "claims" in the same manner as other providers. Pharmacies
should electronically submit information to SelectHealth. If you have any questions or
concerns about the amount you were charged for your prescriptions or any other matter
relating to your prescription benefits under these plans and you would like a written decision
made with respect to your benefits, you should submit a claim to Blue Cross of Idaho.
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Determination of a Post Service Claim. Based on the Plan provisions, Blue Cross of
Idaho or SelectHealth will process the claim. You will not receive a written decision from
SelectHealth. A claim must be submitted to Blue Cross of Idaho as described in the "How
to File a Post Service Claim" section to receive a written decision.
For claims processed by Blue Cross of Idaho, you will be notified about the status of your
claim within a reasonable period of time, but not usually longer than 30 days after your
claim is received.
This 30 day period may be extended for an additional 15 days if more time is required due
to matters beyond the control of the Plan; for example, if you did not provide all the
information required to make a claim. You will receive a written notice indicating the reason
for the extension if this happens.
If you are asked to provide additional information, you will have at least 45 days to do so.
You must provide any requested information within the time period required or a decision
will be made without considering any additional information.
If your claim is denied, you will receive a notice of the denial containing the following
information:
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The reason for the denial;
A reference to and a description of the Plan provisions on which the denial is based;
Information on how to request a review of the denial; and
Other information about the reason for the denial and your options.
Information on processed claims can be found by following this menu path on Micron’s
intranet: MERC > HROnline. You can also find this information from home by going to
www.micronhealth.com.
Payment to a Covered Provider. If the Covered Provider is a Contracting Provider,
payment is made directly to the Contracting Provider based on contracted rates in the
provider’s geographic area. Blue Cross of Idaho will mail you an Explanation of Benefits
anytime payment is made to a Contracting Provider.
If the Covered Provider is a Contracting Pharmacy, payment is made directly to the
Contracting Pharmacy based on contracted rates. You will receive a receipt from the
Contracting Pharmacy at the time the Prescription Drug is dispensed. You will not receive an
Explanation of Benefits from SelectHealth or Blue Cross of Idaho.
Payment to You. If your Covered Provider is not a Contracting Provider, payment will be
made to you or the Covered provider based on the Maximum Allowance determined by Blue
Cross of Idaho.
In the event of your death, Blue Cross of Idaho will pay your spouse, if married, or your
estate, if not married, any outstanding payments owed to you.
Request to Withhold Payment. Blue Cross of Idaho is not able to withhold payment of
benefits upon request by a Participant once Covered Services are rendered and a claim is
submitted by a Covered Provider.
Assignment of Benefits. Except as required by law, the Plan’s right to pay a Participant
directly is not assignable and cannot be waived or transferred.
Mental or Physical Incompetence. If the Plan determines that a Participant who is
entitled to payments under the Plan is incompetent by reason of mental disability or other
cause, the Plan can choose to make payments to another person, including a spouse.
Payments made in this situation shall completely discharge the Plan, Blue Cross of Idaho
and Micron of any further responsibility for payment to the Participant.
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Unclaimed Property. If the Plan is unable to pay the Participant or Contracting Provider to
whom the payment is owed because the Participant or Contracting Provider cannot be
located or because a benefit check is uncashed, the Plan will make an effort to locate the
Participant or Contracting Provider by sending a notice to the last known address of the
Participant or Contracting Provider. If after two years the Participant or Contracting Provider
is not located or the check remains uncashed, the payment will be canceled and you will be
unable to claim that benefit from the Plan. If required by applicable law, the amount
payable on an uncashed benefit check will be turned over to the applicable state within the
time required by law. If that happens, you must contact the applicable state to obtain
payment.
Pre-Service Claim
In order for you to receive the full benefits under these plans for an Inpatient hospital stay,
Prosthetic Device, Transplant Service, non-contracting specialty provider, infusion services
where the primary service being performed is the infusion of medication, or certain
prescription drugs, you must receive preauthorization approval in advance. Once
preauthorization has been received, claims should be submitted according to the rules set
forth for post service claims. See the "Post Service Claim" section for more information.
Requesting Preauthorization for Inpatient Hospital Stay, Prosthetic Device,
Infusion services where the primary service being performed is the infusion of
medication, and Transplant Service. Requesting authorization for Non-Contracting
Specialty Provider. It is your responsibility to initiate and complete the preauthorization,
or authorization approval for the above Covered Services by contacting Blue Cross of Idaho
at (800) 358-5527. Nurses are available from 7 am until 6 pm, Mountain Time, Monday
through Friday. During non-office hours, your call will be recorded and Blue Cross of Idaho
will follow-up with you the next business day. When you call, be prepared to provide the
following information:
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Patient’s name, address, subscriber number and birth date,
Your name and subscriber identification number,
Name, address and phone number of the attending Physician’s office, and
For hospital stays, diagnosis and planned procedures, name and address of the hospital,
date of proposed admission, and proposed length of stay.
Evaluation of Preauthorization Request. You will receive a letter regarding your request
within a reasonable period of time, but not usually longer than 15 days after your
preauthorization request is received.
The 15 day period may be extended for an additional 15 days if more time is required due to
matters beyond the control of the Plan; for example, if you did not provide all the
information required. You will receive a written notice indicating the reason for the
extension if this should happen.
If you are asked to provide additional information, you will have at least 45 days to do so.
You must provide any requested information within the time period required or a decision
will be made without considering any additional information.
If your preauthorization request is denied, you will receive a notice of the denial containing
the following information:
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The reason for the denial,
A reference to and a description of the Plan provisions on which the denial is based,
Information on how to request a review of the denial, and
Other information about the reason for the denial and your options.
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If your preauthorization request was improperly filed (for instance, filed with the wrong
person), you will be notified within five days of receipt of the preauthorization request by
the proper person.
Evaluation of Preauthorization Request for an Urgent Care Claim. If your
preauthorization request is considered an urgent claim, and if your claim is both correctly
filed and complete, you will receive notification of whether the claim is approved or denied
within 72 hours after receipt of the claim.
If the claim is not complete, or if the claim was improperly filed, you will receive verbal
notification within 24 hours after receipt of the claim and will be told what specific
information is needed to complete the claim. You will have 48 hours to obtain and provide
Blue Cross of Idaho with the needed information either by phone, fax or in writing. If you do
not provide the additional information within this time period, a decision will be made within
48 hours based the original information received. If you do provide the additional
information within the time period, a decision will be made within 48 hours from the time
you provided Blue Cross of Idaho with the additional information.
You will receive written notification of the decision on your urgent care claim whether
approved or not.
Failure to Preauthorize. If you fail to preauthorize Inpatient hospital admissions,no
benefits will be paid for Covered Services that are not found to be Medically Necessary.
