Health Maintenance Organization (HMO)

The HMOs of Blue Cross and Blue Shield of Illinois (BCBSIL) offer two different contracting provider networks — BlueAdvantage^SM HMO and HMO Illinois—with the same range of features, which include:

Broad hospital coverage
No coinsurance
No deductible
Predictable copayments for health care services including hospital visits and wellness
A vast network of contracting retail and mail service pharmacies
A Commendable Accreditation from the National Committee for Quality Assurance (NCQA)

Learn more below about BlueAdvantage HMO and HMO Illinois.

A Powerful Choice

The HMOs of BCBSIL: A Powerful Choice

Members trust our HMOs:

We provide health care benefits to more people than any other HMO in the state.

We are "owned" by our members and policy holders, not by stock holders:

As a non-investor owned company, we can focus on increasing the value of the benefits we offer to our clients and members rather than focusing on shareholders.

Members are satisfied with our HMOs:

Nine out of ten members are satisfied with their Blue Cross HMO.

With the Blue Ribbon Report, the Blue Star Medical Group/IPA Report and the Blue Star Hospital Report, you can make more informed decisions when choosing a network doctor or hospital.

In our online Provider Finder^®

directory, we place a Blue Ribbon icon by the name of contracting Medical Groups/Independent Practice Associations (MG/IPA) that have earned the highest member satisfaction rates. We also place a Blue Star symbol by the name of contracting MGs/IPAs that have either met or exceeded national guidelines for providing preventive care and treating chronic conditions. Blue Ribbon and Blue Star are made possible by our Quality Improvement Fund.

You can also review the annual HEDIS^® and CAHPS^® reports for more information about the HMOs and member care and service.

The HEDIS (Health Care Effectiveness Data and Information Set) is a nationally standardized set of measures related to important areas of member care and service (developed by the National Committee for Quality Assurance). The CAHPS^® survey (Consumer Assessment of Health Plans Survey) reports how members feel about their experience with care and service.

We are one of the only insurers in Illinois to meet with contracting MGs/IPAs. You get more with our HMO:

Your Blue Cross HMO staff actually meets with contracting medical groups to help strengthen our services to the groups and members.

Employers trust us:

Year after year, 95 percent of employers continue to renew with BCBSIL.

BCBSIL is the only HMO insurer to implement a QI Fund:

Our Quality Improvement (QI) Fund rewards MGs/IPAs that meet specified clinical and non-clinical targets, which are updated annually. MGs/IPAs achieving high member satisfaction scores earn a Blue Ribbon; they earn Blue Star(s) for achieving high levels of clinical performance. Blue Ribbon or Blue Star MGs/IPAs are also rewarded with public recognition when we publish these designations on our Web site and the member newsletter. Publishing these designations has proven to motivate MGs/IPAs while providing members with a helpful decision tool in choosing medical groups.

More health care options at no additional cost:

Members have the option of utilizing the BlueExtras discount program. This program offers discounts on alternative and complementary health care services for chiropractic care, acupuncture, and massage therapy as well as thousands of health and wellness products and vision care.

You and your contracting MGs/IPAs make decisions about your health care:

We believe medical decisions should be made between the member and the member's contracting MGs/IPAs—not by us.

We only get involved if members ask us to. This sets us apart from most other HMOs:

If members are not satisfied with decisions made by their MGs/IPAs, they can file an appeal with us.

We meet or exceed national accreditation standards

Our HMOs have been awarded a Commendable Accreditation from the National Committee for Quality Assurance (NCQA). Achieving an accreditation status of Commendable from NCQA is a sign that a health plan is serious about quality. It is awarded to plans whose service and clinical quality meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement. The NCQA standards are publicly reported in five categories:

Access and Service
Qualified Providers
Staying Healthy
Getting Better
Living with Illness

Visit NCQA

to learn more:

BCBSIL HMOs voluntarily participate in the NCQA accreditation process. Not all HMO insurers participate in the NCQA accreditation process.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Medical Benefits

Whether you enroll in HMO Illinois or BlueAdvantageSM HMO, you'll have access to the same range of benefits when care is provided by or coordinated through your primary care physician (PCP), including:

