Important Benefits Change

You do need a waiver if you receive a service:

• in a contiguous county from a provider not contracted with a Blue Cross and Blue Shield Plan.
• outside Illinois and its contiguous counties.

You do not need a waiver if you receive a service:

• in Illinois.
• in a contiguous county from a provider who is contracted with a Blue Cross and Blue Shield Plan.

The waiver approval or denial will be provided within 15 days after we receive your request. It will be mailed through the United States Postal Service. Please note, waiver approval is not guaranteed.

A review will be conducted to determine:

• The location of the service being requested,
• Whether the service being requested is available in Illinois,
• Whether there is a Blue Cross and Blue Shield Plan where the service will be provided, and
• Whether the provider is contracted with the Blue Cross and Blue Shield Plan where the service will be provided.

A waiver may be granted to receive non-urgent or non-emergency care from:

• Providers outside Illinois and its contiguous counties if the service being requested is not available in Illinois or from a provider contracted with a Blue Cross and Blue Shield Plan in its contiguous counties.
• An out-of-network provider in a contiguous county if the service being requested is not available from an in-network provider in Illinois or its contiguous counties.

A waiver applies only to the provider and service for which it was approved. For example, if a waiver was approved for an inpatient stay, you will need to get an approved waiver for outpatient care, even if it is for the same condition.

Generally, waivers are approved for the least amount of time needed to find an in-network or in-state provider. Waivers may be approved for up to 2 months. Once a waiver expires, a new waiver will need to be requested and approved.

The approved waiver will show:

• Subscriber and member information
• Effective date
• Expiration date
• Days/units certified
• Onset of service/admission date
• Treatment setting
• Physician
• Service location
• Facility/provider
• Service type

Before adding visits/days/units of service to any approved waiver request, be sure to contact us before the expiration date shown on the approved waiver to ensure coverage.

In addition, you’ll need to contact us if any of the below changes after you submit your request:

• The treatment plan or level of care is changed,
• The ordering physician or facility is changed, or
• The date of service is changed or canceled.

A waiver request may be denied when there are in-network providers (participating in your area and part of your health plan) who can provide your care.

If your waiver request is denied, you will receive information on how to appeal this decision.

• You do not need a waiver to see any provider in Illinois.
• If the provider is not in your plan’s network, you may have to pay any out-of-network cost sharing.
• Keep in mind that any out-of-network cost sharing will be higher than if you went to an in-network provider.

This plan requirement applies to “snowbirds,” students who attend school outside Illinois, and covered dependents who reside outside Illinois.