If you fail to preauthorize Prosthetic Appliances, Infusion services where the primary service
being performed is the infusion of medication, and Transplant Services, reimbursement for
expenses for Covered Services will be reduced by $500 . This reduction does not apply
towards your Out-of-pocket Maximum. No benefits will be paid for Covered Services that are
not found to be Medically Necessary.
If you fail to authorize a non-contracting specialty provider within the service area, the
Plan’s regular non-contracting provisions will apply.
Requesting Preauthorization for Certain Prescription Drugs. It is your responsibility to
initiate the preauthorization approval process by requesting that your Physician call Blue
Cross of Idaho at 800-358-5527.
You or your provider must call Blue Cross at (800) 358-5527 to obtain approval for a
prescription drug that requires preauthorization. Participants cannot initiate a prescription
drug preauthorization.
If you fail to preauthorize a Prescription Drug, the Plan will provide no coverage.
Continued Inpatient Hospital Stay Claims
In order for you to receive the full benefits under these plans for a continued Inpatient
hospital stay beyond the days that have already been preauthorized, including a maternity
stay of greater than 48 hours for a normal delivery or 96 hours for a cesarean section or a
newborn baby who must stay longer than the mother, you must receive preauthorization
approval for the additional days. Once preauthorization has been received, claims should be
submitted according to the rules set forth for post service claims. See the "Post Service
Claim" section for more information.
Requesting Preauthorization. It is your responsibility to initiate the preauthorization for
the continued Inpatient hospital stay. Follow the same steps you took to preauthorize your
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Inpatient hospital stay.
Evaluation of Preauthorization Request. You will receive a letter regarding your
preauthorization request within a reasonable period of time, but not usually longer than 15
days after your concurrent care request is received.
Evaluation of Preauthorization Request for an Urgent Claim. If the concurrent care
request involves urgent care, you will receive notification within 24 hours of the receipt of
the request, provided the request was received at least 24 hours prior to the scheduled
discharge.
Dental Benefits
Plan terms and definitions (for example, appeal procedures) are the same for dental
benefits, except as specifically provided otherwise in this section.
This Plan covers four types of dental services. Benefit payment differs for each type of
service.
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Type I services are preventive and include oral examinations, cleaning, x-rays and space
maintainers.
Type II services are basic and include fillings, root canals, oral surgery, intravenous
sedation, non-intravenous sedation, and periodontics.
Type III services are major and include inlays, crowns, bridges and dentures.
Type IV services are orthodontic and include installation of tooth-straightening
appliances and treatment to correct abnormally positioned teeth.
Benefit Payment
Benefits you receive through this Plan are subject to the following features.
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Yearly Dental Plan Maximum
Lifetime Orthodontic Maximum
Yearly Maximum
The most this Plan pays for Types I, II and III services combined is $2,000 for each member
each calendar year.
Lifetime Maximum
The most this Plan pays for Type IV services is $2,000 for each member. Type I, II, and III
services have no lifetime maximum.
Covered Providers
The following types of providers are the only types of providers covered by this Plan, as long
as they are practicing within the scope of their license for the state where services are
provided.
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Dentists
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Orthodontists
Dental Specialists
Denturists
Dental Hygienists
How to Find Providers.
A list of dental Providers in your area can be found at www.micronhealth.com.
Covered Services
The following is a complete list of the services covered by this Plan.
Type I Services-Preventive Dental Services
Description of Covered Services
Oral Examination
Conditions and Limitations
Limited to once every six months
(includes examination for a second opinion)
Emergency Oral Examination
Complete Mouth Series or Panoramic X-ray
Covered for trauma, acute infection or acute pain
Limited to one time in any five consecutive calendar year
period unless specifically requested by Blue Cross of Idaho
for verification of treatment claimed.
(Includes bite-wings and 10 to 14 periapical x-rays)
Individual Periapical X-rays
Limited to the same benefit as a complete mouth series or
panoramic x-ray. Individual periapical x-rays are not covered when performed during root canal therapy as an
intra-operative procedure
Occlusal and/or Extraoral X-rays
Limited to once per calendar year
Bitewing X-rays
Limited to once per calendar year
Other X-rays
Dental Prophylaxis (cleaning)
Limited to once every six months. Benefits are limited to
prophylaxis once every six months regardless of type
(dental prophylaxis or periodontal maintenance)
Fluoride Treatments
Limited to one treatment per calendar year for Eligible
Participant under age 26
Palliative Treatment
Paid as a separate benefit only if no other service (except xrays) is rendered during the visit
Topical Application of Sealants per Tooth
Limited to permanent posterior unrestored dentition of Eligible Participant under age 16. Limited to one time per tooth
in any three consecutive years.
Biopsy of Soft or Hard Oral Tissue
Type II Services-Basic Dental Services
Description of Covered Services
Conditions and Limitations
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Restorations involving multiple surfaces will be combined for
benefit purposes and paid according to the number of
surfaces treated. Benefit limited to the cost of amalgam or
composite restorations. Limited to once every two years for
the same tooth surface
Pin Retention
Simple Extractions
Surgical Removal of an erupted or partially erupted
tooth or mucoperiosteal flap or incision
of soft tissue
Impaction that requires incision of overlying soft
tissue, elevation of a flap and either removal of bone
and tooth or sectioning and removal of the tooth
(extraction of tooth, partial bony impaction)
Impaction that requires incision of overlying soft
tissue, elevation of a flap, removal of bone, and
sectioning of the tooth for removal
(extraction of tooth, complete bony extraction)
Impaction that requires incision of overlying soft
tissue, elevation of flap, removal of bone, sectioning
of tooth for removal, and/or presents unusual
difficulties and circumstances (including report)
Root Recovery
Excision of Periocoronal Tissue
Tooth Reimplantation
Tooth Transplantation
Separate benefits are not payable for donor site charges
Alveoplasty or Alveolectomy
Not separately payable if performed on the same date as
extraction
Removal of Exostosis
Frenectomy (Frenulectomy)
Excision of Hyperplastic Tissue
Incision and Drainage
Radical excision
Not payable in addition to extraction performed in same site
(lesion diameter up to or greater than 1.25 cm)
on same date
Excision pericoronal gingiva (Operculectomy)
Excision of benign tumor
Not payable in addition to extraction performed in same site
(lesion diameter up to or greater than 1.25 cm)
on same date
Removal of odontogenic cyst or tumor
Not payable in addition to extraction performed in same site
(diameter up to or greater than 1.25 cm)
on same date
Suture of small wounds
General Anesthesia
Non-Intravenous Sedation
I.V. Sedation
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Pulp Cap (direct or indirect)
Pulpotomy
Root Canal Therapy
Multiple endodontic treatments on the same tooth within a
period of one year, are subject to dental review and approval
by the Plan
Apicoectomy and Retrograde Filling
Hemisection
Scaling and Root Planing
Limited to once per quadrant of the mouth
Periodontal Maintenance
Limited to twice per calendar year. Benefits are limited to
every three calendar years
prophylaxis twice per year regardless of type
(dental prophylaxis or periodontal maintenance)
Gingivectomy
Only one such surgical procedure is covered per quadrant of
Osseous Surgery
Only one such surgical procedure is covered per quadrant of
the mouth every three calendar years
the mouth per calender year
Osseous Grafts
Autogenous graft only
Synthetic grafting techniques are not covered
Pedicle Grafts
Free Soft Tissue Grafts
Occlusal Guard
Limited to one appliance every two calendar years
Full Mouth Debridement
Limited to once every three calendar years
Type III Services-Major Dental Services
Description of Covered Services
Conditions and Limitations
Synthetic Bone Grafting Procedures
Periodontal Splinting Procedures
Recement Inlays; Recement Crowns; Recement
Bridges
Dental Implants and Initial Crown
Crown replacement five year waiting period is waived for
initial crown immediately following Dental Implant
Crown Build-up
Covered only for endodontically treated teeth that require
Tissue Conditioning
Limited to repairs or adjustments performed more than 12
Repairs to Full Dentures, Partial Dentures,
Limited to repairs performed more than 12 months after the
and/or Bridges
initial insertion of the prosthesis
crowns and only if medically necessary
months after the initial insertion of prosthesis
Repairs to Crowns
Inlays and Onlays
Covered only when the tooth cannot be restored by a filling,
and only if more than five years have elapsed since last
placement. If a tooth can be restored with a filing, the benefit
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will be limited to the allowable benefit for an amalgam or
composite restoration
Crowns & Laminate Veneers
Covered only when the tooth has visible destruction of tooth
surface from decay and cannot be restored by a filling.