Doctor office visits
Specialist care
Preventive care and wellness services for children and adults including:
- Routine physicals, immunizations, screenings for breast, cervical, prostate and colon cancer
- Reminders for flu shots, mammograms and Pap tests
For female members, choice of a Woman's Principal Health Care Provider, in addition to a primary care physician (PCP)
Hospital services and treatment on an outpatient and inpatient basis, including surgery and diagnostic tests
Maternity care
Programs to help people with asthma, diabetes and other chronic health problems manage their conditions
Inpatient and outpatient mental health and substance abuse treatment (Note: Members of Physicians Care Network, Inc. (PCN) coordinate mental health care directly with the behavioral health network provider)
Rehabilitative therapy (such as physical, speech and occupational)
Diabetic supplies
Durable medical equipment
Transition of care benefits

You do not need a PCP referral for these benefits and discounts:

Emergency room benefits
Out-of-area coverage when traveling or temporarily living out-of-state
Substance abuse treatment (inpatient and outpatient)

Prescription Drug Coverage

If you have prescription drug coverage through Blue Cross and Blue Shield of Illinois:

Your coverage may be based on either the standard formulary or the generics plus formulary
Helpful information is provided to assist you in understanding your prescription drug coverage and options, including convenient services and any limitations.
Your benefit plan includes a 90-day supply program that allows you to obtain covered maintenance medication through a network of 90-day supply retail and mail service pharmacies.
A variety of online tools are available that can help you learn more about prescription drugs and manage your pharmacy benefits. Just log in to Blue Access for Members^SM and visit your Rx Drugs page.

Network Choices

When considering an HMO plan, you want a choice of reliable and affordable networks without compromising on plan benefits or member services. BCBSIL offers two HMO plans:

BlueAdvantage^SM HMO is a subset of the HMO Illinois network, offering a smaller, yet broad contracting provider network. Tailored for members who prefer a more affordable health care premium, BlueAdvantage HMO employee costs are typically less than HMO Illinois'.
HMO Illinois, usually available at a higher premium cost than BlueAdvantage HMO, is one of the largest contracting networks of doctors and hospitals in Illinois. Many members don't need to change doctors when they join.

Same Range of Services

BlueAdvantage HMO and HMO Illinois provide access to the same range of benefits whenever care is provided or coordinated through the member's PCP, including:

The same range of Blue Cross and Blue Shield HMO health care services, including preventive care and emergency room care at any hospital
Many provider choices, including one of the largest pharmacy networks in the state
The same Blue Cross and Blue Shield Member Services support and resources
The same trusted Blue Cross and Blue Shield name
The same decision-making process concerning your health care—you, your network PCP and medical group/independent practice association* (MG/IPA) make decisions about your health care, not Blue Cross. This sets us apart from many other HMOs.
The same doctor credentialing process

Member Services

Whether you enroll in HMO Illinois or BlueAdvantage^SM HMO, you'll have access to the same member services.

As an HMO member, you'll want to sign up for Blue Access for Members^SM, our secure member service Web site. With Blue Access for Members, you can:

Locate a doctor or hospital in the network
Confirm coverage for you and your dependents
Change medical groups
View and print explanation of benefit (EOB) statements
Opt out of receiving paper EOB statements
Receive e-mails when claims paid by your BCBSIL HMO are finalized
Print a temporary ID card or request a new ID card
Explore extensive online health management tools and programs through the Personal Health Manager
Compare hospitals based on specific diagnoses and procedures

If you don't have Internet access, call us at (800) 892-2803 weekdays from 8:30 a.m. to 5 p.m. for assistance with these and other member services. TDD: (800) 888-7114.

More Online Resources

Our members search for health and benefit information and take care of many membership changes by using online search tools and resources.

The Provider Finder^® tool provides easy access to contracting doctors, hospitals, and other health care providers.
The online pharmacy search and formulary system enables members to search for a contracting pharmacy, check to see if their prescription medication is on the formulary and download applicable forms.
The Vision Provider Finder tool provides easy access to a Davis Vision provider.
Blue Cross and Blue Shield of Illinois offers two reports to help HMO members select health care providers that best meet their needs. The Blue Star Medical Group/IPA Report recognizes HMO contracting medical groups/Independent Practice Associations (IPAs) that have documented high levels of performance in providing patient care. Similarly, the Blue Star Hospital Report measures several hospital quality and patient safety performance measures for 94 urban Illinois hospitals.

Health Management Programs

BCBSIL offers members health management programs at no additional charge.