Benefits will not be allowed when placement of the crown or
veneer is for micro fractures, stress fractures, or craze lines.
Coverage is allowed if more than five years have elapsed
since last placement. For Eligible Participants less than 16
years of age, benefits are limited to plastic or stainless steel
crowns
Post and Core
Full Dentures
The benefit includes all adjustments within six months of
installation. Replacement of a denture is covered only if the
existing denture is more than five years old and cannot be
repaired. There are no additional benefits for overdentures or
customized dentures
Partial Dentures
The benefit includes two clasps and rests, all teeth, and all
adjustments within six months of installation. Replacement of
a partial denture with another denture or fixed bridgework is
eligible for benefits only if the existing denture is more than
five years old and cannot be repaired. There are no additional
benefits for precision or semi-precision attachments
Each additional Clasp and Rest (beyond two)
Denture Adjustments
One adjustment per calendar year, and only if performed
more than six months after the insertion of the denture
Relining Dentures
Relines must be performed 12 months after initial placement
and no more than once in a 24 month period
Bridges
Upgrading from a partial denture to bridgework is covered
only if the arch cannot be adequately restored with a partial
denture. Replacement of an existing bridge or partial denture
is eligible only if the existing appliance is more than five
years old and cannot be repaired.
Type IV Services-Orthodontic Services
Description of Covered Services
Limitations
Orthodontia
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Vision Benefits
Plan terms and definitions (for example, appeal procedures) are the same for vision
benefits, except as specifically provided otherwise in this section.
Benefit Payment
Benefits you receive through this Plan are subject to the following features.
•
Yearly Vision Plan Maximum
Yearly Maximum
The most this Plan pays for vision services for each member each calendar year is:
One Eye exam (glasses or contacts) – up to $90.00
Contact Lenses – up to $200.00 OR
Frames & Lenses – up to $300.00
Covered Providers
The following types of providers are the only types of providers covered by this Plan, as long
as they are practicing within the scope of their license for the state where services are
provided. There are no contracting providers for vision benefits.


Optometrists
Ophthalmologists
Vision Claims
You or your enrolled dependents must pay the provider or optical shop in full for vision
services at the time service and/or materials are provided. You must submit a receipt for
vision expenses incurred for yourself and/or your covered dependents for reimbursement
through Brookfield. Brookfield will reimburse the team member for vision services according
to the Yearly Maximum benefit. Participants are responsible for all vision costs exceeding
the Yearly Maximum amount.
Appeals
There are two different types of appeals allowed for under this Plan.
•
First Level Appeal
•
Second Level Appeal
You or your enrolled dependents have 180 calendar days after notice is received of an
adverse benefit determination to request a first level appeal. The appeal must be received
within the deadline specified. The appeals process varies depending on the type of appeal.
First Level Appeal
Eligibility, Enrollment, or Vision Appeal. If you or your enrolled dependents disagree
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with a decision regarding your eligibility, enrollment, or vision claim you have 180 days
from the date of the original notice of the denial in which to file a written request for review.
The appeal must be received within the deadline specified.
You, your enrolled dependent,or an authorized representative must e-mail, mail or fax a
written request for review to the address below.
First Level Eligibility, Enrollment, or Vision Appeal:
HR Customer Service Center, MS 01-727
Micron Technology, Inc.
8000 South Federal Way
P.O. Box 6
Boise, Idaho 83707-0006
Fax: (208) 368-1553
E-mail: [email protected]
Medical, Prescription, or Dental Claim Processing Appeal. If you or your enrolled
dependents disagree with the decision regarding a claim for medical, prescription or dental
benefits, you have 180 days from the date of the original notice of the denial in which to file
a written request for review. If the appeal is for a decision to reduce or terminate an ongoing program of benefits (that is, a concurrent care decision), an appeal must be filed
within 30 days of your receipt of the notification of the decision to reduce or terminate
treatment.
You, your enrolled dependent,or an authorized representative must send or fax a written
request for review to the address below.
Medical or Dental Claim Appeal:
Customer Service Department
Blue Cross of Idaho
P.O. Box 7408
Boise, Idaho 83707
(208) 331-7699
(800) 627-1006
Fax: (208) 331-7493
Prescription Claim Appeal:
Appeals Department
SelectHealth
P.O. Box 30192
Salt Lake City, UT 84130-0192
Fax (801)-442-0762
Authorized Representative. If you or your enrollent dependent are physically or mentally
incapacitated (for example, you are in a coma), your spouse, parent or other individual
designated by a court shall be deemed to be an authorized representative. In the case of an
urgent care claim a treating Physician is also an authorized representative.
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Appeal Review Process. The First Level Appeals Committee will review the appeal and a
decision will be made consistent with the terms of the Plan and applicable law. The persons
who made the initial decision will not decide the first level appeal.
If the claim involves medical judgment, the review of an independent medical professional
with appropriate experience in the area of treatment may be sought.
The First Level Appeals Committee, and Blue Cross of Idaho or SelectHealth, as applicable,
have full discretionary power to interpret the Plan and decide all questions concerning the
Plan and the eligibility of any person to participate in the Plan, with such interpretation and
decisions to be final and conclusive on all person’s claiming benefits under the Plan subject
only to the decision of the Second Level Appeals Committee, if applicable.
A written decision will be provided regarding the written appeal within a reasonable period
of time, but not usually longer than 15 days for a pre-service claim, 30 days for a postservice claim, or 60 days for an Eligibility and Enrollment appeal after the appeal is
received.
The notice will include the following information:
•
The results of the request for review,
•
The reason(s) for the decision,
•
A reference to and description of the Plan provision(s) on which the decision is based,
and
•
Other information about the review and your options as required by federal law.
Second Level Appeal
Eligibility, Enrollment, or Vision Appeal.
If you or your enrolled dependent disagree with the result of the first eligibility, enrollment,
or vision appeal, you or your enrolled dependent may file a second written request for
review. You have 60 days from the date you receive the outcome of the first appeal in which
to file the written request for a second review. The second level appeal must be received
within the deadline specified.
You, your enrolled dependent, or your authorized representative must e-mail, mail or fax
your written request for review to:
Second Level Appeals Committee
MS 01-727
HR Customer Service Center
Micron Technology, Inc.
8000 South Federal Way
P.O. Box 6
Boise, Idaho 83707-0006
Fax: (208) 368-1553
E-Mail: [email protected]
Medical, Prescription, or Dental Claim Processing Appeal.
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If you or your enrolled dependents disagree with the result of the first claim processing
appeal, you or your enrolled dependent may file a second written request for review. You
have 60 days from the date you receive the outcome of the first appeal in which to file the
written request for a second review. The second level appeal must be received within the
deadline specified.
You, your enrolled dependent, or an authorized representative must send or fax a written
request for review to the address below.
Mecical or Dental Claim Appeal:
Customer Service Department Second Level Appeals Committee
Blue Cross of Idaho
P.O. Box 7408
Boise, Idaho 83707
(208) 331-7699
(800) 627-1006
Fax: (208) 331-7493
Prescription Claim Appeal:
Appeals Department
SelectHealth
P.O. Box 30192
Salt Lake City, UT 84130-0192
Fax (801)-442-0762
Appeal Review Process. The Second Level Appeals Committee will review the appeal and
will make a decision consistent with the terms of the Plan and applicable law. The persons
who decided the first level appeal will not decide the second level appeal.
If the claim involves medical judgment, the review of an independent medical professional
with appropriate experience in the area of treatment may be sought.
The Second Level Appeals Committee has full discretionary power to interpret the Plan and
decide all questions concerning the Plan and the eligibility of any person to participate in the
Plan, with such interpretation and decisions to be final and conclusive on all persons
claiming benefits under the Plan.
A written decision will be provided regarding the appeal within a reasonable period of time,
but not usually longer than 30 days for a post-service claim after the request is received.
The notice will include the following information:
•
The results of the request for review,
•
The reason(s) for the decision,
•
A reference to and description of the Plan provision(s) on which the decision is based,
and
•
Other information about the review and your options as required by federal law.
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Your Appeal Rights
You and your enrolled dependents have the following rights for all appeals:
•
You have the right to receive, upon written request, copies of all documents, records,
and other information used in the review of your claim at no cost. A document, record or
other information is considered related to your claim if it was relied on in making the
benefit determination; was submitted, considered, or generated in the course of making
the benefit determination; demonstrates compliance with the Plan's administrative
processes and consistency safeguards required in making the benefit determination or
constitutes a statement of policy or guidance with respect to the Plan concerning the
benefit for your diagnosis.
•
You have the right, within the specified time limits, to submit written comments,
documents, records, and other information relating to your claim.
•
If the denial of your claim was based in whole or in part on a medical judgment, you
have the right to require Blue Cross of Idaho, Inc. or SelectHealth to consult with a
health care professional who has appropriate training and experience in the field of
medicine involved in the medical judgment and who was neither part of the previous
decision(s) to deny your claim nor the subordinate of any such individual.
•
If Blue Cross of Idaho, Inc. or SelectHealth gets advice from a medical or vocational
expert in connection with your claim, you have the right to be notified that an expert
was used and, upon written request by you, the name of the expert.
Appeals Committee Membership. Micron’s Vice President of Human Resources may
appoint and remove members of the eligibility and enrollment Appeals Committees.
Lawsuits. This Plan requires that the Plan’s claims and appeals processes must be
exhausted before bringing any suit in court. The Plan also requires any suit must be brought
within the earlier of one year after the date the Second Level Appeals Committee has made
a final denial of the claim or two years after the date service or treatment was provided.
Subrogation and Reimbursement Rights
If benefits are provided when a third party is legally responsible for your injury, harm or
loss, or if you are entitled to medical benefits under any 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 policy of insurance, contract
or underwriting plan, this Plan will be subrogated and will succeed to your rights of recovery
or, in the event of your death, to the rights of your estate, heirs or personal representatives.
In addition, any amounts recovered by voluntary payment, suit, settlement or otherwise
which are in any way related to your injury, harm or loss must be paid to this Plan to the
extent that benefits were provided under this Plan.
As a condition of receiving benefits for Covered Services in such an event, you are required
to furnish Blue Cross of Idaho, Inc., in writing, with the full details of the event and the
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names and addresses of the party or parties responsible. You also are required to fully
cooperate in good faith with this Plan in its investigation, evaluation, litigation and/or
collection efforts, including without limitation by providing information and by signing
authorizations, consents, releases, assignments, liens and other documents promptly upon
request.
You may not take any action which may in any way prejudice or reduce this Plan’s rights to
subrogation and reimbursement. This Plan also may initiate litigation on its own behalf and,
in its sole discretion, in the name of the affected Plan Participant against any third party or
parties.
These subrogation rights apply to both claims already incurred, and to payments to be made
in the future on account of the injury, harm or loss. When recoveries exceed the incurred
claims, a special deductible shall apply to future benefits and services provided as a result of
the injury, harm or loss.
The "make whole doctrine" arising under federal common law and under state law does not
apply to this Plan’s reimbursement or subrogation rights. This Plan retains its
reimbursement and subrogation rights described herein regardless of whether your receipt
of payment from other sources fully reimburses you or whether you have been "made
whole".
If you fail to provide information or otherwise do not cooperate with this Plan in these
matters, this Plan may, in its sole discretion, deny any related claims for benefits under this
Plan and may seek reimbursement from you for any related claims which have been paid.
This Plan may, in its sole discretion, enter into any compromise or settlement regarding its
interests in any subrogation or reimbursement matter.
Refunds, Settlements and Other Payments
If the Plan receives any refund, settlement or other payment related to Plan activities, the
payment will first be paid over to Micron until all amounts Micron has paid toward Plan
expenses out of the general assets of Micron have been repaid. Further payments will then
be paid to the Participants in a pro-rata manner or such other manner as is deemed
equitable under the circumstances by Micron in its sole and absolute discretion.