Asthma Project

Since this project was initiated, the BCBSIL HMOs rate of asthma hospitalization has decreased annually. To improve asthma care, we:

Offer a personal asthma care kit at no additional charge to members with asthma
Send an annual reminder urging members with asthma to get flu shots
Distribute an asthma care diary to help members better manage their asthma care
Survey a random sample of members with asthma to evaluate its impact on their daily lives and to assess whether their asthma medical care follows national guidelines, and then provide survey feedback to medical groups
Provide asthma care guidelines to doctors and actively encourage them to give written self-management plans to their asthmatic patients
Feature asthma care articles in member newsletters

Diabetes Project

To improve the care that diabetic members receive, the HMOs of BCBSIL:

Adopted diabetes clinical practice guidelines and distributed them to all medical groups and primary care physicians
Monitors compliance with the use of the guidelines, including the percentage of diabetic patients receiving eye examinations
Actively encourages network physicians to use diabetes flowsheets to provide patient care in accordance with the diabetes guidelines
Presents several workshops for both doctors and office personnel on diabetic care management
Sends quarterly education materials on diabetes care to diabetic members

Coronary Artery Disease Program

In 2003, BCBSIL implemented pay-for-performance programs in which HMO medical groups/ IPAs can earn additional compensation for documenting that coronary artery disease care is tracked on a flowsheet.

The flowsheet must be organized to trend results over time and remind the practitioner that a service is due. The amount of the payment is contingent upon the percentage of members with diabetes for whom management of specific risk factors is tracked on a flowsheet.

For the three years prior to implementation of this program, the HEDIS Cholesterol Management "After Acute Cardiovascular Events" rate showed little change. In 2003, the first year of the program, the screening rate increased by 11 percentage points and the percentage of members with CAD with LDL <130 increased by eight percentage points.

Mental Health Program

In 2001, BCBSIL implemented a pay-for-performance program in which HMO medical groups/IPAs are rewarded based upon the percentage of members with a mental health admission having a follow-up visit with a behavioral health provider within 30 days of hospital discharge.

Each year since implementation, the mental health follow-up visit rate has increased. The rate has consistently been well above the Quality Compass national average.

Preventive Care Programs

BCBSIL offers members preventive care programs at no additional charge.

Breast Cancer Program

To increase the rate of mammography screening and early detection of breast cancer, the HMOs of Blue Cross and Blue Shield of Illinois:

Promote preventive care and screening mammography guidelines via member and doctor communications
Send annual reminders to encourage female members age 40 and older to schedule mammograms and clinical breast exams to detect breast cancer
Provide feedback to doctors on their screening rates and offers educational programs
Provide a preventive flow sheet to doctors to make it easier to identify when members are due for a mammogram

Influenza Program

To improve the influenza vaccination rate for at-risk members, the HMOs of BCBSIL:

Mail reminder brochures each fall to high-risk members urging them to get a flu vaccination
Reinforce the importance of flu shots in member communications
Encourage doctors to target high-risk members for flu shots in the fall and provides a list of high-risk members
Measure the influenza vaccination rate for each medical group, and actively encourage medical groups to improve their rates

Cervical Cancer (Pap Smear) Screening Program

The Cervical Cancer Program:

Targets women age 18 to 64 to receive Pap smear reminder cards
Provides medical groups/IPAs a list of women ages 18-64 who should be encouraged to receive Pap smears
Distributes health education materials related to cervical cancer screening to members at health fairs, open enrollments and work site seminars

Childhood Immunization Program

Our Childhood Immunization program was implemented in 2001 with the goal of increasing the number of children who receive all of the recommended childhood immunizations.

Between 2001 and 2004, the Combination 1 rate (children who have been continuously enrolled from their first birthday to the second birthday who have had 4 DTP/DTaP, 3 IPV, 1 MMR, 3 HiB and 3 Hepatitis B immunizations within defined timeframes on or before the second birthday) increased by 11 percentage points (from 63 percent to 74 percent) and the Combination 2 rate (Combination 1 immunizations plus varicella-chickenpox vaccine) increased 21 percentage points (from 47 percent to 68 percent).