Release of Information
As a condition of coverage under this Plan, each team member on behalf of themselves and
their Eligible Dependents:
•
authorize Covered Providers and other entities to provide this Plan and it’s business
partners any and all medical records and other information pertaining to health related
services submitted for consideration of payment under this Plan,
•
authorize this Plan and it’s business partners to use this information for Plan purposes
including but are not limited to reviewing, investigating and evaluating all claims and
enabling the Plan and all it’s business partners to provide the services outlined in the
Plan.
•
authorize this Plan and it’s business partners to disclose any medical information
obtained or payments made if such disclosures are necessary to allow the administration
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of services, the processing of claims or other disclosures allowed by HIPAA,
•
authorize your providers to testify regarding the condition, care, or treatment of any
covered individual; any and all provisions of law or professional ethics forbidding such
disclosures or testimony are waived by and in behalf of each Participant, and
•
authorize this Plan and it’s business partners to pay Contracting Providers directly.
Business partners include Blue Cross of Idaho, SelectHealth, Blue Cross and/or Blue Shield
affiliates and other business associates.
Mistaken Benefits Payment
If this Plan mistakenly pays benefits for which you are not entitled, you must reimburse the
benefits paid in error. The reimbursement is due and payable as soon as this Plan notifies
you and requests reimbursement. If reimbursement is not made in a timely manner, future
benefits may be offset.
Availability of Covered Services
Receipt of Covered Services are subject to the availability of Facility Providers and
Professional Providers. This Plan is not responsible for nor has any liability for conditions
beyond it’s control which affect the Participant’s ability to obtain Covered Services.
Exclusion of General Damages
Liability under this Plan for benefits, including recovery under any claim or breach of this
Plan, shall be limited to the actual benefits available under this Plan and shall specifically
exclude any claim for general damages including but not limited to alleged pain, suffering or
mental anguish, or for economic loss, consequential loss or punitive damages.
Termination of Coverage
Enrollment in this Plan ends on the earlier of the following dates:
•
the date your assignment in the United States ends
•
the date this Plan terminates,
•
the date a Participant reaches the Comprehensive Lifetime Benefit Limit,
•
the day after an Eligible Dependent dies,
•
the last day of the month after a Participant who is a team member dies,
•
a date of termination described in the “Change in Status” section, or
•
the last day of the month during which a Participant who is a team member loses
eligibility under the Plan due to job status change including any approved leave of
absence greater than 12 weeks and when a Participants’ employment with Micron ends.
This Plan may also terminate a Participant’s coverage for any fraud, misrepresentation,
omission or concealment of facts that could have impacted eligibility for coverage under this
Plan.
In the event of termination, the following benefit will continue.
•
Participants who are hospitalized at the time their coverage in this Plan ended continue
to be eligible for Inpatient Hospital Services until earlier of discharge or reaching the
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Comprehensive Lifetime Benefit Limit. No other Covered Services are continued.
You will be mailed a Certificate of Coverage upon your termination from this Plan. The
Certificate of Coverage is a written certification provided to you for the purpose of
confirming the duration and type of your coverage under this Plan.
Under certain circumstances, you and your Eligible Dependents may continue to participate
on an after-tax basis provided you elect to continue participation in this Plan pursuant to
your rights under the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”)
and you make the required monthly premium payments to Micron. See the Health Care
Continuation Coverage Notice (found in the Benefits Handbook) for more information about
your rights and responsibilities.
Newborns’ and Mothers’ Health Protection Act of 1996
Group health plans and health insurance issuers generally may not, under federal law,
restrict benefits for any hospital length of stay in connection with childbirth for the mother
or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours
following a cesarean section. However, federal law generally does not prohibit the mother’s
or newborn’s attending provider, after consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans
and issuers may not, under federal law, require that a provider obtain authorization from
the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96
hours). This Plan complies with this law.
Women’s Health and Cancer Rights Act of 1998
This Plan, as required by the Women's Health and Cancer Rights Act of 1998, provides
benefits for mastectomy-related services including reconstruction and Surgery to achieve
symmetry between the breasts, prostheses and complications resulting from a mastectomy
including lymphedema. Keep this notice for your records and call Micron’s HR Service Center
at (800) 336-8918 or (208) 368-4748 for more information.
Health Insurance Portability and Accountability Act (HIPAA)
This Plan has been written to comply with all requirements of HIPAA.
•
You may request a certificate of creditable coverage at any time by calling Blue Cross of
Idaho, Inc. at (800)-358-5527 . You will also receive a Certificate of Creditable
Coverage when your enrollment in this Plan ends.
•
See the HIPAA Privacy Notice (found in the Benefits Handbook) for more information on
how this Plan uses and discloses your medical information.
Definitions
Accidental Injury. An objectively demonstrable impairment of bodily function or damage
to part of the body caused by trauma from a sudden, unforeseen outside force or object,
occurring at an identifiable time and place, and without a Participant's foresight or
expectation.
Alcoholism. A behavioral or physical disorder caused by repeated excessive consumption of
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alcohol to the extent that it interferes with a Participant's health or social or economic
functioning.
Alcoholism or Substance Abuse Treatment Facility. A Facility Provider that is primarily
engaged in providing detoxification and rehabilitative care for Alcoholism or Substance
Abuse or Addiction.
Ambulatory Surgical Facility. A Medicare Certified Facility Provider with an organized staff
of Physicians which:
•
has permanent facilities and equipment for the primary purpose of performing surgical
procedures on an Outpatient basis,
•
provides treatment by or under the supervision of Physicians and provides Skilled
Nursing Care when the Participant is in the facility,
•
does not provide Inpatient accommodations appropriate for a stay of longer than 12
hours, and
•
is not primarily a facility used as an office or clinic for the private practice of a Physician
or other Professional Provider.
Ambulance. A specially designed and equipped vehicle used only for transporting the sick
and injured.
Artificial Organs. Permanently attached or implanted man-made devices that replace all or
part of a Diseased or non-functioning body organ, including but not limited to, artificial
hearts and pancreases.
Birthing Center. A Facility Provider, with an organized staff of Physicians, which:
•
has permanent facilities and equipment for the primary purpose of normal vaginal
childbirth,
•
provides treatment by or under the supervision of Physicians and provides Skilled
Nursing Care while the Participant is in the facility,
•
does not provide Inpatient accommodations appropriate for stays longer than eight
hours beyond delivery,
•
is not, other than incidentally, a facility used as an office or clinic for the private practice
of a Physician or other Professional Provider, and
•
meets the freestanding Birthing Center requirements of the State Department of Health
in the state in which the covered person receives the services.
Blue Cross of Idaho Health Service, Inc. A non-profit mutual insurance company, hired
by Micron to act as the dental third party contract administrator to perform claims
processing and other specific administrative services as outlined in this Plan and/or
Administrative Services Agreement.
Certified Nurse Midwife. An individual licensed to practice as a Certified Nurse Midwife by
the state where the service was provided.
Certified Registered Nurse Anesthetist. A licensed individual registered as a Certified
Registered Nurse Anesthetist by the state where the service was provided.
Certified Speech Therapist. An individual certified to perform Speech Therapy by the
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state where the service is provided.
Chemotherapy. The treatment of malignant Disease by chemical or biological antineoplastic agents.
Chiropractic Physician. An individual licensed to practice chiropractic care by the state
where the service is provided.
Clinical Nurse Specialist. An individual licensed to practice as a Clinical Nurse Specialist
by the state where the service was provided.
Clinical Psychologist. An individual licensed to practice clinical psychology by the state
where the service was provided.
Congenital Anomaly. A condition existing at or from birth, which is a significant deviation
from the common form or function, whether caused by a hereditary or a developmental
defect. In this Plan, Congenital Anomalies include cleft lips, cleft palates, birth marks,
webbed fingers or toes, and other conditions that Blue Cross of Idaho may determine to be
Congenital Anomalies. Except as specifically listed above, the term Congenital Anomaly shall
not include conditions related to the teeth, or inter-oral structures supporting the teeth, or
to irregularities resulting from growth or development.
Contraceptive Device. A device or over-the-counter item used as a method of
contraception that is not a prescription drug.
Contracting Provider. Contracting Providers are Covered Providers who have agreed to
recognize the applicable Maximum Allowance as their fee for Covered Services by entering
into an agreement.
Covered Service. A Covered Service is a service, supply or procedure listed below that is
both Medically Necessary and provided by a Covered Provider.
Custodial Care. Care designed principally to assist a Participant in engaging in the
activities of daily living; or services which constitute personal care, such as help in walking
and getting in and out of bed; assistance in bathing, dressing, eating and using the toilet;
preparation of special diets, and supervision of medication, which can usually be self
administered and which does not entail or require the continuing attention of trained
medical personnel. Custodial Care is normally, but not necessarily, provided in a nursing
home, convalescent home, rest home or similar institution. Custodial Care also includes
Home Health Skilled Nursing Care when it is expected to exceed 20 days.
Dentist. An individual licensed to practice dentistry by the state where the service was
provided.
Denturist. An individual licensed to make dentures by the state where the service is
provided.
Diagnostic Imaging Provider. A Medicare Certified person or entity that is licensed,
where required, to provide diagnostic imaging services by the state where the service was
provided.
Diagnostic Service. A test or procedure performed on the order of a Professional Provider
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because of specific symptoms, in order to identify a particular condition, Disease, Illness or
Accidental Injury. Diagnostic Services include but are not limited to:
•
radiology services,
•
laboratory and pathology services, and
•
cardiographic, encephalographic and radioisotope tests.
Disease. Any alteration in the body or any of its organs or parts that interrupts or disturbs
the performance of vital functions, thereby causing or threatening pain, weakness or
dysfunction. A Disease can exist with or without an Participant’s awareness of it and can be
of known or unknown cause.
Durable Medical Equipment Supplier. A business that is Medicare Certified and licensed,
where required, to sell or rent Durable Medical Equipment, by the state where the service
was provided.
Effective Date. The date when coverage for a Participant begins under this Plan.
Electroencephalogram (EEG) Provider. A Facility Provider that participates with Medicare
and has technologists certified by the American Board of Registration of
Electroencephalographic and Evoked Potential Technologies, licensed by the state to provide
Covered Services where the service was provided.
Emergency Medical Condition. A condition in which sudden and unexpected symptoms
are sufficiently severe to necessitate immediate medical care. Emergency Medical
Conditions, include but are not limited to, heart attacks, cerebrovascular accidents,
poisonings, loss of consciousness or respiration, and convulsions.
Enterostomal Therapy. Counseling and assistance provided by a specifically trained
enterostomal therapist to patients who have undergone a surgical procedure to create an
artificial opening into a hollow organ (e.g., colostomy).
Free Standing Diabetes Facility. A person or entity that is recognized by the American
Diabetes Association to provide Covered Services by the state where the service is provided.
Free Standing Dialysis Facility. A Medicare Certified or JCAHO Certified Facility Provider,
that is primarily engaged in providing dialysis treatment, maintenance or training to
patients on an Outpatient or home care basis, and licensed where required, by the state
where the service was provided.
Free Standing Diagnostic Imaging Center. A Facility Provider that is primarily engaged
in providing radiological services to patients on an Outpatient basis.
Growth Hormone Therapy. Treatment administered by intramuscular injection to treat
children with growth failure due to pituitary disorder or dysfunction.
Home Health Agency. Any agency or organization that is duly licensed by the appropriate
licensing authority to provide Skilled Nursing Care services and other therapeutic services in
the state it which it operates.
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Home Intravenous Therapy. Treatment of a medical condition by intravenous injection,
administered primarily at the Participant’s home at or under the direction of a Home Health
Agency or other Covered Provider.
Home Intravenous Therapy Company. A Medicare Certified and licensed, where
required, entity that is principally engaged in providing Skilled Nursing Care services,
medical supplies and equipment for certain covered home infusion Therapy Covered
Services to patients in their homes or other locations outside of a Licensed General Hospital.
Hospice. A Medicare Certified public agency or private organization designated specifically
to provide services for care and management of terminally ill patients, primarily in the
home.
Hospital. An institution which is engaged primarily in providing medical care and treatment
of sick and injured persons on an inpatient basis and which is accredited as a Hospital by
the Joint Commission on Accreditation of Healthcare Organizations or the American
Osteopathic Association Healthcare Facilities Accreditation Program; it is approved by
Medicare as a Hospital; it maintains diagnostic and therapeutic facilities on the premises for
surgical and medical diagnosis and treatment of sick and injured persons by or under the
supervision of a staff of Physicians; it continuously provides on the premises 24 hour-a-day
nursing services by or under the supervision of registered nurses (R.N.’s) and it is operated
continuously with organized facilities for operative surgery on the premises.
Illness. A deviation from the healthy and normal condition of any bodily function or tissue.
An Illness can exist with or without a Participant's awareness of it and can be of known or
unknown cause.
Independent Laboratory. A Facility Provider that is primarily engaged in providing
laboratory services to patients on an Outpatient basis.
Inpatient. A Participant who is admitted as a bed patient in a Licensed General Hospital or
other Facility Provider and for whom a room and board charge is made.
Intensive Outpatient Program (IOP). A treatment program that includes extended
periods of therapy sessions, several times a week for a minimum of three (3) hours per day,
a minimum of three (3) days per week and a minimum of nine (9) hours per week. It is an
intermediate setting between traditional therapy sessions and partial hospitalization.
Investigational/Experimental. Any technology (service, supply, procedure, treatment,
drug, device, facility, equipment or biological product), which is in a developmental stage or
has not been proven to improve health outcomes such as length of life, quality of life and
functional ability.