HMO Members Rights and Responsibilities

Your Rights	Your Responsibilities
Membership
You have the right to:	You have the responsibility to:
Receive information about BCBSIL benefit programs and covered services, as well as which network providers are available for you to receive the maximum level of benefits.	Read all BCBSIL benefit materials, become familiar with your plan and ask questions when necessary.
Select a medical group and/or a primary care physician (PCP) from the appropriate network. You also have the right to change your PCP and/or medical group at any time.* *Not applicable to PPO	Develop a relationship with your health care providers based on trust and cooperation.
Receive a BCBSIL identification (ID) card.	Carry your BCBSIL ID card in the event you need to receive health care services.
Obtain a copy of your rights and responsibilities as a member and to make recommendations regarding its content.	Follow the member guidelines for your healthcare benefits plan.
Choose an OB/GYN as your Woman's Prinicpal Health Care Provider (WPHCP) or additional OB/GYN PCP as outlined in your health plan guidelines.* *Not applicable to PPO	Notify BCBSIL or your Medical Group/Independent Practice Association (MG/IPA) if you wish to change your WPHCP or OB/GYN PCP.* *Not applicable to PPO
Access
You have the right to:	You have the responsibility to:
Have your PCP provide or authorize the covered services of your benefit plan that are necessary for your health care.* *Not applicable to PPO	Obtain services from or through your PCP, or within your medical group or product network.* *Not applicable to PPO
Reasonable access to appropriate medical services based on level of need. You also have the right to speak promptly with a physician or other provider when illness occurs.	Notify your PCP of any care or treatment received outside of your medical group, without your PCP's authorization or outside of your product network.* *Not applicable to PPO
Care from a specialist when medically necessary.	If care or treatment occurs without PCP authorization or outside of your product network, be familiar with the requirements of your plan and know your financial obligations.* *Not applicable to PPO
When this care is authorized by your PCP, you will receive the maximum level of benefits available.* *Not applicable to PPO	Keep scheduled appointments or give adequate notice of delay or cancellation.
If your PCP determines specialist services are not required, you have the right to be informed of the reason and an alternative treatment plan, as well as the right to appeal if you do not agree.* *Not applicable to PPO	Discuss your questions and concerns about specialty care with your PCP or health care provider.
Emergency care in any hospital emergency room 24 hours a day.	Contact your PCP, medical group or health care provider as soon as possible after treatment for an emergency, and coordinate follow-up care with your PCP or health care provider.
Mental health and substance abuse treatment.	Obtain necessary mental health or substance abuse services by following the requirements of your plan and calling the number indicated on the back of your member ID card.
Communication
You have the right to:	You have the responsibility to:
Communicate openly and fully with network providers, knowing that all information will be treated confidentially.	Be honest with your health care providers and communicate any information that may affect diagnostic and treatment decisions.
Receive considerate and courteous care, with respect for personal privacy and dignity.	Treat all network provider personnel and BCBSIL personnel respectfully and courteously.
Confidential health records, except when disclosure is required by law or authorized by you in writing, and to review your medical records with your PCP or health care provider, given adequate notice.	Help your health care provider maintain accurate and current medical records.
Receive information and to have a full discussion about all appropriate or medically necessary treatment options for your condition in order to make an informed decision regardless of cost or benefit coverage.	Ask questions and make certain that you understand all options, financial obligations and plan requirements related to the agreed-upon treatment. These requirements may include pre-authorization from or notification to BCBSIL* *Not applicable to PPO
Be completely informed of your diagnosis, treatment and outlook and to participate in decisions involving your medical care.	Follow the agreed-upon treatment plans and instructions for care and to consider the potential consequences if you refuse to comply with treatment plans or recommendations.
An advance directive (such as a durable power of attorney for health care) concerning treatment, with the expectation that your PCP or health care provider will honor the intent of the directive to the extent permitted by law.	Notify your PCP or health care provider as well as family members of any advance directive.
Express a complaint about clinical or administrative issues related to your health plan, appeal plan decisions and receive timely response.	Express your opinions, concerns and complaints in a constructive manner to your PCP, medical group, health care provider or BCBSIL.

Reconstructive Surgery

Federal and State of Illinois laws require group health plans and insurers to provide coverage for reconstructive surgery following a mastectomy. These laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for:

reconstruction of the breast on which the mastectomy has been performed
surgery and reconstruction of the other breast to produce a symmetrical appearance
prostheses and treatment for physical complications for all stages of mastectomy, including lymphedemas

BCBSIL is pleased to provide coverage for mastectomies and the above procedures, subject to the terms of the member's applicable health care benefits coverage.