A technology is considered investigational if it fails to meet any one of the following criteria:
•
The technology must have final approval from the appropriate government regulatory
body. This applies to drugs, biological products, devices and other products/procedures
that must have approval from the U.S. Food and Drug Administration (FDA) or another
federal authority before they can be marketed. Interim approval is not sufficient. The
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condition for which the technology is approved must be the same as the condition it was
used to treat in the relevant benefit claim.
•
The scientific evidence must permit conclusions concerning the effect of the technology
on health outcomes. The evidence should consist of current published medical literature
and investigations published in peer-reviewed journals. The quality of the studies and
consistency of results will be considered. The evidence should demonstrate that the
technology can measure or alter physiological changes related to a Disease, Injury, Illness or condition. In addition, there should be evidence that such measurement or
alteration affects health outcomes.
•
The technology must improve the net health outcome. The technology's beneficial effects
on health outcomes should outweigh any harmful effects on health outcomes.
•
The technology must be as beneficial as any established alternatives.
•
The technology must show improvement that is attainable outside the investigational
setting. Improvements must be demonstrated when used under the usual conditions of
medical practice. If a technology is determined to be Investigational, all services
specifically associated with the technology, including but not limited to associated
procedures, treatments, supplies, devices, equipment, facilities or drugs associated with
the investigational/experimental care will also be considered investigational. Unproven
technologies are those which after clinical review do not have enough evidence-based
medicine data to support a more favorable outcome.
• Standard of care items will be covered services regardless of participation in a
Qualified Clinical Trial.
•
In determining whether a technology is Investigational/Experimental, Blue Cross of
Idaho, Inc. may review evidence in the peer-reviewed published medical literature,
technology assessments and structured evidence reviews, evidence-based consensus
statements, expert opinions of healthcare providers, and evidence-based guidelines from
nationally recognized professional healthcare organizations and public health agencies.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). An
independent, not-for-profit organization, governed by a board that includes physicians,
nurses, and consumers. JCAHO sets the standards by which health care quality is measured.
Licensed Clinical Professional Counselor (LCPC). An individual providing diagnosis and
treatment of Mental or Nervous Conditions, Alcoholism and Substance Abuse or Addiction
and licensed by the state where the service was provided.
Licensed Clinical Social Worker (LCSW). An individual providing diagnosis and treatment
of Mental or Nervous Conditions, Alcoholism and Substance Abuse or Addiction and licensed
by the state where the service was provided.
Licensed General Hospital. A short-term, acute care general hospital, residential
treatment facility or transitional living center that:
•
is an institution duly licensed in and by the state in which it is located and is lawfully
entitled to operate as a general, acute care hospital, residential treatment facility or
transitional living center,
•
for compensation from or on behalf of its patients, is primarily engaged in providing
Inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of
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injured and sick persons by or under the supervision of Physicians,
•
has organized, functioning departments of medicine and Surgery,
•
provides 24 hour nursing service by or under the supervision of licensed registered
nurses, and
•
is not predominantly a Skilled Nursing Facility, nursing home, Custodial Care home,
health resort, spa or sanatorium, place for rest, place for the aged, place for the
treatment or rehabilitative care of Mental or Nervous Conditions, place for the treatment
or rehabilitative care of Alcoholism or Substance Abuse or Addiction, or place for Hospice
care.
Licensed Marriage and Family Therapist. An individual licensed to practice as a Marriage
and Family Therapist by the state where the service was provided.
Licensed Occupational Therapist. An individual licensed to practice Occupational Therapy
in the state in which the service is provided.
Licensed Rehabilitation Hospital. A Facility Provider principally engaged in providing
diagnostic, therapeutic, and Physical Rehabilitation Services to Participants on an Inpatient
basis.
Lithotripsy Provider. A facility licensed to perform Lithotripsy by the state where the
service is provided.
Medicaid. Title XIX (Grants to States for Medical Assistance Programs) of the United States
Social Security Act as amended.
Medicare. Title XVIII (Health Insurance for the Aged and Disabled) of the United States
Social Security Act as amended.
Medicare Certified. Centers for Medicare and Medicaid Services (CMS) develops standards
that health care organizations must meet in order to begin and continue participating in the
Medicare and Medicaid programs. These minimum health and safety standards are the
foundation for improving quality and protecting the health and safety of beneficiaries. These
standards are the minimum health and safety requirements that providers and suppliers
must meet in order to be Medicare and Medicaid Certified.
Mental or Nervous Condition. All mental disorders, mental Illnesses, psychiatric Illnesses,
mental conditions and psychiatric conditions whether organic, non-organic, biological, nonbiological, chemical or non- chemical origin and irrespective of cause including the following
conditions: psychoses, neurotic disorders, schizophrenic disorders, affective disorders,
personality disorders and psychological or behavioral abnormalities associated with transient
or permanent dysfunction of the brain or related neurohormonal systems.
Non-Network. Service providers who are not PHCS or MultiPlan service providers at the
time service is rendered.
Nurse Practitioner. An individual licensed to practice as a Nurse Practitioner by the state
where the service was provided.
Nutritional Formula. A form of nutrition unavailable from normal commercial sources for
use in circumstances in which a medical disorder or route of delivery necessitates special
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nutrition for sustained growth and health.
Nutritional Formula Therapy. Treatment of a medical condition by means of Nutritional
Formula.
Occupational Therapy. The treatment of a physically disabled Participant by means of
constructive activities designed and adapted to promote the restoration of the Participant’s
ability to satisfactorily accomplish the ordinary task of daily living and those tasks required
by the Participant’s particular occupational role.
Ocularist. An individual who is licensed to practice fabrication and fitting of custom made
ocular prosthetics by the state where the service was provided. In states where Ocularists
are not required to be licensed, one who is skilled in the design, fabrication and fitting of
artificial eyes and the making of prostheses associated with the appearance of function of
the eyes, and who is a Board Certified Ocularist by the National Examining Board of
Ocularists.
Office Visit. Any direct one-on-one examination and/or exchange, conducted in the
Covered Provider’s location, other than a hospital, skilled nursing facility, military treatment
facility, community health center, state or local public health clinic or intermediate care
facility, where the health professional routinely provides health examinations, diagnosis, and
treatment of illness or injury, between a Participant and a Provider, or members of his or
her staff for the purposes of seeking care and rendering Covered Services. For purposes of
this definition, a Medically Necessary visit by a Physician to a Homebound Participant’s place
of residence may be considered an Office Visit.
Optometrist. An individual licensed to practice optometry by the state where the service
was provided.
Orthodontist. A person licensed to practice orthodontia and performing within the scope of
their license.
Outpatient. A Participant who receives services or supplies while not an Inpatient.
Partial Hospitalization Program (PHP). A treatment program that provides
interdiciplinary medical and psychiatric services. PHP involves a prescribed course of
psychiatric treatment provided on a predetermined and organized schedule and provided in
lieu of hospitalization for a patient who does not require full-time hospitalizaiton.
Participant. An Eligible team member or Eligible Dependent who has enrolled as required
by this Plan.
Pharmacist. An individual licensed to practice pharmacy by the state where the service was
provided.
Physical Therapist. An individual licensed to practice Physical Therapy by the state where
the service was provided.
Physical Therapy. The treatment by physical means, hydrotherapy, heat or similar
modalities, physical agents, biomechanical and neurophysiological principles, or devices to
relieve pain, restore maximum function or prevent disability following a condition, Disease,
Illness, Accidental Injury or loss of a body part.
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Physician. A doctor of medicine (M.D.) or doctor of osteopathy (D.O.) licensed to practice
medicine by the state where the service was provided.
Physician Assistant. An individual licensed to practice as a Physician Assistant by the state
where the service was provided.
Podiatrist. An individual licensed to practice podiatry by the state where the service was
provided.
Plan. The Micron Technology, Inc. Select US Medical Plan and the Micron Technology, Inc.
Dental Plan as set forth in this document as amended from time to time.
PPO. The Plan’s Contracting Provider networks consisting of PHCS and MultiPlan.
Pregnancy or Related Condition. A normal Pregnancy or complication of Pregnancy:
•
Normal Pregnancy includes all conditions arising from Pregnancy or delivery including
any condition usually associated with the management of a Pregnancy.
•
Complications of Pregnancy include cesarean section delivery, ectopic Pregnancy that is
terminated, spontaneous termination of Pregnancy that occurs during a period of
gestation in which a viable birth is not possible, missed abortion, puerperal infection and
eclampsia.
•
Complications of Pregnancy requiring Inpatient admission that are due to a diagnosis
other than Pregnancy, but are adversely affected by Pregnancy or are caused by
Pregnancy, including acute nephritis, nephrosis, cardiac decompensation, missed
abortion and similar medical and surgical conditions of comparable severity.
•
Complications of Pregnancy do not include false labor, occasional spotting, Physician
prescribed bed rest during the period of Pregnancy, morning sickness, hyperemesis
gravidarum, pre-eclampsia and similar conditions associated with the management of a
difficult Pregnancy not constituting a nosologically distinct complication of Pregnancy.
Prescription Drug. A drug, biological or compounded prescription that meets all of the
following criteria:
•
Can be dispensed only pursuant to a written prescription given by a Physician,
•
Is listed and accepted in the United States Pharmacopeia, National Formulary, or AMA
Drug Evaluations published by the American Medical Association (AMA),
•
Is prescribed for human consumption, and
•
Is required by law to bear the legend “Caution – federal law prohibits dispensing without
prescription”.
The following items are also considered a Prescription Drug for the purposes of this Plan:
•
Growth hormone, and
•
Diabetic supplies including insulin syringes, insulin pen needles, lancets, and test-strips
(both glucose and urine), and insulin pump supplies (reservoirs and syringes,
administration sets, and access sets). Supplies are covered as a Prescription Drug only if
the supply is used in the treatment of diabetes or if there is a valid prescription for a self
administered injectable and the prescription is supplied in a pre-mixed syringe.
Primary Care Physician. A Physician whose practice is considered Emergency Medicine,
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Family Practice, Family Practice Geriactric Medicine, Family Practice Sports Medicine,
General Practice, Geriactrics, Gynecology, Internal Medicine, Manipulative Therapy,
Obstetrics, Maternal and Fetal Medicine, OB Gynocology, Obstetrics and Gynecology,
Occupational Medicine, Pediatrics, Pediatric Emergency Medicine, Preventive Medicine, Public
Health and General Preventive Medicine and Urgent Care Center.
Prosthetic and Orthotic Supplier. A person or entity that is Medicare Certified and
licensed, where required, to render Covered Services.
Psychiatric Hospital. A Facility Provider principally engaged in providing diagnostic and
therapeutic services and rehabilitative care for the Inpatient treatment of Mental or Nervous
Conditions, Alcoholism or Substance Abuse or Addiction. Such services must be provided by
or under the supervision of an organized staff of Physicians. Continuous nursing services
must be provided under the supervision of a licensed registered nurse.
Radiation Therapy. The treatment of Disease by x-ray, radium or radioactive isotopes.
Radiation Therapy Center. A Facility Provider that is primarily engaged in providing
Radiation Therapy Services to patients on an Outpatient basis.
Rehabilitation Hospital. A Facility Provider principally engaged in providing rehabilitative
services for the Inpatient or Outpatient treatment of Accidental Injuries, Diseases and
Illnesses that are not primarily Mental or Nervous Conditions, Alcoholism and Substance
Abuse or Addiction. Services must be provided by or under the supervision of an organized
staff of Physicians. Continuous nursing services must be provided under the supervision of a
licensed registered nurse.
Renal Dialysis. The treatment of an acute or chronic kidney condition, which may include
the supportive use of an artificial kidney machine.
Respiration Therapy. Treatment of respiratory disorders via the introduction of dry or
moist gases into the lungs.
SelectHealth Prescriptions. A company, hired by Micron to act as the third party contract
administrator to perform prescription drug claims processing and other specific
administrative services as outlined in this Plan and/or Administrative Services Agreement.
Skilled Nursing Care. Nursing service that must be provided by or under the direct
supervision of a licensed registered nurse to maximize the safety of a Participant and to
achieve the medically desired result pursuant to the orders and direction of an attending
Physician. The following components of Skilled Nursing Care distinguish it from Custodial
Care, which does not require professional health training:
•
the observation and assessment of the total medical needs of the Participant,
•
the planning, organization and management of a treatment plan involving multiple
services where specialized health care knowledge must be applied in order to attain the
desired result, and
•
the provision of direct nursing services to the Participant where the ability to provide the
services requires specialized training.
Skilled Nursing Facility. A licensed Facility Provider primarily engaged in providing
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Inpatient Skilled Nursing Care to patients requiring convalescent care rendered by or under
the supervision of a Physician. Other than incidentally, a Skilled Nursing Facility is not a
place or facility that provides minimal care, Custodial Care, ambulatory care, or part time
care services; or care or treatment of Mental or Nervous Conditions, Alcoholism, or
Substance Abuse or Addiction.
Specialist. A Phycian who is not a Primary Care Physician.
Speech Therapy. The treatment for correction of a speech impairment resulting from a
condition, Illness, Disease, Surgery or Accidental Injury; or from Congenital Anomalies or
previous therapeutic processes.
Substance Abuse or Addiction. A behavioral or physical disorder caused by repeated
excessive use of a drug or alcohol to the extent that it interferes with a Participant’s health,
social or economic functioning.
Surgery and/or Surgical Services. Surgery and/or Surgical Services include the following
services:
•
Generally accepted operative and cutting procedures,
•
Endoscopic examinations and other invasive procedures utilizing specialized instruments,
•
The correction of fractures and dislocations, and
•
Customary preoperative and postoperative care.
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